儿童法洛四联症术后呼吸机相关性肺炎的临床研究

目的探讨法洛四联症(tetralogy of Fallot,TOF)术后呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)的发生率、病原菌特点、危险因素及预后情况。方法纳入2013年1月至2017年12月在广东省人民医院心外科行TOF术后机械通气超过48 h的181例患儿,男121例、女60例,平均年龄(11.2±10.4)个月。将患者分为VAP组(n=44)和非VAP组(n=137),用t检验、χ~2检验及logistic回归分析方法,筛选VAP发病的可能危险因素。结果共纳入181例,其中VAP组44例,非VAP组137例,VAP发生率为24.3%。VAP常见病原菌为革兰阴性菌,占69.7%。单因素分析发现两组在术前缺氧发作、术前肺炎、术前使用呼吸机、体外循环(CPB)时间、气管插管重插管、肺不张、低心排血量、腹腔引流、输注新鲜冰冻血浆等方面差异有统计学意义(P0.05);多因素logistic回归分析显示:体外循环时间(OR=1.011)、气管插管重插管(OR=14.548)、肺不张(OR=6.139)、低心排血量(OR=3.054)为法洛四联症术后VAP发生的独立危险因素(P0.05)。与非VAP组相比,VAP组患儿机械通气时间长、ICU停留时间长,总住院时间长。结论 TOF术后VAP发生率较高,致使患者机械通气时间及住院时间延长,应根据VAP的危险因素采取综合防治措施,以期降低其发生率。     

机械通气患者早期肠内营养留置鼻胃肠管不同长度的临床应用

目的:比较神经外科重症监护病房(Neurosurgery Intensive Care Unit,)NI机CU械通气患者早期肠内营养留置鼻胃肠管不同长度的临床应用价值。方法:将NICU收治的50例机械通气患者随机分为A组(25例)和B组(25例),A组鼻胃肠管置管60～65cm,B组鼻胃肠管置管45～55cm,观察两组留置鼻胃肠管不同长度实施早期肠内营养可以耐受的起始时间、达目标喂养量所需时间、并发症情况和机械通气时间。结果:A组肠内营养可以耐受起始时间、达目标喂养量所需时间明显比B组短(P<0.01),并发症发生率和呼吸机相关肺炎(VAP)发生率明显减少(P<0.05),机械通气时间较B组明显缩短(P<0.05)。结论:机械通气患者留置鼻胃肠管实施早期肠内营养置管60～65cm比置管45～55cm更为有效、安全,并有助于减少VAP发生,有助于尽早脱机。     

气囊上滞留物清除预防呼吸机相关性肺炎

目的 观察气囊上滞留物清除技术对降低机械通气患者呼吸机相关性肺炎(VAP)发生率的作用.方法 将58例行气管插管机械通气治疗48 h以上患者随机分为观察组(32例)和对照组(26例),对照组采用常规气道护理,观察组在此基础上实施气囊上滞留物清除技术.观察两组机械通气1周、2周及2周后VAP发生率以及机械通气时间.结果 机械通气1周、2周观察组VAP发生率显著低于对照组(均P＜0.05),机械通气时间显著短于对照组(P＜0.01).结论 气囊上滞留物清除技术可显著减少VAP的发生,缩短机械通气时间,但气囊上滞留物并不是引起VAP的唯一因素.     

小儿先天性心脏病术后通气相关性肺炎及危险因素

目的探讨先天性心脏病(先心病)病儿术后通气相关性肺炎(VAP)的危险因素.方法回顾分析62例先心病术后机械通气d病儿VAP的发生与相关危险因素间的关系.结果该组病儿均痊愈出院,发生VAP39例;VAP发生于术后(4.79±2.81)d,术后(5.67±2.90)     

吸湿冷凝加湿器联合密闭式吸痰预防呼吸机相关性肺炎的效果

目的观察吸湿冷凝加湿器联合密闭式吸痰在预防呼吸机相关性肺炎(VAP)中的意义。方法将入住ICU行机械通气超过48h的96例患者,按随机数字表法分为观察组(49例)和对照组(47例)。观察组采用吸湿冷凝加湿器联合密闭式吸痰,对照组采用加温加湿器联合开放性吸痰。比较两组VAP发生率、VAP发病时间及住院时间,机械通气不同时间通气参数及血气指标。结果观察组VAP发生率显著低于对照组,出现VAP的时间显著长于对照组,住院时间显著短于对照组(P0.05,P0.01);不同机械通气时间两组通气的各项参数及血气分析指标比较,差异无统计学意义(均P0.05)。结论吸湿冷凝加湿器联合密闭式吸痰,能够延缓并降低VAP的发生,缩短患者住院时间。     

