Nursing care and epidemiological profile of patients with ventilator-associated pneumonia / Cuidados de enfermagem e perfil epidemiológico de pacientes com pneumonia associada à ventilação mecânica / Cuidados de enfermería y perfil epidemiológico de pacientes con neumonía asociada a ventilador

Background and Objectives: to assess the epidemiological profile of patients diagnosed with ventilator-associated pneumonia (VAP) in an Intensive Care Unit (ICU) and to investigate nursing care adequacy. Methods: a quantitative retrospective cohort study, applied in the ICU of a hospital in the countryside of Rio Grande do Sul. It involved 100% of medical records of patients over 20 years of age, in the year 2019, who developed VAP. Results: a total of 3,215 patients were on invasive mechanical ventilation (IMV), and of these 13 developed VAP (2.47%). Most were men (76.92%), with a mean age of 60.3 years, whose main causes of hospitalization were heart problems (30.77%), multiple trauma (30.77%) and stroke (15.39%). The main pathogens found in tracheal aspirates were Acinetobacter sp. (15%) and Pseudomonas aeruginosa (15%). The mean ICU stay was 30.61 days, and 61.53% died. For nursing care assessment, the mean checklist of the VAP bundle applied was calculated, according to the number of days in VMI. The result was 2.62 checklists per day, with the institution recommending four. Conclusion: the study made it possible to know the epidemiological profile of patients with VAP, in addition to observing the need for improvement in nursing care, considering that the checklist completion was below the recommended.(AU)

Justificativa e Objetivos: avaliar o perfil epidemiológico de pacientes diagnosticados com pneumonia associada à ventilação mecânica (PAVM) em Unidade de Terapia Intensiva (UTI) e investigar a adequação dos cuidados de enfermagem. Métodos: estudo quantitativo de coorte, retrospectivo, aplicado na UTI de um hospital do interior do Rio Grande do Sul. Envolveu 100% dos prontuários de pacientes com mais de 20 anos de idade, no ano de 2019, que desenvolveram PAVM. Resultados: estiveram em ventilação mecânica invasiva (VMI) 3.215 pacientes e, desses, 13 desenvolveram PAVM (2,47%). A maioria era homens (76,92%), com média de idade de 60,3 anos, cujas principais causas de internação foram problemas cardíacos (30,77%), politraumatismo (30,77%) e acidente vascular cerebral (15,39%). Os principais patógenos encontrados nos aspirados traqueais foram Acinetobacter sp (15%) e Pseudomonas aeruginosa (15%). A média de permanência na UTI foi de 30,61 dias, e foram a óbito 61,53%. Para avaliação dos cuidados de enfermagem, foi calculada a média de checklist do bundle de PAVM, aplicados, conforme a quantidade de dias em VMI. O resultado foi de 2,62 checklists por dia, sendo que a instituição preconiza quatro. Conclusão: o estudo permitiu conhecer o perfil epidemiológico dos pacientes com PAVM, além de observar a necessidade de melhora nos cuidados de enfermagem, considerando que a realização do checklist ficou abaixo do recomendado.(AU)

Justificación y Objetivos: evaluar el perfil epidemiológico de pacientes con diagnóstico de neumonía asociada a ventilación mecánica (NAVM) en una Unidad de Cuidados Intensivos (UCI) e investigar la adecuación de los cuidados de enfermería. Métodos: estudio de cohorte cuantitativo, retrospectivo, aplicado en el UCI de un hospital del interior de Rio Grande do Sul. Involucró el 100% de las historias clínicas de pacientes mayores de 20 años, en el año 2019, que desarrollaron NAVM. Resultados: un total de 3.215 pacientes estaban en ventilación mecánica invasiva (VMI), y, de estos, 13 desarrollaron NAVM (2,47%). La mayoría eran hombres (76,92%), con una edad media de 60,3 años, cuyas principales causas de hospitalización fueron problemas cardíacos (30,77%), politraumatismos (30,77%) y accidentes cerebrovasculares (15,39%). Los principales patógenos encontrados en los aspirados traqueales fueron Acinetobacter sp (15%) y Pseudomonas aeruginosa (15%). La estancia media en UCI fue de 30,61 días, y falleció el 61,53%. Para la evaluación de la atención de enfermería, se calculó el checklist promedio del bundle VAP aplicado, de acuerdo con el número de días en VMI. El resultado fue de 2,62 checklists por día, y la institución recomendó cuatro. Conclusión: el estudio posibilitó conocer el perfil epidemiológico de los pacientes con NAVM, además de observar la necesidad de mejoría en la atención de enfermería, considerando que el llenado del checklist estuvo por debajo de lo recomendado.(AU)

