European Journal of Cardiovascular Medicine

Individuals admitted to intensive care units (ICU) typically face a significant risk of mortality(MT), attributable not only to their underlying critical conditions but also to the potential for secondary complications, including nosocomial infections(NC-IF).[1] These IF are usually prevalent in the ICU, impacting 27% of all critically ill patients, with 86% of cases linked to mechanical ventilation(MV).[1] Biomarkers, including C-reactive protein, procalcitonin, and soluble triggering receptor expressed on myeloid cells (sTREM-1), have been suggested as potential diagnostic indicators for ventilator-associated pneumonia (VAP). Nonetheless, these markers exhibit limitations in accuracy, and their application for VAP diagnosis is currently not endorsed.[2-4] There is currently no gold standard for diagnosing VAP, no effective preventative(PVN) measures, and antibiotic resistance(AB-RS) is on the rise, therefore, all of these factors pose problems for the therapy of VAP. To lower the number of cases of VAP & improve the outcomes for patients on MV, it is important to make the risk factors of VAP clear for clinical PVN and management.[5] Intravenous antimicrobial therapy serves as the fundamental approach for the treatment of VAP. There is a tough situation for doctors because they need to avoid treatments that don't work because the wrong first antimicrobial therapy is linked to higher death rates [6], but they also want to use as few broad-spectrum antibiotics as possible because these antibiotics make bacteria more resistant.[7] Therefore, VAP is a serious complication (sepsis and organ failure, and may result in death) can occur in patients who are receiving MV in a medical ICU . Hence, it become utmost important for a patient with VAP to

receive prompt & appropriate tretament to minimize its risk & improve chances of recovery.

Thus, the goal of our study was to assess VAP predictors(PD), Complications(C) & Outcome(O).

Our current study was done with 144 patients in the department of Medicine, JLN Medical College,  Ajmer to those who were clinically diagnosed with VAP from November 2022 to May 2024, after receiving ethical clearance & informed consent form.

Study Design: Hospital based, observational study

Inclusion Criteria:

1. >18 year
2. Both genders
3. Patient on MV for more than 48 hour

Exclusion Criteria:

1. MT within 96 hour
2. Pneumonia developed within 48 hour
3. Present with pneumonia at the time of admission

Methodology

In our study, we have asked patients to fill questionnaire form (Age, sex, date of admission to the ICU, date of initiating MV.In each patient, ventilator mode and settings are recorded, and any change in setting were recorded daily. Patients’ vital signs, general and physical examination, oxygen saturation, and position are monitored regularly)

and were randomly selected. During the initial stage of ventilation, if needed, patients are adequately sedated. All necessary measures were taken for the prevention of hospital-acquired infections (HAI). A routine and special investigations, such as tracheal tube, blood, and urine culture, was performed. Sputum from the patients were collected from the tip of the suction catheter and transported to the laboratory in a sterile tube. The outcome of VAP is noted as full recovery or low morbidity (MD) & mortality (MT). Routine investigation include CBC Neutrophil % Lymphocyte % Monocyte% Esinophil% Basophil% N/L Ratio, Blood Sugar, Lipid profile, Total cholesterol, Triglycerides, HDL,LDL,VLDL, Renal profile, Blood urea, Serum cretinine, Liver function tests, Serum electrolytes, Novel Markers Of Inflamation, IL-6, HS-CRP and D-DIMER. Radiological investigation which include X ray chest PA view and special investigation like culture & sensitivity (SN) of tracheal aspirate (TC-AS) and ET tube tip culture, blood & urine culture and finally, arterial blood gas analysis (ABG). Our result was made by using chi-square test and student- test.

TABLE 1: COMPLICATION ASSOCIATED

Table 1 shows that, significantly more cases of PL-EF were observed in VAP present cases as compared to absent cases. Significant sepsis & septic shock were more common in VAP-present cases as compared to non-VAP cases (P<0.001S). No significant association was observed in recurrent VAP according to VAP status.

TABLE 2: COMPLICATION IN PRESENCE OF EARLY & LATE VAP

 Table 2 shows that, effusion sepsis, septic shock, and mortality were significantly higher in late VAP as compared to early VAP (P = 0.019, 0.013, 0.036 & 0.05 respectively).

TABLE 3: OUTCOME

Table 3 shows that, patients without VAP had a higher MT rate(R) (25.53%) compared to those with VAP (3.57%). Survival (SV) R were also higher in patients without VAP (78.72%) than in those with VAP (46.43%). Overall, the SV & MT-R are almost balanced in the total population, with 50.67% surviving and 49.33% experiencing mortality. While VAP presence appears to be associated with a lower MT-R, patients without VAP also have a significantly higher chance of SV.

TABLE 4: PREDICTOR

Table 4 shows that, SpO2, PaO2/FiO2 & TP were significantly higher in VAP present cases as compared to absent cases (P<0.001). Fever was present in almost all the cases 100% vs 73.40%. Among patients without VAP, 48 out of 94 (51.06%) had secretions, whereas, in the VAP group, 42 out of 56 (75%) showed secretions. In the non-VAP group, 47 out of 94 (50%) required an increased frequency of suction, while 38 out of 56 (67.86%) in the VAP group needed it more frequently. Only 15 out of 94 patients (15.96%) without VAP exhibited infiltration on X-ray, whereas a much larger proportion, 50 out of 56 (89.29%), in the VAP group showed X-ray infiltrations. This data suggests that patients with VAP tend to have higher occurrences of secretions, an increased need for suction, and significantly more frequent X-ray infiltrations. Table also found that the mean SD of N/L ratio is 5.92±1.86 in VAP absent while9.62±3.171 in VAP present cases (P=<0.001S) The mean SD of IL6 is 34±0.23in VAP absent while 51.57±14.677 in VAP present cases (P=0.268NS) The mean SD of D-DIMER is 1.95±0.495 in VAP absent while2.13±1.436 in VAP present cases (P=0.268NS) mean SD of HSCRP is 42±0.23 in VAP absent while65.02±15.12 in VAP present cases (P=0.001S).

