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VAP Case Studies HANYS VAPP Series

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					     HANYS
    Webinar
  April 16, 2008
VAP Case Studies
                  VAP Case Study #1
Admitting Note
Patient ID# 76-12-00
Diagnosis: Coronary Atherosclerosis, Aortocoronary
Bypass
78-year old male (DOB: 12/03/28) who after evaluation
by cardiovascular surgery service on 4/29,
was diagnosed with coronary artery disease.
Admitted on 5/18 for elective surgery after an extensive
pre-hospital multi-system work up.
He has lost 30 pounds in the last 3 months.
Cefazolin ordered on call to the operating room. (L)
peripheral IV inserted.
VAP Case Study # 1(Cont.)

 PMH: Hyperlipidemia, renal insufficiency,
 myocardial infarction, obesity, pneumonia and
 urinary tract infection, bilateral cataracts,
 cholecystectomy 10 years ago, unstable angina.

 Admission Vital Signs & Labs: BP 130/70, P
 88, R 20, Temp 37.1, Na 135, K 3.8, BUN 15, Cr
 1.5, WBC 8.7, HCT 36.
VAP Case Study # 1(Cont.)

    Surgical Procedure: Coronary Artery Bypass
    Graft using (L) greater saphenous vein as donor
    vessel was performed on 5/18 while the patient
    was under general anesthesia. Duration: 4
    hours and 10 minutes. Joseph Thompson, M.D
    (065). ASA class 3; wound class clean (I).

    Admitted to CTICU on 5/18 and transferred to 8
    West on 5/27.
VAP Case Study # 1(Cont.)
Date     Temp         Daily Notes & Diagnostic Findings
5/18     Afebrile Lungs clear; intubated. (RIJ) internal jugular IV
                  access device inserted. Foley catheter draining
                  clear yellow urine.
5/19 -   36.5     Bilateral rhonchi; Thin yellow blood-tinged
POD 1             secretions. Chest x-ray shows bilateral edema.
                  Sternal wound site and donor leg site are without
                  redness.

5/20 -   36.7     Lungs with rhonchi; suctioned for moderate thick
POD 2             clear secretions, CXR - improvement in bilateral
                  edema, extubated in p.m.

5/21 -   38.3     Incision dressings clean and dry; Respiratory
POD 3             distress, R=40, episodes of bradycardia, BP-
                  96/50. Reintubated. CXR-opacity in Right lower
                  lobe. Suctioned for thick tan secretions. Sputum
                  and blood cultures sent for C&S. RIJ D/C’d and
                  Rt. subclavian catheter inserted.
#1 Does this patient meet criteria for a VAP?
   The Facts:
    – POD #3 patient reintubated, placed on a ventilator
    – Had been on a vent. within the last 48 hours
    – Febrile (38.6)
    – New onset of purulent sputum
    – Respiratory Distress (Rate=56)
    – New CXR with RLL infiltrate


   Is there evidence of Pneumonia?
            –   YES, fever, purulent sputum,
   Are the NHSN Criteria for pneumonia met?
            – NO: Only 1 CXR with infiltrate (need 2)
VAP Case Study #1(Cont.)



  5/22 - 38.9       Suctioned for thick tan/yellow. Rales on (L),
  POD 4             rhonchi on (R), decreased O2 saturation,
                    CXR – RLL consolidation, Sputum gram
                    stain, many GPC in clumps and many WBC.
                    Preliminary sputum culture- gram positive
                    cocci,
                    Blood culture no growth.

  5/24/     37.6    Blood culture no growth. Sputum culture -S.
  POD 6             aureus

  5/27      37.0    Final blood culture no growth
Does this meet NHSN criteria for VAP?
YES- Patient was intubated and ventilated
 – Now with second CXR showing RLL consolidation
 – Signs and Symptoms- Fever (38.9), purulent sputum,
  and rales.
Which NHSN Pneumonia event is reported?
PNEU1, 2 or 3?
           PNEU1
Which patient care unit is assigned the VAP
           CTSICU
* required for saving     **required for completion
Facility ID:45678
         ID:45678                                          Event #:Case Study #1

*Patient ID:761200                                        Social Security #:

          ID:
Secondary ID:

Patient Name, Last:                                             First:                                      Middle:
*Gender:       F    M                                     *Date of Birth:12/03/1928

*Event Type: PNEU                                         *Date of Event:   5/22/07
*Post-
*Post-procedure PNEU:          Yes     No                 Date of Procedure:

NHSN Procedure Code:                                      ICD-
                                                          ICD-9-CM Procedure Code:

*Location:   CTSICU                                       *Date Admitted to Facility:     5/18/07
Risk Factors

*Ventilator:        Yes      No

*For NICU only: Birth weight: ____________grams



Event Details

*Specific Event:

                        Clinically defined pneumonia (PNU1)
                   Pneumonia with specific laboratory findings (PNU2)
                   Pneumonia in immunocompromised patients (PNU3)

*Secondary Bloodstream Infection: Yes            No



**Died:      Yes        No                                PNEU Contributed to Death:        Yes        No

Discharge Date:                                           *Pathogens Identified:          Yes     No

                                                             *If Yes, specify on page 2
      VAP Case Study # 2

Same patient as in Case Study #1
     but with a few changes
VAP Case Study # 2(Cont.)
Date     Temp         Daily Notes & Diagnostic Findings
5/18     Afebrile Lungs clear; intubated. (RIJ) internal jugular IV access
                  device inserted. Foley catheter draining clear yellow
                  urine.
5/19 -   36.5     Bilateral rhonchi; Thin yellow blood-tinged secretions.
POD 1             Chest x-ray shows slight congestion with infiltrate in
                  RLL. Blood gases WNL. Sternal wound site and donor
                  leg site are without redness. Blood gases WNL.
                  Extubated. Foley catheter DC’d.
5/20 -   38.6     Incision dressings clean and dry; Labored respirations
POD 2             (R=36), episodes of bradycardia, BP-96/50. Decreased
                  O2 saturation,CXR-opacity in RLL. Bilateral rales on
                  rhonchi. Suctioned for thick tan secretions. Sputum
                  and blood cultures sent for C&S. RIJ DC’d and Rt.
                  subclavian catheter inserted. IV antibiotics q6h. Nasal
                  02 at 6 Liters.
VAP Case Study # 2 (Cont.)

5/21 - 38.0       CXR: persistent RLL consolidation. Coughing
POD 3             yellow secretions. Blood gases improved. Still
                  some rales and rhonchi. Nasal 02 decreased
                  to 3 liters

5/22 - 37.6       5/20 Sputum gram stain, many GPC in
POD 4             clumps and many WBC. Preliminary sputum
                  culture- gram positive cocci,
                  Blood culture no growth.

5/24/    36.4     Preliminary blood culture no growth. Final
POD 6             sputum culture -S. aureus

5/27     36.4     Final blood culture - one of two (peripheral)
                  grew CNS
   Does this patient meet criteria for a
                  VAP?
The Facts:
 – Had been on a vent. within the last 48 hours
 – Febrile (38.6)
 – New onset of purulent sputum
 – Respiratory Distress (Rate=36)
 – 2 CXRs with RLL consolidation

Is there evidence of Pneumonia?
       – YES, fever, purulent sputum,
Does this meet NHSN VAP Criteria?
# 2 Does this meet NHSN criteria for VAP?
YES- Patient was intubated and ventilated
within 48 hours AND
 – Two serial CXRs showing RLL consolidation
 – Signs and Symptoms- Fever (38.9), purulent sputum,
   and rales.
Which NHSN Pneumonia event is reported?
PNEU1, 2 or 3?
           PNEU1
Which patient care unit is assigned the VAP
           CTSICU
* required for saving     **required for completion
Facility ID:45678
         ID:45678                                          Event #:Case Study #2

*Patient ID:761200                                        Social Security #:

          ID:
Secondary ID:

Patient Name, Last:                                             First:                                      Middle:
*Gender:       F    M                                     *Date of Birth:12/03/1928

*Event Type: PNEU                                         *Date of Event:   5/22/07
*Post-
*Post-procedure PNEU:          Yes     No                 Date of Procedure:

NHSN Procedure Code:                                      ICD-
                                                          ICD-9-CM Procedure Code:

*Location:   CTSICU                                       *Date Admitted to Facility:     5/18/07
Risk Factors

*Ventilator:        Yes      No

*For NICU only: Birth weight: ____________grams



Event Details

*Specific Event:

                        Clinically defined pneumonia (PNU1)
                   Pneumonia with specific laboratory findings (PNU2)
                   Pneumonia in immunocompromised patients (PNU3)

*Secondary Bloodstream Infection: Yes            No



**Died:      Yes        No                                PNEU Contributed to Death:        Yes        No

Discharge Date:                                           *Pathogens Identified:          Yes     No

                                                             *If Yes, specify on page 2
VAP Case # 3
                 VAP Case Study #3
Admitting Note

Patient ID # 93-62-81

Diagnosis: Drug overdose in a ,
22-year-old (DOB: 2/13/85) male graduate student
brought to the ED on 6/17, unconscious and intubated.
CPR conducted in the field by paramedics with sucessful
stablization. Lungs with bibasilar crackles noted. Chest
x-ray shows possible aspiration pnuemonia. Foley
catheter inserted and Right subclavian catheter inserted
in the ED.
Case Study #3 (Cont.)

