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Continuous Aspiration of Subglottic Secretions (CASS) in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

¹Clinical Microbiology and Infectious Diseases ²Ciber de Enfermedades Respiratorias (CIBERES) and ³Anesthesiology, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain

ebouza{at}microb.net

Abstract

OBJECTIVEAspiration of endotracheal secretions is a major step in the prevention of Ventilator-Associated Pneumonia (VAP). We compared conventional and Continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS).

MATERIAL AND METHODSRandomized comparison during a 2-year period.

RESULTS714 patients were randomized (24 excluded, 359 CASS and 331 controls).The results for CASS and controls (per protocol and Intention to Treat analysis) were: VAP incidence 3.6% vs 5.3%, P=0.2 and 3.8% vs 5.1%; incidence density: 17.9 vs 27.6/1000 ventilation days(vd), P=0.18 and 18.9 vs 28.7/1000 vd; hospital antibiotic use in daily defined doses (DDD): 1213 vs 1932, P<.001, and 1392 vs 1932, P<.001.

In patients on mechanical ventilation >48h, the comparisons of CASS and controls were: VAP incidence 26.7% vs 47.5%, P=0.04; incidence density 31.5 vs 51.6/1000 vd, P=0.03; median days of ICU stay 7 vs 16.5, P=0.01; hospital antibiotic use in DDD 1206 vs 1877, P<.001; C. difficile-associated diarrhea 6.7 vs 12.5%, P=0.3 and, overall mortality 44.4% vs 52.5%, P=0.3. Reintubation increased the risk of VAP (RR 6.07; 95%CI 2.20-16.60; p<0.001) while CASS was the only significant protective factor (RR 0.40; 95%CI0.16-0.99; p=0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 euros vs 1.5 euros for the conventional tube.

CONCLUSIONSCASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients at risk. CASS use should be encouraged, at least in patients undergoing MHS.

Key Words: Ventilator-associated pneumonia • prevention • subglottic aspiration • major heart surgery • intensive care