集束化干预策略对高原ICU机械通气患者呼吸机相关性肺炎的预防效果

目的探讨实施集束化干预策略对预防高原ICU机械通气患者呼吸机相关性肺炎（VAP）的效果,为高原地区VAP预防策略提供依据。 方法选取青海省人民医院ICU行机械通气的患者作为研究对象,其中2017年4至12月入院未实施集束化护理策略的418例患者为对照组,2018年2至10月入院实施集束化干预策略的437例患者为观察组。比较2组患者的机械通气时间、ICU住院时间、VAP发生率、误吸发生率、气囊压力监测情况及2组医务人员手卫生依从性情况。 结果观察组机械通气时间及ICU住院时间均显著短于对照组,2组间比较差异有统计学意义[机械通气时间：（5.94±4.17）d vs （9.72±5.66）d,t=11.14,P<0.001;ICU住院时间：（9.63±6.41）d vs （14.48±8.30）d,t=9.55,P<0.001];VAP及误吸发生率均少于对照组,2组间比较差异有统计学意义（VAP发生率：3.4%和8.1%,χ²=9.39,P=0.001;误吸发生率：0.7% vs 2.2%,χ²=4.82,P=0.030）;气囊压力监测达标率高于对照组,2组间比较差异有统计学意义（96.4% vs 61.7%,χ²=2.50,P<0.001）。观察组医务人员手卫生依从性高于对照组,2组间比较差异有统计学意义（79.0% vs 48.5%,χ²=4.76,P<0.001）。 结论集束化干预策略可有效缩短机械通气时间、ICU住院时间,减少高原地区VAP及误吸的发生率,提高气囊压力监测达标率及医护人员手卫生依从性,值得临床应用。     