重症急性胰腺炎患者早期肠内营养误吸风险预测模型的构建

目的 分析急性胰腺炎患者早期肠内营养误吸的风险因素,为临床早期识别和护理干预提供指导.方法 收集296例重症急性胰腺炎患者的临床病例资料,根据给予患者早期肠内营养48 h以内是否发生误吸分为发生组和未发生组,通过logistic回归分析确定早期肠内营养误吸的独立危险因素,同时建立列线图可视化预测模型,采用C-index...     

强化冷凝水控制对呼吸机相关性肺炎的影响

目的探讨呼吸机冷凝水的管理对呼吸机相关性肺炎(VAP)发生的影响。方法将106例行机械通气治疗48h以上患者分为观察组(53例)和对照组(53例),对照组采用常规的冷凝水管理方法,观察组采用加热导线型湿化器防止冷凝水形成,观察及比较两组机械通气VAP发生率及病死率。结果观察组VAP发生率为20.8%、病死率为17.0%,对照组分别为41.5%、35.8%,两组比较,差异有统计学意义(均P<0.05)。结论强化冷凝水的控制可明显减少VAP发生率及病死率。     

老年患者胸腔镜手术后肠内营养并发胃潴留影响因素分析

目的分析老年胸腔镜手术患者术后肠内营养并发胃潴留的影响因素。方法回顾性分析2017年6月至2019年6月在我院行胸腔镜手术治疗的98例老年患者的临床资料,患者年龄60～75岁,术后均给予肠内营养支持。对患者术后肠内营养并发胃潴留的影响因素进行单因素和多因素分析。结果 98例胸腔镜手术患者中,术后并发胃潴留28例,占28.57%。单因素与非条件多项Logistic回归分析显示,糖尿病、肺部感染、行机械通气治疗、期间肠鸣音减弱、电解质紊乱以及低血钾均可能是诱发老年胸腔镜手术患者术后肠内营养并发胃潴留的影响因素。结论针对老年胸腔镜手术患者术后肠内营养并发胃潴留的影响因素,临床上对存在糖尿病、肺部感染、机械通气治疗、期间肠鸣音减弱、电解质紊乱、低血钾的患者均应重点关注并及时给予相应措施进行干预。     

常规刷牙预防呼吸机相关性肺炎的效果观察

目的探讨常规刷牙在预防呼吸机相关性肺炎(VAP)中的作用,为寻找更为有效的口腔护理方法提供依据。方法将98例经口气管插管机械通气患者随机分为两组,对照组(48例)应用传统擦拭法进行口腔护理,观察组(50例)采用常规刷牙方法进行口腔护理;两组口腔护理后均给予口腔冲洗和咽部深吸引。比较两组机械通气1周后VAP发生率、机械通气时间及ICU住院时间。结果观察组机械通气1周后VAP发生率显著低于对照组(P<0.05),机械通气时间及ICU住院时间显著短于对照组(均P<0.01)。结论常规刷牙配合口腔冲洗及咽部深吸引能显著降低VAP的发生率,缩短机械通气及ICU住院的时间。     

两种气管导管预防机械通气患者呼吸机相关性肺炎效果比较

目的探讨圆柱形与锥形气囊气管导管对机械通气患者微误吸致呼吸机相关性肺炎(VAP)的预防效果。方法将机械通气≥48h的气管插管患者64例随机分为A组32例,采用圆柱形气囊气管导管;B组32例,采用锥形气囊气管导管。将机械通气≥48h的气管切开患者72例随机分为C组36例,采用圆柱形气囊气管导管;D组36例,采用锥形气囊气管导管。观察并记录四组患者VAP发生率和时间、机械通气时间、痰液变化量、声门下分泌物变化量、脱机成功率。结果 B、D组VAP发生率显著低于A、C组;痰液变化量和声门下分泌物变化量显著多于A、C组(P0.05,P0.01)。四组机械通气时间、7d内脱机成功率、14d内脱机成功率差异无统计学意义(均P0.05)。结论使用锥形气囊的气管导管可以更好地预防微误吸的发生,从而预防VAP的发生。     

Risk Factors for Early-onset, Ventilator-associated Pneumonia in Critical Care Patients: Selected Multiresistant versus Nonresistant Bacteria

Background: Ventilator-associated pneumonia is the leading nosocomial infection in critically ill patients. The frequency of ventilator-associated pneumonia caused by multidrug-resistant bacteria has increased in recent years, and these pathogens cause most of the deaths attributable to pneumonia. The authors, therefore, evaluated factors associated with selected multidrug-resistant ventilator-associated pneumonia in critical care patients.

