mouth care guideline intensive care/high dependency stream icu education collaborative group august...
TRANSCRIPT
Mouth CareGuideline
Intensive Care/High Dependency Stream
ICU Education Collaborative Group
August 2011Reviewed November 2012
Why is Oral Health important in ICU??
• Poor oral health may increase the risks of serious complications in Critically Ill Patients.
– Ventilator associated pneumonia is a major source of morbidity and mortality in the ICU.
– During periods of critical illness mouth care is sometimes relegated to a lower priority and often forgotten.
• What are some of the barriers to proper oral care in ICU???• An intact oral mucosa, like our skin is an effective barrier to
microbes
Why is Oral Health important in ICU??
• Dental plaque provides a breeding ground for respiratory pathogens
• A extracellular matrix• 1mm3 of plaque contains about 100 million bacteria • A resistant layer microorganisms adheres tenaciously to
teeth surfaces.
• Potential association between pathogenic bacteria in the mouth with those identified in the lungs.
• Healthy vs. ICU intubated pt
Oropharynx Colonisation-Pneumonia Pathway
Pathogenesis of VAP
Exogenous microbes Endogenous microbes
What is the current rate of infection?
• Reported mortality rates for VAP range from 24% to 50% – potential higher figures in immunocompromised
patients or when multi-resistant organisms are involved.
– Cost of VAP in the US;• A rise in the cost of care to $ US 10,000 – 40,000 per
case.• With increased mechanical ventilation days & LOS • Difficult to study due to problems with diagnosis.
Consequences of Poor Oral Hygiene
1. Xerostomia 2. Gingivitis3. Mucositis4. Periodontitis5. Candidiasis6. Halitosis
1.
2.
3.4.
5.
Normal Oral Environment• Normal Oral Flora
– Predominately Gram – positive streptococci and dental micro-organisms.
• Functions of Saliva– Lubricates– Buffering Properties– Antimicrobial Properties
• Immunoglobulin A which obstructs microbial adherence• Lactoferrin which inhibits bacterial infection• Fibronectin which blocks pathogenic bacterial attachment to oral
mucous membranes
During Critically Illness• The oral flora shifts dramatically to aerobic Gram –
negative bacilli and staphylococcus aureus within 48hrs of admission.
• Why??• More vulnerable for being colonised with exogenous microbes from
the ICU environment .• Increased severity of illness and length of stay • Patients are on multiple medications causing salivary dysfunction and
xerostomia• Constant opened mouth leading to dry mucus membranes. • Accumulation of dental plaque• A reduction in salivary immune factors such a Immunoglobulin A (IgA)• Increased levels of proteases in their oral secretions causing a
– Depletion of fibronectin exposing tooth surfaces to the attachment of organisms, such as pseudomonas aeruginosa.
Dental Plaque & Biofilms
• If plaque is allowed to grow undisturbed
• Bacterial adherence due to depletion of fibronectin
• Colonisation of the mouth• Changes in oral flora• Micro aspiration of
subglottic secretions.• Increase risk of developing
VAP
What has already been implemented to reduce VAP to date?
Ventilator BUNDLESHead of bed elevation to 30
– 45 degreesDaily ‘sedation vacations’
and assessment of readiness to wean
Peptic ulcer prophylaxisDVT ProphylaxisOral care with Chlorhexidine
GuidelinesGeneral
– Ventilation minimisation• Closed in line suctioning• Weekly circuit changes
– Hand hygieneSpecific
– Prevention of aspiration• Subglottic suctioning• Deep pharyngeal suctioning
– Reduce colonization of oropharyngeal tract
– Prevent contamination of respiratory equipment
HNEAH Mouth Care Guideline
Our aim is;• Maintain mouth moisture • Provide adequate salivary
flow together with
• Control of plaque formation* Through• Mechanical cleansing with a
tooth brush• Chemical cleansing with
Chlorhexidine.
HNEAH Mouth Care Guideline
• The HNEAH Guideline utilizes ;• Comprehensive mouth care assessment• Mouth care intervention plan• Twice daily brushing teeth, gums and tongue using a
soft paediatric toothbrush• Application of 0.2% chlorhexidine gel• Stimulation of the oral mucosa 2 - 4 hourly with a foam
swab to promote salivary flow• Maintain lip moisturizing every 4 hours with white soft
paraffin.
