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When it comes to preventing ICU infections, less is more

Heading off common complications calls for fewer interventions and strategic use of ventilators, sedatives

From the June ACP Observer, copyright 2006 by the American College of Physicians.

By Deborah Gesensway

From poor hand-washing to adjusting and changing catheters and dressings too frequently, physicians and nurses are contributing to some of the most serious—and preventable—problems encountered in intensive care units (ICUs).

As a result, patients now suffer from more infections, clots, ventilator-associated pneumonia, and problems related to both too much and too little sedation.

“We are the cause of a lot of the complications that happen in ICUs—either by omission or commission,” said David P. Gurka, ACP Member, director of the medical ICU and head of critical care medicine at Chicago’s Rush University Medical Center. Dr. Gurka’s presentation was part of a two-day pre-session course on critical care medicine.

Heading off infections

Research consistently finds that contaminated catheters, skin, dressings and fluids are sources of infection in ICUs, he said. It's a case where less is much better for patients: Infections are less likely to be spread throughout the units—and hospitals as a whole—when providers do less to patients. That means leaving central venous catheters in as long as possible and changing dressings only as often as needed.

Other factors that can help head off infections include:

  • Handwashing. All ICUs should have protocols in place to reduce bloodstream infections. “Health care workers’ hands are the biggest problem,” Dr. Gurka said. Handwashing is particularly critical before placing central lines. Guidelines from the Centers for Disease Control and Prevention now recommend using new gloves for new catheters, choosing chlorhexidine 2% antiseptic and not routinely changing lines or dressings before they truly need to be changed.

  • Nurse-to-patient ratio. Studies have also found that a key way to prevent infections is to reduce nurse-to-patient ratios. “The best is 1-to-1” to ensure that physicians and nurses don’t inadvertently pass infections from one patient to another, Dr. Gurka said. Those kinds of ratios, however, come with high costs.

  • Subclavian lines. Using subclavian lines as often as possible instead of femoral lines can help infection control and reduce the incidence of clots, said Dr. Gurka. One-third of catheters produce clots—and the risks of thrombotic complications from femoral catheters and internal jugulars are much higher than from subclavian ones.

  • Prophylaxis treatments. Most patients are candidates for thromboprophylaxis, and internists play a big role in prescribing heparin or other drugs for DVT prophylaxis or for ordering mechanical prophylaxis.

Ventilators, sedation

Dr. Gurka also addressed other challenges in the ICU including ventilator-associated pneumonia, which tends to occur three to four days after intubation in about 9% of ICU patients on ventilators.

That high rate makes a strong case for using fewer ventilators. Instead, physicians should choose noninvasive ventilation techniques or extubate patients as quickly as possible. If a patient is intubated, Dr. Gurka said, physicians should make sure the head of the bed is raised and brush patients' teeth daily to reduce risks of aspiration.

Another enormous challenge in the ICU is appropriate sedation—enough sedation “so patients can tolerate the ICU environment,” said Curtis N. Sessler, MD, critical care medical director at Medical College of Virginia Hospitals and professor of medicine at Virginia Commonwealth University Health System in Richmond, Va.

When patients aren’t sedated enough in the ICU they report increased pain, anxiety and sleep deprivation. They also can pull out lines and be so agitated that they are violent toward nurses and other caregivers, explained Dr. Sessler, another speaker at the two-day pre-session.

Studies have found that between 45% and 82% of critically ill patients suffer from pain and that an alarming number of patients suffer from post-traumatic stress disorder following their ICU stays, speakers said.

But too much sedation causes its own problems, including masking neurological changes, contributing to delirium, and making it harder for physicians to evaluate and treat pain, Dr. Sessler said.

As a result, some hospitals are now experimenting with sedation protocols, screening tools and strategies to help ICUs give as little sedative as necessary for each particular patient to tolerate his ICU stay and for adequate pain control. Techniques being tried, Dr. Sessler said, include daily awakenings—also known as "sedation vacations"—and avoiding continuous administration of sedatives.

When daily awakenings aren’t feasible—due to staffing limitations, for example—some ICUs have written new sedation protocols that aim for intermittent therapy instead of continuous infusion, Dr. Sessler said.

In addition, he advised physicians to expect and be more aware of opioid and benzodiazepine withdrawal in patients after their ICU stays and to treat those symptoms.

“Withdrawal is very common, and it might be due to the overloading of so many drugs,” he said.

Other drugs may also be overprescribed regularly in ICUs. For instance, Dr. Gurka said, critical care medicine experts are now debating the practice of giving nearly all ICU patients an IV acid-suppressive therapy as prophylaxis for stress ulcers.

The problem, he said, is not usually in the ICU, where about 50% of patients experience erosive esophagitis and 25% have bleeding. But many of these patients unnecessarily continue on acid-suppressing therapy once they leave the ICU.

In addition, he said, studies have shown no difference in the effectiveness of H2 antagonists or more expensive proton-pump inhibitor drugs, but both are used regularly. More enteral nutrition could reduce the risks of GI bleeding, he said.

High temperatures, antibiotics

Other sessions during the two-day course addressed everything from lung injury management to vasopressor and vasodilatory therapy, pneumonia, stroke, and acute coronary syndromes.

At one session, George H. Karam, FACP, professor of medicine at Louisiana State University School of Medicine in New Orleans, discussed how physicians need to do a better job discerning if a patient’s high body temperature is truly a fever, or if it is merely hyperthermia. Presuming all temperatures are fevers—and due to infections—leads to unnecessary antibiotic use, which contributes to antibiotic resistance.

In fact, Dr. Karam said, many conditions other than infections cause body temperature to rise, including some endocrine conditions and drug and alcohol withdrawal. Even when a high temperature really is a fever, the cause can be non-infectious, such as surgery, the side effects of some drugs, inflammation and immune-mediated diseases.

"We tend to err and give antibiotics to these people," he said. "If we can more accurately distinguish hyperthermia from fever, and if we can then separate infectious from non-infectious causes of fever, we may be able to reduce the rate at which antibiotic resistance is developing."

Meanwhile, the spread of multi-drug-resistant pathogens means that some patients are being overtreated and others undertreated as physicians search for any drug that may help their particular patient, said Michael S. Niederman, FACP, chair of medicine at Winthrop-University Hospital in Mineola, N.Y., and professor of medicine at State University of New York at Stony Brook.

One solution, he said, is to take a thorough history. “If you know what antibiotic a patient recently received, you can avoid it and use a different agent,” he said. Recent studies have shown that if patients received an antibiotic in the last three months, they need to be prescribed a different one.

“You can’t use the same antibiotic over and over again,” he said, even if it worked well the last time.

The dilemma is how to aggressively use antibiotics early in the course of an infection—which studies have shown is necessary—while not giving inappropriate therapy, which is driving more resistance. Dr. Niederman recommended that physicians develop protocols that use “combination therapy,” then adjust that therapy and modify drug doses and types throughout the course of each patient’s disease.

“Using the right dose," he said, "is just as important as using the right drug."

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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Techniques to help reduce ventilator-associated pneumonia

  • Promote handwashing
  • Limit changes of ventilator circuits or inline suction devices
  • Change heat moisture exchangers at least every 24 hours
  • Handle condensate carefully
  • Ensure adequate cuff pressure
  • Raise head of bed at least 30 degrees
  • Monitor gastric residual
  • No nasal intubation
  • Limit stress ulcer prophylaxis
  • Use cholorhexidine oral rinse
  • Ensure immunization

Source: Chest, June 2004

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