3. Peptic Ulcer Disease (PUD) Prophlaxis
Patients who are on mechanical ventilation are much more predisposed to gastric stress ulcers then ICU patients not being mechanically ventilated. Stress ulceration can raise gastric pH and promote growth of bacteria in the stomach, which can cause problems if a ventilated patient aspirates any reflux of gastric contents¹. Although the gastric ulcer treatment itself is not related to VAP, it does have an impact on the possible occurrence of VAP.
Stress ulcer prophylaxis has historically been treated with antacids or an H2 proton pump inhibitors. When an antacid or proton pump inhibitor is used to prevent ulceration of the stomach the normally low pH (acidic) environment of the stomach is changed and bacterial growth can proliferate¹.
This results in a higher incidence of VAP in these patients who are more prone to gastric reflux accumulating in the area above the glottis. H2 inhibitors such as cimetidine and ranitidine block the secretion of gastric acid. Sucralfate does not significantly alter gastric pH since its action is to bind to the proteins of an ulcer site.
4. Deep Vein Thrombosis Prophlaxis
Prevention of deep vein thrombosis (DVT) is not targeted directly at the prevention of VAP but VAP rates decreased dramatically in hospitals where all elements of the bundle, including DVT prophlaxis were used.
Ventilated patients are confined to a bed and in many cases have blood pressure or circulatory problems. The lack of mobility combined with age, circulatory problems and comorbidity such as trauma or COPD place them at high risk for deep vein thrombosis. Prevention of deep vein thrombosis includes empiric anticoagulant therapy such as heparin or low molecular weight heparin and warfarin¹.
Patients at risk for bleeding difficulties such as post surgical procedures or trauma where anticoagulant therapy is contraindicated can benefit from physical manipulation of the muscles of the leg to enhance efficient venous drainage. Pneumatic stockings, sometimes known as squeezers continuously milk the muscles and vasculature of the legs improving blood flow and preventing clot formation. Any patient confined to an ICU bed and especially mechanically ventilated patients should be maintained on prophylactic therapy for DVT prevention.