超声造影评价横纹肌溶解致急性肾损伤肾的血流灌注实验

目的探讨超声造影定量参数评价横纹肌溶解致急性肾损伤大鼠肾血流灌注的变化。 方法将60只SD大鼠随机分为模型组和对照组，每组30只，模型组大鼠双后肢肌肉注射50%甘油生理盐水10 ml/kg，对照组大鼠双后肢肌肉注射0.9%生理盐水10 ml/kg。于注射后0.5 h、2 h、6 h、12 h和24 h五个时间点每组取6只大鼠行超声造影检查，获取肾皮质和髓质时间-强度曲线及相关定量参数［上升斜率（AS）、曲线下面积（AUC）、下降斜率（DS）、降半时间（DT/2）、峰值强度（PI）］，分析不同时间点肾超声造影特征。超声检查结束后下腔静脉取血检测血清尿素氮、肌酐、胱抑素C、肌酸激酶水平，肾组织固定后制备病理切片观察。采用t检验或Mann-Whitney U检验比较模型组和对照组间超声造影相关定量参数和血清生化指标的差异，采用单因素方差分析或Kruskal-Wallis H检验比较组内不同时间点各指标的差异。 结果与对照组相比，模型组0.5 h、2 h、6 h和12 h的血清肌酸激酶、尿素氮、肌酐及2 h、6 h血清胱抑素C显著升高，差异具有统计学意义（血清肌酸激酶：Z=-2.242，P=0.025；Z=-2.882，P=0.004；Z=-2.882，P=0.004；Z=-2.562，P=0.010；尿素氮：t=4.288，P=0.002；t=4.450，P=0.001；t=10.812，P＜0.001；t=5.260，P＜0.001；肌酐：t=6.327，P=0.001；t=10.577，P＜0.001；t=2.612，P=0.035；t=4.694，P=0.001；胱抑素C：t=3.460，P=0.009；t=2.391，P=0.038）；模型组0.5 h的皮质AUC明显升高［（2636.84±150.99）dB·s vs（2308.20±210.50）dB·s］，差异具有统计学意义（t=3.107，P=0.011），2 h、6 h和12 h的皮质DS及6 h、12 h和24 h的皮质AS显著减小［DS：（0.16±0.05）dB/s vs（0.23±0.03）dB/s，（0.16±0.03）dB/s vs（0.23±0.04）dB/s，（0.16±0.05）dB/s vs（0.23±0.03）dB/s；AS：（0.54±0.22）dB/s vs（0.84±0.15）dB/s，（0.58±0.21）dB/s vs（0.86±0.20）dB/s，（0.67±0.20）dB/s vs（0.96±0.13）dB/s］，差异具有统计学意义（t=-3.342、-3.542、-3.226、-2.733、-2.318、-2.809，P=0.007、0.005、0.009、0.021、0.043、0.019），12 h的皮质DT/2明显增加［（55.78±12.28）s vs（40.09±6.29）s］，差异具有统计学意义（t=2.789，P=0.019）；0.5 h、2 h、6 h和12 h的髓质AUC明显升高［（2382.40±189.84）dB·s vs（1910.82±140.13）dB·s，（2637.35±258.55）dB·s vs（1999.88±409.52）dB·s，（2424.63±409.39）dB·s vs（1910.47±263.59）dB·s，（2353.54±348.2）dB·s vs（1958.43±95.37）dB·s］，差异具有统计学意义（t=5.025、3.217、2.669、3.014，P=0.001、0.009、0.024、0.013），2 h和6 h的髓质DS及AS显著减小［DS：0.13（0.07，0.15）dB/s vs 0.22（0.19，0.24）dB/s，0.13（0.11，0.16）dB/s vs 0.21（0.20，0.23）dB/s；AS：（0.44±0.22）dB/s vs（0.77±0.14）dB/s，（0.41±0.21）dB/s vs（0.80±0.10）dB/s］，差异具有统计学意义（Z=-2.892、-2.585，P=0.004、0.010；t=-3.063、-4.042，P=0.015、0.005），2 h、6 h和12 h的髓质DT/2明显增加［（61.44±15.52）s vs（38.88±8.80）s，（54.60±12.47）s vs（37.59±8.71）s，（56.08±14.57）s vs（38.42±6.00）s］，差异具有统计学意义（t=3.105、2.724、3.003，P=0.011、0.021、0.013）。病理结果显示：对照组肾小球及肾小管结构均正常；模型组肾小球结构未见明显改变，部分肾小管刷状缘脱落，上皮细胞扁平化，0.5 h开始肾小管管腔扩张明显，以远曲小管为主，2 h开始出现肾小管管型，并且随着建模时间的增加，肾小管损伤逐渐加重，24 h最严重。 结论超声造影能够敏感地反映横纹肌溶解致急性肾损伤大鼠肾血流灌注的变化过程，具有一定的诊断价值。     

细菌过滤器联合加热湿化器对预防呼吸机相关性肺炎的效果

目的研究细菌过滤器联合加热湿化器对呼吸机相关性肺炎（VAP）发生率的影响。 方法采用前瞻性随机对照试验方法,选择2017年3月至2020年3月在南京医科大学第一附属医院ICU需行机械通气≥48 h的患者210例,将其随机分为细菌过滤器组（104例）和对照组（106例）。对照组患者采用加热湿化器,不联合任何过滤装置,实验组采用加热湿化器联合细菌过滤器。采用单因素logistic回归分析研究VAP发生的危险因素,采用Kaplan-Meier法比较2组患者VAP的累积发生率,采用亚组分析及Cox生存回归分析研究细菌过滤器预防VAP的效果。 结果细菌过滤器组气管切开患者比例较对照组低,差异有统计学意义（19.2% vs 38.7%,χ²=9.634,P=0.002）。2组VAP患病率比较,差异无统计学意义（22.1% vs 34.0%,χ²=3.647,P=0.066）,Logistic回归分析显示,细菌过滤器未能有效减少VAP的发生率（OR=0.552,95% CI=0.299~1.019,P=0.058）;Kaplan-Meier分析未显示细菌过滤器在预防VAP方面具有显著优势（log-rank检验,P=0.060）;亚组分析及Cox生存回归分析显示,在机械通气＜25 d的患者中,细菌过滤器显著减少VAP的发生率（HR=0.373,P=0.004）。 结论在机械通气＜25 d的患者中,细菌过滤器联合加热湿化可以显著减少VAP的发生率,但随着机械通气时间的延长而不再有意义。     

