Procedimento Operacional Padrão (POP) de higiene bucal na prevenção de pneumonia associada à ventilação mecânica - PAVM, em Unidade de Terapia Intensiva: Estudo não randomizado, aberto, com avaliador cego.
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Data
2019-07-30
Autores
De Luca, Fernando Augusto
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Universidade Estadual Paulista (Unesp)
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Introdução: Um dos problemas relacionados à internação em Unidades de Terapia Intensiva (UTI), diz respeito à condição bucal dos pacientes. Falta ou deficiência de higiene bucal podem levar a quadros de infecção por microrganismos patogênicos, sendo a principal delas, a pneumônica associada à ventilação mecânica (PAVM). Procedimentos Operacionais Padrão - POP de higiene bucal nem sempre são seguidos à risca, além de não contarem, na maioria das vezes, com a participação de cirurgião dentista em suas elaborações. Diante desse quadro, o objetivo desse trabalho é a criação de novo protocolo de higiene bucal para pacientes internados e intubados no Serviço de Terapia Intensiva (SETI) do Hospital das Clínicas da Faculdade de Medicina de Botucatu – UNESP e avaliar seu impacto na prevenção de PAVM. Materiais e métodos: Foram estudados 72 pacientes divididos em dois grupos: estudo, internados na Ala 1 do SETI, e controle, internados na ala 2 do SETI. Critérios de inclusão: pacientes em ventilação mecânica a no máximo 24 horas e que permaneceram nessa condição por período mínimo de 96 horas, idade mínima de 18 anos. Critérios de exclusão: neoplasias sob quimioterapia, imunossuprimidos, extubação (voluntária ou não) ou óbito antes do prazo mínimo de 96 horas. No grupo de estudo, foi realizada higiene bucal com clorexidina 0,12% líquida, 2 X dia, de acordo com o procedimento operacional padrão desenvolvido; no grupo controle, a higiene bucal foi realizada de acordo com o procedimento operacional padrão existente no Hospital das Clínicas para pacientes internados no SETI. Nos dois grupos, foram colhidos material microbiológico dos pacientes, da porção mais posterior da língua em contato com o tubo oro traqueal, com swab estéril, no 1º e 4º dias de intubação. O diagnóstico de PAVM foi realizado e entregue para utilização do estudo pela Comissão de Controle de Infecção Relaciona à Assistência à Saúde (CCIRAS). Na análise estatística foram utilizados, para proporções, o teste estatístico Chi Quadrado e, para comparações médias, o t-Student; para significância foi utilizado p < 0,05. Resultados: A PAVM ocorreu em 12 pacientes, sendo 4 no grupo de estudo (33,33%) e 8 no grupo controle (66,67%). Apesar da forte tendência na diminuição da incidência de PAVM, não houve significância estatística (p = 0,2059). O total de óbitos foi de 32, sendo17 no grupo de estudo (47,22%) e 15 no grupo controle (41,67%), sem significância estatística (p = 0,6353). O tempo de internação em UTI, entre os grupos, foi de 15,06 +- 9,88 dias no grupo de estudo contra 15,25 +- 8,34 dias no grupo controle, sem significância estatística (p = 0,9284). O tempo de ventilação mecânica entre os grupos foi de 10,0 +- 4,72 dias no grupo de estudo e 10,5 +- 4,42 dias no grupo controle, sem significância estatística (p = 0,6441). Conclusão: Os resultados mostram forte tendência na diminuição de eventos de PAVM entre os grupos de estudo e controle, apenas lançando mão de escovação dental com solução de clorexidina a 0,12% e higienização oral padronizada.
