A 48-year-old patient with Guillain Barre Syndrome who has been hospitalised for 30 days was recently re-admitted to your ICU with septic shock. He required mechanical ventilation via his tracheostomy, vasopressor treatment, and is now recovering.
a) What factors in this patient contribute to an increased risk for nosocomial infections?
(30% marks)
b) How would you reduce the risk of him acquiring another nosocomial infection while in the ICU?
(70% marks)
This question had several aspects to it that required structure to cover those elements. Candidates were expected to cover elements related to the specific patient care of the individual patient but also to cover general ICU aspects in regard to infection prevention management. Detailed descriptions were not required, as long as the general elements were covered with some relevant examples. Especially important points are underlined.
A)
Recognition that long stay patient in hospital who has a tracheostomy is a high risk patient for exposure to and/or colonisation with potential resistant flora and is therefore at risk for development of nosocomial infections (3 marks)
B)
NG tube/sinusitis- consider PEG.
Increased risk in GBS patients is hard to discuss, not because the topic is entirely unfamiliar to senior ICU trainees, but rather because the answer requires a structured approach, and with so much to discuss, it is difficult to know how best to structure such a vast amount of information. A certain discipline is also going to be required. A well-informed exam candidate will squander many minutes writing everything they know about this.
Let us consider this in terms of predisposing factors and the possible infection they cause. One way is to organise the factors is according to the infections they promote, and the process which has caused them. The ideas used to populate this table came from this article by Henderson et al (2003).
Infectious consequences | Contributing factors |
VAP |
|
Sinusitis |
|
Hospital-acquired pneumonia |
|
Pressure area infections |
|
Line-related sepsis |
|
Urinary tract infection |
|
Increased predisposition to infection |
|
Resistant organisms |
|
With this exercise behind us, we can easily recombine the contributing factors into a structured list of interventions designed to address them:
Factor | Intervention |
Prolonged intubation |
|
Gram-negative colonisation of the lower airway |
|
Poor oral hygiene |
|
Weak cough |
|
Prolonged NGT dwell-time |
|
Impaired airway defence reflexes |
|
Prostration and basal atelectasis |
|
Prolonged immobility |
|
Prolonged need for parenteral medications |
|
Long term IDC |
|
Immunosuppressant therapies |
|
Malnutrition |
|
Resistant organisms |
|
Cross-contamination with MROs |
|
Henderson, R. D., et al. "The morbidity of Guillain-Barré syndrome admitted to the intensive care unit." Neurology 60.1 (2003): 17-21.