Resultados de la asincronía ventilatoria en pacientes con esfuerzo inspiratório / Outcomes of ventilatory asynchrony in patients with inspiratory effort

RESUMO Objetivo: Identificar la relación de la asincronía paciente-ventilador con el nivel de sedación y evaluar la asociación con los resultados hemogasométricos y clínicos. Métodos: Estudio prospectivo de 122 pacientes admitidos en la unidad de cuidados intensivos con > 24 horas de ventilación mecánica invasiva y esfuerzo inspiratorio. En los primeros 7 días de ventilación, diariamente se evaluó la asincronía paciente-ventilador durante 30 minutos. La asincronía paciente-ventilador severa se definió con un índice de asincronía > 10%. Resultados: Se evaluaron 339.652 ciclos respiratorios en 504 observaciones. La media del índice de asincronía fue 37,8% (desviación estándar 14,1% - 61,5%). La prevalencia de asincronía paciente-ventilador severa fue 46,6%. Las asincronías paciente-ventilador más frecuentes fueron: trigger ineficaz (13,3%), auto-trigger (15,3%), flujo insuficiente (13,5%) y ciclado demorado (13,7%). La asincronía paciente-ventilador severa se relacionó con el nivel de sedación (trigger ineficaz: p = 0,020; flujo insuficiente: p = 0,016; ciclado precoz: p = 0,023) y el uso de midazolam (p = 0,020). La asincronía paciente-ventilador severa se asoció con las alteraciones hemogasométricas. La persistencia de la asincronía paciente-ventilador severa fue un factor de riesgo independiente para fracaso en la prueba de ventilación espontánea, tiempo de ventilación, neumonía asociada al ventilador, disfunción de órganos, mortalidad en la unidad de cuidados intensivos y estadía en la unidad de cuidados intensivos. Conclusión: La asincronía paciente-ventilador es un trastorno frecuente en los pacientes críticos con esfuerzo inspiratorio. La interacción del paciente con el ventilador debe optimizarse para mejorar los parámetros hemogasométricos y los resultados clínicos. Se requieren otros estudios que confirmen estos resultados.

Abstract Objective: To identify the relationship of patient-ventilator asynchrony with the level of sedation and hemogasometric and clinical results. Methods: This was a prospective study of 122 patients admitted to the intensive care unit who underwent > 24 hours of invasive mechanical ventilation with inspiratory effort. In the first 7 days of ventilation, patient-ventilator asynchrony was evaluated daily for 30 minutes. Severe patient-ventilator asynchrony was defined as an asynchrony index > 10%. Results: A total of 339,652 respiratory cycles were evaluated in 504 observations. The mean asynchrony index was 37.8% (standard deviation 14.1 - 61.5%). The prevalence of severe patient-ventilator asynchrony was 46.6%. The most frequent patient-ventilator asynchronies were ineffective trigger (13.3%), autotrigger (15.3%), insufficient flow (13.5%), and delayed cycling (13.7%). Severe patient-ventilator asynchrony was related to the level of sedation (ineffective trigger: p = 0.020; insufficient flow: p = 0.016; premature cycling: p = 0.023) and the use of midazolam (p = 0.020). Severe patient-ventilator asynchrony was also associated with hemogasometric changes. The persistence of severe patient-ventilator asynchrony was an independent risk factor for failure of the spontaneous breathing test, ventilation time, ventilator-associated pneumonia, organ dysfunction, mortality in the intensive care unit, and length of stay in the intensive care unit. Conclusion: Patient-ventilator asynchrony is a frequent disorder in critically ill patients with inspiratory effort. The patient's interaction with the ventilator should be optimized to improve hemogasometric parameters and clinical results. Further studies are required to confirm these results.