143例ICU老年创伤患者的流行病学分析

目的探讨单中心老年创伤重症患者流行病学特点,为临床救治提供参考。 方法回顾性分析2017年1月至2018年6月陆军军医大学大坪医院重症医学科（ICU）收治的65岁以上老年创伤患者143例,分析患者性别、年龄、致伤机制、损伤严重程度评分（ISS）、并发症、住院时间等资料。采用Mann-Whitney检验比较ISS评分、急性生理与慢性健康评分（APACHE Ⅱ评分）、ICU时间、住院时间在不同受伤机制和不同年龄之间的差异,使用Pearson χ²检验比较年龄分层计数、基础疾病分类计数、好转出院例数在不同受伤机制和不同年龄之间的差异,应用Logistic回归分析法分析并发症发生的危险因素。 结果所有创伤患者中,男性患者71例（49.65%,71/143）,女性72例（50.34%,72/143）;年龄65~99岁,平均年龄（78±1）岁;多发伤43例（30.07%,43/143）,单部位伤100例（69.93%,100/143）。跌倒伤是首位致伤原因90例（62.94%,90/143）,其次为车祸伤40例（27.97%,40/143）。跌倒伤ISS［9（9,9）分vs 22（16,27）分,Z=7.574,P<0.001］、APACHE II评分［15（14,17）分vs 17（15,21）分,P=0.001］均较低,住ICU时间［2（1,3）d vs 8（1,16）d,Z=4.407,P<0.001］和住院时间［（16（12,22.25）d vs 30（19,49）d,Z=4.779,P<0.001）］较非跌倒伤更短,好转出院率比较差异无统计学意义（P>0.05）。≥80岁患者与<80岁患者比较,APACHE Ⅱ评分明显升高［16（15,20）分vs 14（15,18）分,Z=2.093,P=0.036）］,住ICU的时间更长［3（1,10）d vs 1（1,7.5）d,Z=2.013,P=0.044］。APACHE Ⅱ评分是并发症发生的危险因素（OR=1.771,P=0.01）。 结论老年患者入住ICU的主要原因是跌倒伤,其次是车祸伤。除年龄外,APACHE Ⅱ评分高时,住ICU时间更长和并发症发生率更高。     

常态化疫情防控背景下不同探视方式在ICU中的应用效果

目的探讨常态化疫情防控背景下不同探视方式在ICU中的应用效果。 方法采用便利抽样法,选取2020年9月至12月入住我院综合ICU的60名患者家属为对照组,2021年1月至4月入住的60名患者家属为研究组。对照组实施以电话沟通为主的探视方式,研究组实施流程细化后的远程视频探视方式,比较2组不同探视方式下家属的满意度、焦虑感及ICU护士认同感。 结果研究组患者家属满意度总分明显高于对照组,差异有统计学意义［（106.92±11.35）分vs（101.28±14.32）分,t=2.388,P=0.019］;家属焦虑程度明显轻于对照组,差异有统计学意义（Z=2.333,P=0.020）;ICU护士认同感总分明显高于对照组,差异有统计学意义［（3.97±0.75）分vs（3.69±0.91）分,t=2.058,P=0.041］。 结论远程视频探视可提高患者家属的满意度,缓解其焦虑感,同时提高ICU护士的认同感,但仍需对其制度与流程进行优化,以减轻护理工作压力,从而促进探视模式的良性发展。     