Methods: The authors prospectively recorded potential risk factors at the time of intensive care unit admission. An endotracheal aspirate was obtained in all patients who met clinical criteria for pneumonia. Patients were considered to have ventilator-associated pneumonia only when they met the clinical criteria and aspirate culture was positive for bacteria 48 h or more after initiation of mechanical ventilation. Pediatric patients were excluded. Adult patients with ventilator-associated pneumonia were first grouped as "early-onset" (< 5 days) and "late-onset," determined by episodes of ventilator-associated pneumonia, and then, assigned to four groups based on the bacteria cultured from their tracheal aspirates:Pseudomonas aeruginosa, Acinetobacter baumanii, methicillin-resistant staphylococci, and all others. The first three bacteria were considered to be multidrug resistant, whereas the others were considered to be antibiotic susceptible. Potential risk factors were evaluated with use of univariate statistics and multivariate regression.

Results: Among 486 consecutive patients admitted during the study, 260 adults underwent mechanical ventilation for more than 48 h. Eighty-one patients (31%) experienced 99 episodes of ventilator-associated pneumonia, including Pseudomonas (33 episodes), methicillin-resistant staphylococci (17 episodes), Acinetobacter (9 episodes), and nonresistant bacteria (40 episodes). Sixty-six of these episodes were early onset and 33 episodes were late onset. Logistic regression analysis identified three factors significantly associated with early-onset ventilator-associated pneumonia caused by any one of the multidrug-resistant bacterial strains: emergency intubation (odds ratio, 6.4; 95% confidence interval, 2.0-20.2), aspiration (odds ratio, 12.7; 95% confidence interval, 2.4-64.6), and Glasgow coma score of 9 or less (odds ratio, 3.9; 95% confidence interval, 1.3-11.3). A. baumanii-related pneumonia cases were found to be significantly associated with two of these factors: aspiration (odds ratio, 14.2; 95% confidence interval, 1.5-133.8) and Glasgow coma score (odds ratio, 6.0; 95% confidence interval, 1.1-32.6).     

乳腺癌患者术后远处转移及其不良结局的危险因素

目的探讨乳腺癌患者术后发生远处转移及其不良结局的危险因素。 方法回顾分析2012年1月至2015年10月期间行手术治疗后发生术后远处转移67例和未发生远处转移130例的女性乳腺癌患者病例资料,随访时间截止2020年10月。采用SPSS 22.0统计软件包分析数据,单因素生存分析采用K-M法,行Log-rank检验;Cox回归模型分析乳腺癌术后转移的多因素分析。 结果脉管状态、组织学分级、肿瘤大小、淋巴结阳性数及化疗方案和靶向治疗是影响乳腺癌术后远处转移的独立危险因素（P<0.05）。67例远处转移患者死亡48例,存活19例,中位生存时间为39个月。多因素分析显示,脉管状态、肿瘤大小、临床分期、组织学分级、转移数目、Her-2状态及化疗方案和靶向治疗是影响远处转移患者预后不良的独立危险因素（P<0.05）。 结论发生脉管癌栓、肿瘤直径越大、临床分期和组织学分级越高、多部位转移、Her-2阳性是影响远处转移患者预后的独立危险因素,术后蒽环类联合紫杉类化疗可以降低远处转移率,提高患者预后。     

Risk factors for early-onset, ventilator-associated pneumonia in critical care patients: selected multiresistant versus nonresistant bacteria