TABLE 5: SCORES

      Table 5 shows that, significantly higher values were observed in VAP cases as compared to non-VAP cases (P<0.001S)

According to our study for early predictors, our research displays the distribution of cases. It was much more common for VAP patients to have abnormal clinical parameters like fever, TP, TC & more secretions. modified auscultation test In virtually all cases, fever was present. The auscultation examination showed a significant change of 100% compared to 73.40%, with a p-value of less than 0.001S. TC & TP were significantly more prevalent in VAP present cases than in VAP absence cases (91.07% vs. 64.96%). 96.43% as opposed to 57.35% (significance level &lt; 0.001) In the group of patients without VAP, secretions were present in 48 out of 94 (51.06%), whereas in the group with VAP, fluids were present in 42 out of 56 (75%). Half of the patients in the non-VAP group (47 out of 94) needed suction more often, while almost two-thirds of the patients in the VAP group (38 out of 56) needed suction more often in addition to X-ray infiltrations. These results indicate that these predictors may be better managed for VAP, and

patients can have better outcomes if they are identified early. It is essential to continuously monitor and evaluate patients in a healthcare. The investigation presents findings on the APACHE II SCORE and CIPS in relation to VAP. The mean standard deviation in the APACHE II score was 11.58 ± 3.272 in cases without VAP, compared to 13.98 ± 3.228 in cases with VAP present. The mean standard deviation of the clinical pulmonary infection score was 2.98±1.072 for people who did not have VAP, but it was 10.45±1.077 for people who did have VAP. In this study, all the parameters that were measured, such as the APACHE II score and the clinical pulmonary infection score, were significantly higher in people with VAP than in people who did not have VAP (P < 0.001). The results are very similar to those of a study done by Zhou XY et al.(2015) and found that APACHE II and CPIS scores were significantly higher in non-survivors than in survivors. The fact that the APACHE II Score and CPIS were much higher in people with VAP suggests that there is a link between these measures and the presence of VAP. The APACHE II scoring system is good at figuring out how likely it is that a person will die, but the CPIS may not be as good at predicting outcomes for people with VAP. [8]

TABLE 6: COMPLICATION

Complications are associated with VAP status, in our study showes significantly greater rates of effusion sepsis, septic shock, and death were seen in late VAP compared to early VAP (P = 0.019, 0.013, 0.036 and 0.05 respectively) in the presence of these sequelae. Therefore, several studies have examined the differences in complications between early and late VAP. This analysis compares the complications in both types of VAP, showing that late VAP is associated with more severe outcomes and a higher incidence of complications. ARDS is more commonly seen in late VAP than early VAP and is leading cause of death in late VAP as shown in table 6. Patients with late-onset VAP exhibit an increased risk of developing sepsis and septic shock due to extended exposure to invasive mechanical ventilation, facilitating bacterial colonization and subsequent al., infection. [11, 12]

As previously documented, the likelihood of fatal complications increases with extended mechanical ventilation.[8] These findings are consistent with the observed increased mortality rate in late ventilator-associated pneumonia.[8] The findings of this study indicate that late VAP is associated with an increased risk of severe complications, such as effusion, sepsis, septic shock, and mortality. Timely identification and proactive intervention for VAP are crucial in mitigating these risks. If a patient has late VAP, they are much more likely to have complications like reintubation, effusion, sepsis, septic shock, and death compared to those who had early VAP. Careful monitoring and management of VAP can improve patient outcomes, as it is associated with worse complications and a later start. Improving patient outcomes and minimizing these complications requires early detection and management of VAP. The present investigation revealed that patients not experiencing VAP had an average ICU duration of 8.85 ± 1.854 days. In contrast, patients with VAP exhibited a markedly extended ICU stay of 22.5 ± 29.369 days. Consequently, the overall mean ICU duration was calculated to be 14.16 ± 19.453 days, with a statistically significant difference (P < 0.001). Additionally, the VAP group used ventilators for a significantly longer period of time (19.25 ± 25.763 days on average vs. 6.58 ± 2.425 days in the non-VAP group), giving the overall mean of 11.51 ± 17.242 days (P < 0.001, indicating statistical significance). The duration of intubation was significantly prolonged in patients with VAP, averaging 7.64 ± 2.163 days compared to 5.29 ± 1.952 days in non-VAP patients. The overall mean duration of intubation across all subjects was 6.21 ± 2.332 days, with a statistically significant difference (P < 0.001). The survival rate in the total population is approximately 50.67%, while the mortality rate stands at 49.33%, indicating a near equilibrium between the two outcomes. Although the presence of VAP seems to correlate with a reduced MTR, patients who do not have VAP exhibit a markedly increased likelihood of survival. The MTR is elevated in cases where VAP is present.

Clinical & lab parameters like fever, TP, TC , secretions, frequency of suction ,Spo2, Pao2/fio2, x-ray infiltration, N/I ratio, IL-6, D-DIMER, HS-CRP & leukocyte count all showed statstically significant difference between the 2 groups. Therefore, we found that, the early predictors of VAP include low oxygen saturation (SpO2), TP, TC & increased secretions and higher APACHE II scores are associated with an elevated risk of developing VAP. On the other hand, the most common for complications were effusion, sepsis and septic shock with late-onset VAP, which are associated with increased MTR. Hence, we come to conclude that, the VAP that starts early may respond well to more targeted treatments, while VAP that starts late needs a close monitoring and care because of higher chance of serious complications.

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