不同口腔护理方法预防呼吸机相关性肺炎的研究

[目的]探讨不同的口腔护理方法预防经口气管插管机械通气病人呼吸机相关性肺炎（VAP）的效果,为选定合适的方法提供理论依据.[方法]选择在ICU使用呼吸机时间超过48 h的病人162例,按入院先后顺序分为对照组53例,试验A组54例,试验B组55例;对照组采用棉球擦拭法行口腔护理,试验A组采用纱块擦拭法行口腔护理,试验B组采用一次性负压吸引牙刷配合冲洗法行口腔护理.[结果]对照组与试验A组口腔护理后菌落数分布差异有统计学意义（Z=-6.680,P＜0.01）,对照组与试验B组口腔护理后菌落数分布差异有统计学意义（Z=-6.232,P＜0.01）,试验A组与试验B组两组口腔护理后菌落数分布差异无统计学意义（Z=-0.703,P=0.482）;口腔护理后清洁评价情况,对照组不满意率为24.52％,A组不满意率7.40％,B组不满意率9.09％,两组均低于对照组（P＜0.05）;病人VAP导管日感染率试验A组为0.307％,试验B组为0.304％,两组明显低于对照组的1.024％,差异有统计学意义（P＜0.05）.[结论]应用纱决擦拭和一次性负压吸引牙刷配合冲洗法行口腔护理应用于经口气管插管病人,可有效地减少口咽部细菌定植的数量,可降低VAP的发生率.     

无创正压通气在重症AECOPD伴肺性脑病患者救治中的体会

目的探讨无创正压通气（NPPV）救治慢性阻塞性肺疾病急性发作期（AECOPD）并发Ⅱ型呼吸衰竭及肺性脑病患者的临床疗效。方法将2011年1月至2013年12月住院的56例AECOPD并Ⅱ型呼吸衰竭伴意识障碍患者分为无创通气（NPPV）组24例和有创通气（MV）组32例,两组均进行常规综合治疗,包括抗感染、化痰、雾化吸入支气管扩张剂。NPPV组在常规治疗基础上用无创呼吸机进行NPPV治疗,MV组进行气管插管及有创通气治疗。观察两组患者治疗前后的APPACHE Ⅱ评分、动脉血气、意识状态情况,同时观察两组动脉血气、血清白蛋白水平、ICU住院时间及呼吸机相关性肺炎（VAP）发生率。结果两组患者治疗前各项指标比较差异无统计学意义（P均〉0.05）。两组治疗72 h指标与治疗前比较,APPACHE Ⅱ评分、GCS评分、p H、Pa CO2、Pa O2、RR、HR差异均有统计学意义（P均〈0.05）。NPPV组治疗6 h血气中p H值低于MV组,Pa CO2高于MV组,72h BE低于MV组,差异有统计学意义（P均〈0.05）;两组治疗72 h与治疗6 h比较,Pa O2、GCS评分、APPACHE Ⅱ评分差异无统计学意义（P均〉0.05）。NPPV组的ICU住院时间短于MV组（P〈0.05）,VAP发生率低于MV组（8.3%vs 37.5%,P〈0.05）,两组血清白蛋白水平比较差异无统计学意义（P〉0.05）。结论 AECOPD并Ⅱ型呼吸衰竭伴不同程度意识障碍患者应用NPPV有较好疗效,可减少患者ICU住院时间及VAP发生率。     