BACKGROUND: Ventilator-associated pneumonia is the leading nosocomial infection in critically ill patients. The frequency of ventilator-associated pneumonia caused by multidrug-resistant bacteria has increased in recent years, and these pathogens cause most of the deaths attributable to pneumonia. The authors, therefore, evaluated factors associated with selected multidrug-resistant ventilator-associated pneumonia in critical care patients. METHODS: The authors prospectively recorded potential risk factors at the time of intensive care unit admission. An endotracheal aspirate was obtained in all patients who met clinical criteria for pneumonia. Patients were considered to have ventilator-associated pneumonia only when they met the clinical criteria and aspirate culture was positive for bacteria 48 h or more after initiation of mechanical ventilation. Pediatric patients were excluded. Adult patients with ventilator-associated pneumonia were first grouped as "early-onset" (< 5 days) and "late-onset," determined by episodes of ventilator-associated pneumonia, and then, assigned to four groups based on the bacteria cultured from their tracheal aspirates: Pseudomonas aeruginosa, Acinetobacter baumanii, methicillin-resistant staphylococci, and all others. The first three bacteria were considered to be multidrug resistant, whereas the others were considered to be antibiotic susceptible. Potential risk factors were evaluated with use of univariate statistics and multivariate regression. RESULTS: Among 486 consecutive patients admitted during the study, 260 adults underwent mechanical ventilation for more than 48 h. Eighty-one patients (31%) experienced 99 episodes of ventilator-associated pneumonia, including Pseudomonas(33 episodes), methicillin-resistant staphylococci (17 episodes), Acinetobacter(9 episodes), and nonresistant bacteria (40 episodes). Sixty-six of these episodes were early onset and 33 episodes were late onset. Logistic regression analysis identified three factors significantly associated with early-onset ventilator-associated pneumonia caused by any one of the multidrug-resistant bacterial strains: emergency intubation (odds ratio, 6.4; 95% confidence interval, 2.0-20.2), aspiration (odds ratio, 12.7; 95% confidence interval, 2.4-64.6), and Glasgow coma score of 9 or less (odds ratio, 3.9; 95% confidence interval, 1.3-11.3). A. baumanii-related pneumonia cases were found to be significantly associated with two of these factors: aspiration (odds ratio, 14.2; 95% confidence interval, 1.5-133.8) and Glasgow coma score (odds ratio, 6.0; 95% confidence interval, 1.1-32.6). CONCLUSIONS: The authors recommend that patients undergoing emergency intubation or aspiration or who have a Glasgow coma score of 9 or less be monitored especially closely for early-onset multidrug-resistant pneumonia. The occurrence of aspiration and a Glasgow coma score of 9 or less are especially associated with pneumonia caused by A. baumanii.     

腹部手术后院内肺炎的危险因素分析

目的:探讨腹部手术后导致院内肺炎的危险因素.方法:采用单因素分析法及非条件Logistic逐步回归分析可能导致院内肺炎的18种危险因素.结果:单因素分析表明吸烟史等10项与术后肺炎的发生有关,进一步多元回归分析表明:并存慢性阻塞性肺病(慢阻肺)(OR=17.01),麻醉方式(OR=16.45),切口长度*(OR=2.25),手术持续时间(OR=0.90),术前0.5h预防性应用抗生素(OR=0.38)及机械通气(OR=0.38)是术后院内肺炎的高危因素.结论:患者并存慢阻肺,术前不预防性应用抗生素,手术切口和手术持续时间太长,采用气管插管,机械通气等全麻方式,是术后发生院内肺炎的主要原因,.     

冠状动脉旁路移植术后早期死亡的危险因素分析

目的 总结并分析冠状动脉旁路移植术(CABG)患者的特点和术后早期死亡的相关危险因素.方法 收集2005年1月至2007年12月接受CABG的全部310例患者的资料,并选择22个备选的死亡危险因素进行统计分析,其中术前指标15项,术中、术后指标7项.结果 单因素分析显示12项危险因素与CABG术后早期死亡相关,包括年龄、糖尿病、神经系统功能障碍、陈旧性心肌梗死、急性心肌梗死、射血分数、左主干病变、三支严重病变、急诊手术、转流时间、心肌阻断时间及术后机械通气时间.逐步Logistic回归分析显示CABG术后早期死亡的独市危险因素为:急诊手术、射血分数、年龄、转流时间和机械通气时间.结论 急诊手术、射血分数、年龄、转流时间和机械通气时间是本组CABG患者术后早期死亡的独立危险因素.     