Mouth Care Assessment Tool
Category Rating 1 2 3
Lips 1 2 3 Smooth and pink Dry, cracked or chapped Peeling, split, ulcerated or bleeding
Tongue 1 2 3 Pink, moist and papillae present
Coated or loss of papillae with shinny appearance with or
without redness
Blistered or cracked, heavy coating, thrush or ulcerated
Saliva 1 2 3 Watery Thick or ropy Absent
Mucous Membranes
1 2 3 Pink and moist Reddened or coated (increased whiteness) without
ulcerations
Ulcerations with or without bleeding
Gingiva 1 2 3 Pink and firm Oedematous with or without redness
Spontaneous bleeding or bleeding with pressure
Teeth or Dentures (or denture
bearing area)
1 2 3 Clean and no debris Plaque or debris in localised areas
(between the teeth)
Plaque or debris generalized along gum line or denture
bearing area
MCAT intervention plan
Score 6 – 8 No Oral Dysfunction
VentilatedBD tooth brushing with chlorhexidine
gel 2 -4th hourly mouth moisturising with
water or water soluble mouth moisturiser
Daily MCAT
Non ventilatedBD tooth brushing with toothpaste
4th hourly mouth moisturising with water or water soluble mouth
moisturiser
Daily MCAT
Score 9 – 12 Mild Oral Dysfunction
BD tooth brushing with chlorhexidine gel
2nd hourly mouth moisturising with Sodium Bicarbonate swabs
Daily MCAT
BD tooth brushing with toothpaste
2nd hourly mouth moisturising with Sodium Bicarbonate swabs
Daily MCAT
Score 13 – 18 Moderate to SevereOral Dysfunction
Consider medical review
(e.g. Ulcerated areas and thrush)
BD tooth brushing with chlorhexidine gel
2nd hourly mouth moisturising with Sodium Bicarbonate swabs
Daily MCAT
BD tooth brushing with toothpaste
2nd hourly mouth moisturising with Sodium Bicarbonate swabs
Daily MCAT
Note
Patients with mucositis require medical review. Chlorhexidine is replaced with Sodium Bicarbonate and bland rinses ( ie Cetylpyridium Chloride or 1.5% Hydrogen Peroxide).
For patients’ ventilated for greater than 14 days tooth brushing with Chlorhexidine gel should be reduced to once a day and replaced with tooth brushing with water or mouth moisteriser.
What is the Evidence say ???
Consensus – Based Clinical Guideline
Tooth brushing
• Dental plaque is a very thick biofilm and requires the mechanical action of cleaning with a toothbrush.– Mouthwashes alone will NOT eliminate dental plaque
formation.– Biofilm protects bacteria against chemical agents such as
chlorhexidine
• Foam swabs do not remove plaque• Pearson (2006) showed the elimination of dental
plaque was more effective using a toothbrush than foam swab.
Denture Care• NB: Remove partial or full dentures from a ventilated patient and do not reinsert until patient is
extubated • For non-ventilated patients remove dentures prior to daily assessment as per Oral Hygiene Care
HNELHD CP11_35
• For all patients with dentures:
• Clean the palate, teeth, gums and tongue with a soft toothbrush or mouth swab• Inspect oral cavity as per MCAT (irritated or broken areas may indicate a poor fitting denture)• If available use patient’s own denture tooth brush and toothpaste to clean dentures with warm water
over a basin – Use only moderate pressure to prevent scratches– Rinse dentures thoroughly
• Dentures should be stored, cleaned and labelled in a denture container filled with water to prevent dentures drying out, shrinking or changing shape. This water needs to be changed every 24hrs and the storage container cleaned regularly to prevent growth of microorganisms
• To remove stains and hardened deposits, add warm water and denture cleaner (patient to supply)• Clean toothbrush thoroughly and store in a clean container separate from other personal hygiene
products.
Chlorhexidine Gluconate (CHG)
• Is an antiplaque agent with potent antimicrobial activity
• CHG binds to oral surfaces and released over time
• Chemically active on tissues for up to 6 – 12 hrs• BUT depends on adherence to CLEAN oral surfaces• Mechanical cleansing with toothbrush is recommended
first.
Chlorhexidine What's The Evidence??