药物球囊治疗冠状动脉支架内再狭窄的临床疗效

目的探讨药物球囊治疗冠状动脉支架内再狭窄后病变血管内膜腔的变化。 方法选取2016年5月至2017年12月确诊的不稳定型心绞痛患者，其在东南大学医学院附属江阴医院曾接受经皮冠状动脉药物洗脱支架植入术，因心绞痛再次接受冠状动脉造影检查，确定为支架内再狭窄的患者96例作为研究对象，将患者分为药物球囊治疗组（47例）及支架植入组（49例），比较术后即刻最小内膜腔面积、支架最小截面积、支架膨胀率等，术后12个月复查冠状动脉造影及血管内超声检查，比较两组心血管事件、最小内膜腔面积、支架最小截面积、内膜增生面积等。 结果经冠状动脉造影及血管内超声检查：药物球囊治组疗术后即刻靶病变最小内膜腔面积和支架最小截面积均小于支架植入组［（10.8±2.8）mm² vs （11.8±3.2）mm²；（11.2±2.9）mm² vs （12.0±3.2）mm²］，差异具有统计学意义（t=2.112、1.987，P=0.025、0.042）；支架相对膨胀率药物球囊治疗组低于支架组（86.7% vs 90.3%），差异具有统计学意义（χ²=2.012，P=0.045）。术后随访12个月，药物球囊治疗组发生心血管事件7例，支架植入组心血管事件9例，2组差异无统计学意义（P=0.699）；药物球囊治疗组与支架植入组支架植入处最小内膜腔面积［（10.6±2.6）mm² vs （10.8±2.7）mm²］比较，差异无统计学意义（P=0.896）；2组患者支架植入处内膜均有增生，但药物球囊治疗组与支架植入组内膜增生面积［（0.30±0.12）mm² vs （0.39±0.15）mm²］比较，差异无统计学意义（P=0.845）；药物球囊治疗组与支架植入组支架最小截面积［（10.9±2.7）mm² vs （11.2±3.0）mm²］比较，差异无统计学意义（P=0.723）。 结论药物球囊治疗支架内再狭窄后12个月其靶病变血管最小内膜腔面积、支架最小截面积、内膜增生面积与支架植入组相当，临床应用安全可靠。     

临床肺部感染评分对重症监护病房机械通气患者下呼吸道检出多重耐药菌的临床分析

目的 调查重症监护病房(ICU)机械通气患者下呼吸道检出多重耐药菌(MDR)时,不同临床肺部感染评分(CPIS)患者MDR的构成特点、检出时间、病死率.方法 采用回顾性研究方法,收集2010年4月至2011年12月ICU机械通气＞48 h且下呼吸道检出MDR的72例患者临床资料,同时进行CPIS评分,其中CPIS评分＞6分即被诊断为呼吸机相关性肺炎(VAP)33例,CPIS评分≤6分39例(非VAP),比较两组患者MDR的构成特点、检出时间及病死率.结果 VAP组MDR主要以鲍曼不动杆菌[49.5％(34/74)]为主,其次为肺炎克雷伯菌[24.3％(18/74)]、大肠埃希菌[20.3％ (15/74)]、铜绿假单胞菌[5A％(4/74)]、耐甲氧西林金黄色葡萄球菌[MRSA,4.1％(3/74)];非VAP组以大肠埃希菌[40.2％ (37/92)]为主,其次为铜绿假单胞菌[33.7％(31/92)]、肺炎克雷伯菌[13.1％(12/92)]、鲍曼不动杆菌[8.7％(8/92)]、MRSA[4.3％ (4/92)].VAP组MDR平均检出时间(d)与非VAP组比较差异无统计学意义(10.7±1.5比94±1.8,P＞0.05);VAP组病死率明显高于非VAP组(39.4％比23.1％,P＜0.05).结论 ICU机械通气患者无论是否发生VAP,下呼吸道均可能检出不同MDR,并不同程度地影响患者预后,应密切监测,并适当初始经验性或动态调整抗菌药物的治疗策略.     