PMH: No history of drug use or previous overdose. Medical
  history unremarkable except for appendectomy age 12.
  Smokes 1-1 ½ ppd.. Allergic to penicillin.
Admission Vital Signs & Labs: BP 110/60, P64, Na 137,
  K 3.7, BUN 23, Cr. 1.4, WBC 5.4, HCT 41
Medical: Afebrile,admitted to the Medical/Surgical ICU on
  6/17, intubated on ventilator support . Possible
  aspiration, started on IV antibiotics
Case Study # 3 (Cont.)
Date   Temp          Daily Notes & Diagnostic Findings
6/18   Afebrile BP 110/60.Remains unconscious. Ventilator
                  support. Lungs with bibasilar rales and chest x-
                  ray shows some perihilar congestion.

6/19   Afebrile Unconscious but remains stable. Scant thin clear
                  secretions suctioned from endotracheal tube.
                  CXR clearing. No infiltrates seen. WBC 8.7
6/21   Afebrile   Lungs with a few baseline crackles. Urinary
                    catheter removed and urine sent for culture.
                    Urinalysis yellow in color, negative for
                    leukocytes and nitrates. WBC 7.6. Patient more
                    responsive.
Case Study # 3 (Cont.)

6/22   39.2    CXR with new LL infiltrate and possible RLL
                 consolidation. Thick yellow secretions requiring
                 frequent suctioning. Patient restless and
                 agitated. Blood gases show decrease
                 oxygenation. Sputum and blood sent for C&S.
                 WBC 15.0
6/23   38.6    Worsening respiratory status. Bedside BAL
                 performed, secretions thick yellow. Specimen
                 sent for C&S. Remains on ventilator.

6/24   37.8    Blood gases improving. Frequent suctioning but
                  secretions thinner. Patient less agitated. 6/22
                  sputum gram stain: many GNR, >25 leukocytes.

6/26   36.5    Began weaning trials. Patient alert. Respiratory
                 secretions decreased. Plan to extubate.
Case Study # 3 (Cont.)


6/27    36.4   Patient extubated. Cultures sent 6/22 reported as:
                 Sputum P. aerugenosa and blood culture CNS.
                 WBC 10.0
6/28    36.4   Improved respiratory status. 6/23 BAL sputum
                 culture reported as K. pneumonia. Final blood
                 culture report CNS. Discharged from ICU to 3
                 West.
#3 Does this meet NHSN criteria for VAP?
YES- Patient was intubated and ventilated
 – Patient without underlying disease AND
 – 1 CXR showing new and progressive infiltrate
 – AND Signs and Symptoms- Fever (38.9), Leukopenia
   (15.3)
 – AND Positive quantitative sputum culture – K.
   Pneumonia (BAL)
Which NHSN Pneumonia event is reported?
PNEU1, 2 or 3?
           PNEU2
Which patient care unit is assigned the VAP
          Medical/Surgical ICU
* required for saving    **required for completion
Facility ID:45678
         ID:45678                                        Event #: Case Study # 3

*Patient ID:936281                                       Social Security #:

          ID:
Secondary ID:

Patient Name, Last:                                             First:                                       Middle:
*Gender:       F   M                                     *Date of Birth:2/13/1985

*Event Type: PNEU                                        *Date of Event:6/23/07

*Post-
*Post-procedure PNEU:         Yes     No                 Date of Procedure:

NHSN Procedure Code:                                     ICD-
                                                         ICD-9-CM Procedure Code:

*Location:   M/S ICU                                     *Date Admitted to Facility:       6/17/07
Risk Factors

*Ventilator:       Yes       No

*For NICU only: Birth weight: ____________grams



Event Details

*Specific Event:

                        Clinically defined pneumonia (PNU1)
                        Pneumonia with specific laboratory findings (PNU2)
                        Pneumonia in immunocompromised patients (PNU3)

*Secondary Bloodstream Infection: Yes           No



**Died:      Yes        No                               PNEU Contributed to Death:          Yes        No

Discharge Date:                                          *Pathogens Identified:            Yes     No

                                                              *If Yes, specify on page 2

				
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