Need to prioritise: end-of-life decision-making in India.

recent prospective, observational study compared 1,252 ICU patients who received oral care with 414 historical controls who did not receive oral care [4]. The incidence rate of VAP was significantly lower in the oral care group than in the non-oral care group. The recent study of KOEMAN et al. [5] reported the results of a randomised, double-blind, placebo-controlled trial with three arms: chlorhexidine, chlorhexidine/colistin and placebo. Trial medication was applied every 6 h in the buccal cavity of the 385 included patients. The daily risk of VAP was reduced in both treatment groups compared with placebo, to 65% for chlorhexidine and 55% for chlorhexidine and colistin. Another prospective, randomised study evaluated the effect of oropharyngeal decontamination by povidone-iodine on VAP in 98 patients with head trauma [6]. The study found a significant reduction in the rate of VAP in the povidone-iodine group when compared with the saline and control groups. In addition, a recent meta-analysis assessed the efficacy of topical chlorhexidine for prevention of VAP [7]. Seven randomised controlled trials met the inclusion criteria. Topical chlorhexidine resulted in a reduced incidence of VAP and subgroup analysis showed that the benefit of chlorhexi-dine was most marked in cardiac surgery patients. Another recent meta-analysis evaluated the effect of oral decontamina-tion on the incidence of VAP and mortality in mechanically ventilated adults [8]. Eleven trials totalling 3,242 patients met the inclusion criteria. Oral decontamination using antiseptics was associated with reduced risk of VAP. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation. Tracheotomy facilitates oral care compared with oral trans-laryngeal intubation. This may partly explain the lower ventilator-associated pneumonia rate that our study found in tracheotomised patients [9]. However, pathogenesis of ventilator-associated pneumonia is multifactorial and prevention of VAP should be based on measures reducing colonisation, aspiration and antimicrobial resistance. Although several simple interventions are useful for reducing ventilator-associated pneumonia rates, opportunities for decreasing these seem to be greatest when multi-module programmes are applied [10]. gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention.