Wednesday, June 26, 2013

The Perils Of A Dirty Mouth

Where is the endotracheal tube?
If there is one thing I can count on in the hospital, it is that inpatients will invariably have the most disgusting oropharynx imaginable. This is particularly true for the elderly, the demented, or the ICU patients. While the nurses are busy checking for decubitus ulcers or IV site infections, the mouth is all too frequently neglected. Whenever I have to intubate an inpatient, I will almost certainly encounter detritus collecting just above the vocal cords. I'm talking about filth like dried phlegm, old blood, or leftover food bits either from poor swallowing ability or regurgitation. And don't ask me about the severe halitosis that comes with all this decaying matter.

It is well known that poor oral hygiene leads to a higher risk of pneumonia. Ventilator associated pneumonia is the second most common nosocomial infection in the ICU. VAP is estimated to occur in 250,000 to 300,000 patients per year in the country. It prolongs a patient's ICU stay and increases the cost of patient care by an estimated $20,000.

The American Association of Critical Care Nurses even has a guideline for how to perform proper oral care in the ICU patient. This includes twice daily brushing of the teeth and oral and lip moisturizers every two to four hours. Yet I have never, EVER, seen an ICU nurse brushing a patient's teeth.

The picture above is of an unfortunate patient that I recently had to intubate. She was elderly, frail, demented, and of course full code. The family wanted everything done thus a trip to the operating room was needed for a minor procedure. After induction I looked into the patient's mouth and saw...nothing. The tongue was so dry that it stuck to the laryngoscope blade. Once I was able to maneuver the scope further back I encountered a wall of debris making it impossible to recognize any normal anatomic landmarks. As I was furiously trying to suction out the trash, her O2 sat dropped perilously, which is all too easy in these kinds of patients. Finally, after I cleared a tunnel through all that organic waste, I caught a glimpse of the vocal cords with the help of some heroic cricoid pressure from the scrub nurse. I shoved the ETT in quickly and breathed a sigh of relief when I got some ETCO2 back on the monitor. Whew. The patient will live to have another operation ravage her body before she finally meets her maker.

As self described leaders in critical care medicine, we anesthesiologists should be advocates for better oral care in our patients. While we are busy in our ivory towers studying the body's inflammatory responses to endotoxins, perhaps we are ignoring the preventive aspects of critical care that will keep sepsis from occurring in the first place. Instead of spending billions of dollars developing new antibiotics for increasingly resistent hospital bacteria, maybe something as simple as brushing a patient's teeth twice a day will do the trick. Instead of being reactive, we should be more proactive. Why wait for an infection to set in when there is a simple, inexpensive, and universal mechanism to keep it from establishing itself and killing our patients? Anybody can intubate a patient. It takes true medical leadership to enforce changes that can actually improve a patient's well being.

3 comments:

  1. Thanks for sharing. Really Interesting. Great Informative. I'll share this with my friends and acquaintances.

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  2. VAP?? I thought VAP was a thing of the past...well according to wats actually reported anyways.

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  3. This is particularly true for the elderly, the demented, or the ICU patients. While the nurses are busy checking for decubitus ulcers or IV site infections, the mouth is all too frequently neglected. Whenever I have to intubate an inpatient, I will almost certainly encounter detritus collecting just above the vocal cords. I'm talking about filth like dried phlegm, old blood, or leftover food bits either from poor swallowing ability or regurgitation. And don't ask me about the severe halitosis that comes with all this decaying matter. how to pass swab drug test

    ReplyDelete