Characterization of post-surgical critical patients with infections associated with healthcare after prolonged perfusion of remifentanil

SUMMARY INTRODUCTION Healthcare associated infections (HAI) are the most frequent complication of hospitalized patients. The aim of this study was to describe the clinical and epidemiological characteristics of critically ill post-surgical patients with a diagnosis of healthcare associated infections, after a pattern of sedoanalgesia of at least 4 days. METHODS All patients over 18 years of age with a unit admission of more than 4 days were consecutively selected. The study population was the one affected by surgical pathology where sedation was based as analgesic the opioid remifentanil for at least 96 hours in continuous perfusion. Patients who died during admission to the unit and those with combined analgesia (peripheral or neuroaxial blocks) were excluded. Data analysis was performed using the statistical package Stata version 7.0. RESULTS The patients admitted to the Post-Surgical Critical Care Unit (PCU) during study were 1789 and the population eligible was comprised of 102 patients. 56.86% of patients suffered IACS. The most frequent IACS was pneumonia associated with mechanical ventilation (30.96 per 1000 days of mechanical ventilation), Pseudomonas aeruginosa being the most frequently isolated germ. The germs with the greatest involvement in multiple drug resistance (MDROs) were enterobacteria, mainly Klebsiella pneumoniae resistant to extended-spectrum beta-lactamases (ESBL). CONCLUSIONS Pneumonia associated with mechanical ventilation is the most prevalent HAI and Pseudomonas aeruginosa is the main etiological agent. The groups of antibiotics most frequently used were cephalosporin and aminoglycosides. It is necessary to implement the prevention strategies of the different HAI, since most of them are avoidable.

RESUMO INTRODUCCIÓN Las infecciones asociadas a cuidados de salud (IACS) constituyen la complicación más frecuente de los pacientes hospitalizados. El objetivo de este estudio es describir las características clínicas y epidemiológicas de los pacientes críticos postquirúrgicos con diagnóstico de infección asociada a cuidados de salud, tras una pauta de sedoanalegia de al menos 4 días. MÉTODOS Se seleccionaron de manera consecutiva todos los pacientes mayores de 18 años con un ingreso en la Unidad de Reanimación Postquirúrgica (URP) superior a 4 días. La población de estudio fue aquella afectada por patología quirúrgica de cualquier origen donde la sedación se basó en cualquier hipnótico y como analgésico el opioide remifentanilo durante al menos 96 horas en perfusión continua. Se excluyeron los pacientes que fallecieron durante su ingreso en la unidad y aquellos pacientes con analgesia combinada (bloqueos periféricos o neuroaxiales). El análisis de los datos se realizó con paquete estadístico Stata versión 7.0. RESULTADOS El número de pacientes que ingresaron en la URP durante el periodo de estudio fueron de 1789. Tras aplicar los criterios de inclusión y exclusión, la población elegible quedó constituida por 102 pacientes. Un 56,86% de pacientes padecieron IACS. La IACS más frecuente fue la neumonía asociada a ventilación mecánica (30,96 por 1000 días de ventilación mecánica) siendo Pseudomona aeruginosa el germen más frecuentemente aislado. Los gérmenes con mayor implicación en las multirresistencias (MDROs) fueron las enterobacterias, principalmente Klebsiella pneumoniae resistente a betalactamasas de espectro extendido (BLEE). CONCLUSIONES La neumonía asociada a ventilación mecánica es la IACS más prevalente y Pseudomona aeruginosa es el principal agente etiológico. Los grupos de antibióticos más frecuentemente empleados fueron cefalosporinas y aminoglucósidos. Es necesario implementar las estrategias de prevención de las distintas IACS, ya que la mayoría de ellas son evitables.

Pneumonia associada à ventilação mecânica: fatores de risco / Ventilator-associated pneumonia: risk factors