Introduction: One of the problems related to hospitalization in Intensive Care Units (ICU) is the patients' oral condition. Absence or deficiency of oral hygiene may lead to infection by pathogenic microorganisms, the main one being ventilator-associated pneumonia (VAP). Oral hygiene standard operating procedures are not always followed to the letter, and in most cases, dental surgeon do not participate in its elaborations. In view of this situation, the objective of this work is the creation of a new oral hygiene standard operational procedure for hospitalized and intubated patients at the Intensive Care Unit of the Hospital das Clínicas of Botucatu Medical School - UNESP and evaluation of its impact on the prevention of VAP. Materials and methods: We studied 72 patients divided into two groups: study, hospitalized in ICU Ward 1, and control, hospitalized in Ward 2 of the ICU. Inclusion criteria: patients on mechanical ventilation for, at most, 24 hours and who remained in this condition for a minimum period of 96 hours, minimum age of 18 years. Exclusion criteria: neoplasms under chemotherapy, immunosuppressed, extubated (voluntary or not) or death before the minimum period of 96 hours. In the study group, oral hygiene was performed with chlorhexidine 0.12% liquid, 2 times a day, according to the standard operational procedure developed; in the control group, oral hygiene was performed according to the standard operational procedure existing in Hospital das Clínicas for ICU patients. In both groups, the patients' microbiological material was collected from the posterior portion of the tongue in contact with the orotracheal tube, with sterile swab, on the first and fourth days of intubation. The diagnosis of VAP was performed and submitted for use of the study by the Infection Control Commission Related to Health Care (CCIRAS). In the statistical analysis, Chi square statistical test was used for proportion, t-Student for average comparisons and p < 0.05 for significance. Results: VAP occurred in 12 patients, 4 in the study group (33.33%) and 8 in the control group (66.67%). Despite the strong tendency to decrease the incidence of VAP, there was no statistical significance (p = 0.2059). The total number of deaths was 32, 17 in the study group (47.22%) and 15 in the control group (41.67%), with no statistical significance (p = 0.6353). The ICU stay between the groups was 15.06 + - 9.88 days in the study group versus 15.25 + - 8.34 days in the control group, with no statistical significance (p = 0.9284) . The mechanical ventilation time between the groups was 10.0 + - 4.72 days in the study group and 10.5 + - 4.42 days in the control group, with no statistical significance (p = 0.6441). Conclusion: The results show a strong trend in the reduction of VAP events between the study and control groups, only using dental brushing with 0.12% chlorhexidine solution and standard oral hygiene.
Introduction: One of the problems related to hospitalization in Intensive Care Units (ICU) is the patients' oral condition. Absence or deficiency of oral hygiene may lead to infection by pathogenic microorganisms, the main one being ventilator-associated pneumonia (VAP). Oral hygiene standard operating procedures are not always followed to the letter, and in most cases, dental surgeon do not participate in its elaborations. In view of this situation, the objective of this work is the creation of a new oral hygiene standard operational procedure for hospitalized and intubated patients at the Intensive Care Unit of the Hospital das Clínicas of Botucatu Medical School - UNESP and evaluation of its impact on the prevention of VAP. Materials and methods: We studied 72 patients divided into two groups: study, hospitalized in ICU Ward 1, and control, hospitalized in Ward 2 of the ICU. Inclusion criteria: patients on mechanical ventilation for, at most, 24 hours and who remained in this condition for a minimum period of 96 hours, minimum age of 18 years. Exclusion criteria: neoplasms under chemotherapy, immunosuppressed, extubated (voluntary or not) or death before the minimum period of 96 hours. In the study group, oral hygiene was performed with chlorhexidine 0.12% liquid, 2 times a day, according to the standard operational procedure developed; in the control group, oral hygiene was performed according to the standard operational procedure existing in Hospital das Clínicas for ICU patients. In both groups, the patients' microbiological material was collected from the posterior portion of the tongue in contact with the orotracheal tube, with sterile swab, on the first and fourth days of intubation. The diagnosis of VAP was performed and submitted for use of the study by the Infection Control Commission Related to Health Care (CCIRAS). In the statistical analysis, Chi square statistical test was used for proportion, t-Student for average comparisons and p < 0.05 for significance. Results: VAP occurred in 12 patients, 4 in the study group (33.33%) and 8 in the control group (66.67%). Despite the strong tendency to decrease the incidence of VAP, there was no statistical significance (p = 0.2059). The total number of deaths was 32, 17 in the study group (47.22%) and 15 in the control group (41.67%), with no statistical significance (p = 0.6353). The ICU stay between the groups was 15.06 + - 9.88 days in the study group versus 15.25 + - 8.34 days in the control group, with no statistical significance (p = 0.9284) . The mechanical ventilation time between the groups was 10.0 + - 4.72 days in the study group and 10.5 + - 4.42 days in the control group, with no statistical significance (p = 0.6441). Conclusion: The results show a strong trend in the reduction of VAP events between the study and control groups, only using dental brushing with 0.12% chlorhexidine solution and standard oral hygiene.
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Unidades de Terapia Intensiva, pneumonia associada à ventilação mecânica, higiene bucal, clorexidina, POP, PAVM, Intensive Care Units, mechanical ventilation-associated pneumonia, oral hygiene, chlorhexidine, protocols