Predictors and outcomes of prolonged ventilation after coronary artery bypass graft surgery

This study investigated and compared the risk factors and outcomes of patients undergoing coronary artery bypass graft surgery with and without the occurrence of prolonged mechanical ventilation. Data in a cardiac surgery database were examined retrospectively. Data selected included any isolated coronary artery bypass graft surgery performed by the surgical group from August 2005 to June 2009. The resulting cohort included a total of 2933 patients which was comprised of 116 patients with a ventilation time of greater than 72 hours (prolonged ventilation) and 2817 patients with a ventilation time of 72 hours or less (no prolonged ventilation). Patients with a prolonged ventilation time were matched (1:3 ratio) to patients not requiring a prolonged ventilation time by year of surgery resulting in our study cohort of 464 patients. To generate the unadjusted risks of each factor, χ(2) and t test analysis were performed. Logistic regression analysis was then used to investigate the adjusted risk between cases and controls and each of the significant variables. χ(2) and t tests were conducted comparing cases and controls with the outcome variables. Patients undergoing coronary artery bypass graft that experienced a prolonged ventilation time (cases) were more likely female, had a New York Hospital Association functional class of III or IV, and had a longer perfusion time. There was no significant difference between cases and controls with diabetes, chronic obstructive pulmonary disease, left ventricular ejection fraction, or body mass index while controlling for all significant risk factors. Careful patient selection and preparation during preoperative evaluation may help identify patients at risk for prolonged mechanical ventilation and thus help prevent the added morbidity and mortality associated with it.     

Disease risk and mortality prediction in intensive care patients with pneumonia. Australian and New Zealand practice in intensive care (ANZPIC II)

This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58-1799, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09-5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08-1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20-0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16-42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20-11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20-17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20-1.75, P=0.001) and the isolation of "high risk" organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43-16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18-0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56). Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.     

Postoperative pulmonary complications: pneumonia and acute respiratory failure

Postoperative pulmonary complications (atelectasis, pneumonia, pulmonary edema, acute respiratory failure) are common, particularly after abdominal and thoracic surgery, pneumonia and atelectasis being the most common. Postoperative pneumonia is associated with increased morbidity, length of hospital stay, and costs. Few institutions have pneumonia prevention programs for surgical patients, and these should be strongly considered. Acute respiratory failure is a life-threatening pulmonary complication that requires institution of mechanical ventilation and admission to the intensive care unit, and is associated with increased risk for ventilator-associated pneumonia. This article discusses epidemiology, risk factors, diagnosis, treatment, and prevention of these pulmonary complications in surgical patients.     

外科重症监护病房老年患者呼吸机相关性肺炎的相关因素分析及防治

目的：了解外科重症监护病房（SICU）老年患者呼吸机相关性肺炎（VAP）的发生率、病死率、易感因素,指导VAP的临床防治。方法：对近3年内我院SICU65例机械通气的老年患者进行回顾性分析。结果：VAP发生率为66．2％,病死率为67．4％,长时间机械通气及高APACHE Ⅱ分、低GCS分和不恰当初始抗菌治疗等是VAP的易感因素。结论：在SICU病房,通过有效的防治措施,可降低老年患者VAP的发生率,提高治愈率。     

Is ventilator-associated pneumonia an independent risk factor for death?

BACKGROUND: Ventilator-associated pneumonia (VAP) has been implicitly accused of increasing mortality. However, it is not certain that pneumonia is responsible for death or whether fatal outcome is caused by other risk factors for death that exist before the onset of pneumonia. The aim of this study was to evaluate the attributable mortality caused by VAP by performing a matched-paired, case-control study between patients who died and patients who were discharged from the intensive care unit after more than 48 h of mechanical ventilation. METHODS: During the study period, 135 consecutive deaths were included in the case group. Case-control matching criteria were as follows: (1) diagnosis on admission that corresponded to 1 of 11 predefined diagnostic groups; (2) age difference within 10 yr; (3) sex; (4) admission within 1 yr; (5) APACHE II score within 7 points; (6) ventilation of control patients for at least as long as the cases. Precise clinical, radiologic, and microbiologic definitions were used to identify VAP. RESULTS: Analysis was performed on 108 pairs that were matched with 91% of success. There were 39 patients (36.1%) who developed VAP in each group. Multivariate analysis showed that renal failure, bone marrow failure, and treatment with corticosteroids but not VAP were independent risk factors for death. There was no difference observed between cases and controls concerning the clinical and microbiologic diagnostic criteria for pneumonia. CONCLUSION: Ventilator-associated pneumonia does not appear to be an independent risk factor for death.