JUSTIFICATIVA E OBJETIVOS: É importante conhecer os fatores de risco para o desenvolvimento de pneumonia associada à ventilação mecânica (PAVM) em cada unidade de atendimento, visando programar ações preventivas. O objetivo deste estudo foi descrever e analisar características epidemiológicas, clínicas, laboratoriais e fatores de risco em PAVM. MÉTODO: Foi realizado um estudo de coorte em indivíduos acimade 18 anos internados em unidade de terapia intensiva (UTI) e submetidos à ventilação mecânica (VM). Foram considerados casos de PAVM aqueles com pelo menos um critério de cada item: temperatura > 38º C ou < 35º C, leucócitos no sangue < 4.000/mm3 ou > 11.000/mm3, aumento da secreção traqueal ou purulência, nova lesão radiológica ou piora de lesão. RESULTADOS: Foram avaliados 59 indivíduos, 72,9% do sexo masculino, média de idade de 56,1 ± 19,9 anos, dos quais 25,4% preencheram critérios para PAVM. Houve efeito protetor do uso prévio de antimicrobianos (p = 0,000; RR 0,207; IC 95% 0,085-0,481). Houve diferença significativa entre a média de leucócitos de indivíduos com e sem PAVM (p = 0,010). Mostraram-se fatores independentes para tempo de internação na UTI, o sexo masculino (p = 0,028), e comorbidade (p = 0,014). Mostraram-se fatores independentes para o óbito a presença de PAVM (p =0,033), comorbidade (p = 0,023) e traqueostomia (p = 0,002). Mostraram-se fatores independentes para PAVM, a presença de traqueostomia (p = 0,016), e, para ausência de PAVM, uso prévio de antimicrobianos (p = 0,029). CONCLUSÃO: A incidência de PAVM foi de 25,4%. Entre os possíveis fatores de risco somente a traqueostomia foi correlacionada com PAVM. A antibioticoterapia diminuiu risco de PAVM.

BACKGROUND AND OBJECTIVES: It's important to know the risk factors for developing ventilator-associated pneumonia (VAP) in each service unit, in order to implement preventive actions. The aim of this study was to describe and analyze the epidemiological,clinical, laboratory, and risk factors of VAP. METHOD: We conducted a cohort study in individuals over 18 years in the intensive care unit (ICU) undergoing mechanical ventilation. Cases of VAP were considered those with at leastone criterion for each item: temperature > 38º C or < 35º C, leukocytes in peripheral blood < 4.000/mm3 or > 11.000/mm3, increased or purulent tracheal secretions, new or worsening ches tradiographic lesion injury. RESULTS: We studied 59 subjects, 72.9% male, mean age 56.1 years, of which 25.4% met criteria for VAP. There was a protectiv eeffect of previous use of antimicrobials (p = 0.000, RR 0.207,95% CI 0.085 to 0.481). There was a significant difference between the average of leukocytes between subjects with and without VAP (p = 0.010). Were independent factors for length of stayin ICU, male gender (p = 0.028) and comorbidity (0.014). Were independent factors for the outcome death the presence of VAP (p = 0.033), presence of comorbidity (p = 0.023) and tracheostomy (p = 0.002). Were independent factors for the presence of VAP, the presence of tracheostomy (p = 0.016), and absence of VAP, prior antibiotic use (p = 0.029). CONCLUSION: Tracheostomy proved to be an independent factor for the presence of VAP and prior antibiotic use for the absence of VAP. The incidence of VAP was 25.4%.

Pneumonia associada à ventilação mecânica: epidemiologia e impacto na evolução clínica de pacientes em uma unidade de terapia intensiva / Ventilator-associated pneumonia: epidemiology and impact on the clinical evolution of ICU patients

OBJETIVO: Apesar de representar uma das principais causas de infecção nosocomial, o papel da pneumonia associada à ventilação mecânica (PAVM) no prognóstico ainda permanece indefinido. O objetivo deste estudo foi avaliar o impacto dessa doença na evolução clínica dos pacientes. MÉTODOS: Estabeleceu-se uma coorte prospectiva de 233 pacientes sob ventilação mecânica (grupo PAV, n = 64; grupo controle, n = 169). Os desfechos primários foram tempo de ventilação mecânica (TVM), tempo de permanência na UTI (TUTI), tempo de permanência hospitalar (TH) e mortalidade na UTI. Os desfechos secundários foram mortalidade hospitalar, perfil microbiológico, uso prévio de antibióticos e fatores de risco para PAVM. RESULTADOS: Os desfechos dos grupos controle e PAVM foram, respectivamente, os seguintes: mediana do TVM (dias), 9 (intervalo interquartílico [II]: 5-15) e 23 (II: 15-37; p < 0,0001); mediana do TUTI (dias), 12 (II: 8-21) e 27 (II: 17-42; p < 0,0001); mediana do TH (dias), 33 (II: 18-64) e 46 (II: 25-90; p = 0,02); e mortalidade na UTI, 38 por cento (IC95 por cento: 31-45) e 55 por cento (IC95 por cento: 42-67; p = 0,02). A PAVM foi um preditor de mortalidade na UTI (OR = 3,40; IC95 por cento: 1,54-1,78). O TVM (OR = 2,27; IC95 por cento: 1,05-4,87) e o uso prévio de antibióticos (OR = 1,07; IC95 por cento: 1,04-1,10) foram fatores de risco para PAVM. A PAVM não afetou a mortalidade hospitalar. Acinetobacter spp. foi o isolado mais frequente (28 por cento). Antibioticoterapia empírica inadequada foi administrada em 48 por cento dos casos. CONCLUSÕES: No presente estudo, houve uma alta incidência de bactérias resistentes e de antibioticoterapia inicial inadequada. TVM longo e o uso prévio de antibióticos são fatores de risco para PAVM.

OBJECTIVE: Although ventilator-associated pneumonia (VAP) is a major cause of nosocomial infection, its role in the prognosis of patients remains undefined. The objective of this study was to evaluate the impact of VAP on the clinical evolution of patients. METHODS: This was a prospective cohort study involving 233 patients on mechanical ventilation (VAP group, n = 64; control group, n = 169). Primary outcomes were time on mechanical ventilation (TMV), time in ICU (TICU), overall length of hospital stay (LHS) and in-ICU mortality. Secondary outcomes were in-hospital mortality, microbiological profile, prior use of antibiotics and risk factors for VAP acquisition. RESULTS: Control and VAP group outcomes were, respectively, as follows: median TMV (days), 9 (interquartile range [IQR]: 5-15) and 23 (IQR: 15-37; p < 0.0001); median TICU (days), 12 (IQR: 8-21) and 27 (IQR: 17-42; p < 0.0001); median LHS (days), 33 (IQR: 18-64) and 46 (IQR: 25-90; p = 0.05); and in-ICU mortality, 38 percent (95 percent CI: 31-45) and 55 percent (95 percent CI: 42-67; p = 0.02). VAP was a predictor of in-ICU mortality (OR = 3.40; 95 percent CI: 1.54-7.48). TMV (OR = 2.27; 95 percent CI: 1.05-4.87) and prior use of antibiotics (OR = 1.07; 95 percent CI: 1.04-1.10) were risk factors for VAP. VAP did not affect in-hospital mortality. Acinetobacter spp. was the most common isolate (28 percent). Inappropriate empirical antibiotic therapy was administered in 48 percent of cases. CONCLUSIONS: In this study, there was a high incidence of infection with resistant bacteria and inappropriate initial antibiotic therapy. Long TMV and prior use of antibiotics are risk factors for VAP.

Ventilator-associated pneumonia in an adult clinical-surgical intensive care unit of a Brazilian university hospital: incidence, risk factors, etiology, and antibiotic resistance

The objective of this study was to evaluate clinical characteristics, etiology, and resistance to antimicrobial agents, among patients with ventilator-associated pneumonia (VAP). A case study vs. patients control under mechanical ventilation and hospitalized into clinical-surgical adults ICU of HC-UFU was performed from March/2005 to March/2006. Patients under ventilation for over 48 h were included in the study including 84 with diagnosis of VAP, and 191 without VAP (control group). Laboratory diagnosis was carried out through quantitative microbiological evaluation of tracheal aspirate. The identification of pathogens was performed by classical microbiological tests, and the antibiotics sensitivity spectrum was determined through the CLSI technique. VAP incidence rate over 1,000 days of ventilation was 24.59. The mean (± SD) duration of mechanical ventilation prior to VAP diagnosis was 23.2 ± 17.2 days. By multivariate analysis the risk factors predisposing for VAP were: mechanical ventilation time and mechanical ventilation > seven days, tracheostomy and use of > three antibiotics. Mortality rate was high (32.1 percent) but lower than that of the control group (46.5 percent). Major pathogens were identified in most of patients (95.2 percent) and included: Pseudomonas aeruginosa (29 percent), Staphylococcus aureus (26 percent), Enterobacter/Klebsiella/Serratia (19 percent) and Acinetobacter spp. (18 percent), with expressive frequencies of P. aeruginosa (52 percent), S. aureus (65.4 percent) and Enterobacteriaceae (43.7 percent) resistant to imipenem, oxacillin and 3/4 generation cephalosporins, respectively. In conclusion, our observation showed VAPs caused by multiresistant microorganisms, the prescription of > three antibiotics, and mortality with unacceptably high rates. The practice of de-escalation therapy appears to be urgently needed in order to improve the situation.