• The evidence for the BEST solution is varied.• Two meta-analysis (Chan & Pineda) looking at
CHG– reported that although CHG may reduce the incidence
of VAP, it doesn’t reduce the time on the ventilator or lower mortality rates.
• A study by DeRiso and colleagues(1996)– showed a reduced number of respiratory infections
by 69% after applying CHG in post op cardiothoracic patients.
Chlorhexidine Gluconate (CHG)
• A study by Tantipong and colleagues showed– That oral decontamination with a higher
concentration of 2% CHG is more effective in preventing VAP than with a lower concentration.
– 9.8% of patients developed irritation of the oral mucosa.
• Adverse effects• Discolouration of the teeth & tongue• Alterations in taste perception• Increase calculus formation
Sodium Bicarbonate
• Is an odour absorber & acid neutraliser• Dissolves mucus and loosen oral debris• Neutralises plaque acids and is a natural
buffer• Breaks up plaque & inhibits the attachment to
tooth surfaces.• Recommended for Mucositis
Moisturizers
• A moisturizer should be used on the lips and inside the mouth to prevent drying and cracking
• Petroleum – based moisturizers should be avoided because they cause inflammation if open wounds are present
• Water – based moisturizers are preferred as such products are easily absorbed by the skin and provide additional hydration.
In Summary– Comprehensive mouth care
assessment with MCAT intervention plan
– Twice daily brushing teeth, with chlorhexidine gel
– Stimulation of the oral mucosa 2th hourly with a foam swab to promote salivary flow
– Maintain lip moisturizing every 4 hours with water soluble gel.
In Summary
References• Berry, A. Davidson, P., Masters, J., & Rolls, K. Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients
Receiving Mechanical Ventilation. American Journal Of Critical Care, 2007; Vol 16, No6, 552 -562.• Berry, A ., Davidson, P., Masters, J., Rolls, K., & Ollerton, R. (2010) “Effects of Three Approaches to Standardized Oral Hygiene to Reduce
Bacterial Colonisation and VAP in Mechanically Ventilated Patients: A Randomised Control Trial”, International Journal o Nursing Studies In print
• Browne, J., Evans, D., Christmas, L., & Rodriguez, M. (2011) “Pursuing Excellence: Development of an Oral Hygiene Protocol for Mechanically Ventilated Patients”, Critical Care Nursing Quarterly , Vol 34, No 1, pp 25 -30.
• Blot,S., Vandijck,D.,& Labeau, S. (2008) “Oral Care of Intubated Patients”, Clinical Pulmonary Medicine Vol.15, Number 3, pp 153 - 160.• Garcia,R., (2005) “ A review of the possible role of oral and dental colonisation on the occurrence of health care – associated
pneumonia: Underappreciated risk and a call for interventions” American Journal of Infection Control, Vol33, No9,pp 527 – 540.• Hutchins,K., Karras, G., Erwin, J., & Sullivan, K. (2008) “Ventilator – associated pneumonia and oral care : A successful quality
improvement project”. American Journal of Infection Control, Vol37, No7, pp 590 – 597.• ICCMU Consensus-based Clinical Guideline for the Provision of Oral Care for theCritically Ill Adult
intensivecare.hsnet.nsw.gov.au/five/doc/intensive%20care%20collaborative%20guidelines/8%20%20Final%20oral%20guideline%20December%205_1.pdf
• Monro, C.L., Grap, M. Elswick, R. & McKinney,J, (2006) Oral Health Status and Development of Ventilated Associated Pneumonia: a descriptive study. American Journal Of Critical Care Vol15, No4, 453 – 460.
• Paji, S., & Scannapieco, F. (2007) “Oral Biofilms, Periodontitis and Pulmonary Infections”. Oral Disease Journal, Vol 13, No6, pp508 -512.• Pear, S. Oral Care is Critical Care: The Role of Oral Care in the Prevention of Hospital –Acquired Pneumonia. Infection Control Today,
2007; Vol11, No 10.• Safdar, N., Crnich, C., & maki, D. (2005) “ The Pathogenesis of Ventilator – Associated Pneumonia: Its relevance to Developing Effective
Strategies for Prevention, Respiratory Care , Vol 50, No6, pp 725 – 741.• Stonecypher, K. (2010)” Ventilator – Associated Pneumonia: The Importance of Oral Care in Intubated Patients”, Critical Care Nursing
Quarterly , Vol 33, No 4, pp 339 – 347.