Prevalência e prognóstico dos pacientes com pneumonia associada à ventilação mecânica em um hospital universitário / Prevalence of ventilator-associated pneumonia in a university hospital and prognosis for the patients affected

OBJETIVO: Determinar prevalência de pneumonia associada à ventilação mecânica em unidade de terapia intensiva, fatores associados e evolução. MÉTODOS: Foram avaliados 278 pacientes sob ventilação mecânica por mais de 24 horas prospectivamente em hospital universitário. RESULTADOS: Desenvolveram a doença 38,1 por cento dos pacientes, 35,7 casos/1.000 dias de ventilação mecânica: 45,3 por cento por bacilos gram negativos, Pseudomonas aeruginosa (22 por cento) o mais comum e 43,4 por cento por germes multi-resistentes. O grupo com pneumonia associada à ventilação mecânica teve maiores tempos de ventilação mecânica, desmame, permanência no hospital e na unidade de terapia intensiva (p < 0,001); atelectasia, síndrome do desconforto respiratório agudo, pneumotórax, sinusite, traqueobronquite e infecção multirresistente foram mais comuns (p < 0,05). Letalidades na unidade de terapia intensiva e no hospital foram semelhantes. Fatores associados à doença (razão de chances; intervalo de confiança 95 por cento): sinusite aguda (38,8; 3,4 - 441), ventilação mecânica >10 dias (7,7; 4,1 - 14,2), imunodepressão (4,3; 1,3 - 14,3), síndrome do desconforto respiratório agudo (3,5; 1,4 - 9,0), atelectasia (3,0; 1,2 - 7,3), parada cardiorrespiratória (0,18; 0,05 - 0,66) e hemorragia digestiva alta (0,07; 0,009 - 0,62]. Fatores associados ao óbito hospitalar: insuficiência renal crônica (26,1; 1,9 - 350,7), admissão prévia na unidade de terapia intensiva (15,6; 1,6 - 152,0), simplified acute physiologic score II > 50 pontos (11,9; 3,4 - 42,0) e idade > 55 anos (4,4; 1,6 - 12,3). CONCLUSÃO: A pneumonia associada à ventilação mecânica aumentou tempos de ventilação mecânica, permanência na unidade de terapia intensiva e no hospital, número de complicações, mas não a letalidade.

OBJECTIVE: To determine the prevalence of ventilator-associated pneumonia in an intensive care unit, as well as to identify related factors and characterize patient evolution. METHODS: This study evaluated 278 patients on mechanical ventilation for more than 24 hours in a university hospital. RESULTS: Ventilator-associated pneumonia developed in 38.1 percent of the patients, translating to 35.7 cases/1000 ventilator-days: 45.3 percent were caused by gram-negative agents (Pseudomonas aeruginosa accounting for 22 percent); and multidrug resistant organisms were identified in 43.4 percent. In the ventilator-associated pneumonia group, time on mechanical ventilation, time to mechanical ventilation weaning, hospital stays and intensive care unit stays were all longer (p < 0.001). In addition, atelectasis, acute respiratory distress syndrome, pneumothorax, sinusitis, tracheobronchitis and infection with multidrug resistant organisms were more common in the ventilator-associated pneumonia group (p < 0.05). Mortality rates in the intensive care unit were comparable to those observed in the hospital infirmary. Associations between ventilator-associated pneumonia and various factors are expressed as odds ratios and 95 percent confidence intervals: acute sinusitis (38.8; 3.4-441); > 10 days on mechanical ventilation (7.7; 4.1-14.2); immunosuppression (4.3; 1.3-14.3); acute respiratory distress syndrome (3.5; 1.4-9.0); atelectasis (3.0; 1.2-7.3); cardiac arrest (0.18; 0.05-0.66); and upper gastrointestinal tract bleeding (0.07; 0.009-0.62). The variables found to be associated with in-hospital death were as follows: chronic renal failure (26.1; 1.9-350.7); previous intensive care unit admission (15.6; 1.6-152.0); simplified acute physiologic score II > 50 (11.9; 3.4-42.0); and age > 55 years (4.4; 1.6-12.3). CONCLUSION: Ventilator-associated pneumonia increased the time on mechanical ventilation and the number of complications, as well as the length...