兔脑死亡状态下肝超声造影微血流灌注研究

目的应用超声造影分析兔脑死亡状态下肝微血流灌注定量参数，探讨评估脑死亡供肝的新方法。 方法制备兔脑死亡组（15只）和对照组（5只）模型并维持状态达8 h，对脑死亡组和对照组于模型制备完成后0 h、4 h、8 h进行肝超声造影检查和微血流灌注定量分析，定量参数包括曲线下面积（AUC）、峰值强度（Peak）、达峰时间（Tp）、平均渡越时间（MTT）。采用t检验比较脑死亡组与对照组0 h、4 h、8 h肝超声造影定量参数AUC、Peak、Tp及MTT的差异，同时进行肝功能和病理检查。 结果脑死亡状态下，13只兔（13/15，86.7%）AUC值呈逐渐下降趋势，15只（15/15，100%）兔的Peak值呈逐渐下降趋势。建模后0 h脑死亡组Peak值高于对照组［（66.1±9.1）% vs （54.9±7.3）%］，建模后8 h脑死亡组Peak值低于对照组［（44.9±10.3）% vs （68.5±2.9）%］，且差异均具有统计学意义（t=-11.276，P=0.032；t=-10.395，P=0.001）；建模后4 h，脑死亡组和对照组的Peak值比较，差异无统计学意义（P＞0.05）。建模后8 h，脑死亡组AUC值小于对照组［（2591.7±732.7）%s vs（4520.0±182.8）%s］，差异有统计学意义（t=-18.762，P=0.001）；建模后0 h、4 h，脑死亡组和对照组的AUC值比较，差异均无统计学意义（P均＞0.05）。建模后0 h、4 h、8 h，脑死亡组和对照组Tp值和MTT值比较，差异均无统计学意义（P均＞0.05）。 结论兔脑死亡状态下肝微血流灌注量下降，超声造影可作为评估脑死亡供肝的有效方法。     

Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center

OBJECTIVE: To determine the attributable cost of ventilator-associated pneumonia from a hospital-based cost perspective, after adjusting for potential confounders. DESIGN: Patients admitted between January 19, 1998, and December 31, 1999, were followed prospectively for the occurrence of ventilator-associated pneumonia. Hospital costs were defined by using the hospital cost accounting database. SETTING: The medical and surgical intensive care units at a suburban, tertiary care hospital. PATIENTS: Patients requiring >24 hrs of mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured occurrence of ventilator-associated pneumonia, in-hospital mortality rate, total intensive care unit (ICU) and hospital lengths of stay (LOS), and total hospital cost per patient. Ventilator-associated pneumonia occurred in 127 of 819 patients (15.5%). Compared with uninfected, ventilated patients, patients with ventilator-associated pneumonia had a higher Acute Physiology and Chronic Health Evaluation II score on admission (p <.001) and were more likely to require multiple intubations (p <.001), hemodialysis (p <.001), tracheostomy (p <.001), central venous catheters (p <.001), and corticosteroids (p <.001). Patients with ventilator-associated pneumonia were more likely to be bacteremic during their ICU stay (36 [28%] vs. 22 [3%]; p <.001). Patients with ventilator-associated pneumonia had significantly higher unadjusted ICU LOS (26 vs. 4 days; p <.001), hospital LOS (38 vs. 13 days; p <.001), mortality rate (64 [50%] vs. 237 [34%]; p <.001), and hospital costs (70,568 dollars vs. 21,620 dollars, p <.001). Multiple linear regression, controlling for other factors that may affect costs, estimated the attributable cost of ventilator-associated pneumonia to be 11,897 dollars (95% confidence interval = 5,265 dollars-26,214 dollars; p <.001). CONCLUSIONS: Patients with ventilator-associated pneumonia had significantly longer ICU and hospital LOS, with higher crude hospital cost and mortality rate compared with uninfected patients. After we adjusted for underlying severity of illness, the attributable cost of ventilator-associated pneumonia was approximately 11,897 dollars.     

Ventilator-associated pneumonia caused by multidrug-resistant organisms or Pseudomonas aeruginosa: prevalence, incidence, risk factors, and outcomes

PURPOSE: The aim of this study was to clarify the prevalence and incidence of, risk factors for, and outcomes from suspected ventilator-associated pneumonia (VAP) associated with the isolation of either Pseudomonas or multidrug-resistant (MDR) bacteria ("high risk" pathogens) from respiratory secretions. MATERIALS AND METHODS: Data were collected as part of a large, multicentered trial of diagnostic and therapeutic strategies for patients (n = 739) with suspected VAP. RESULTS: At enrollment, 6.4% of patients had Pseudomonas species, and 5.1% of patients had at least 1 MDR organism isolated from respiratory secretions. Over the study period, the incidence of Pseudomonas and MDR organisms was 13.4% and 9.2%, respectively. Independent risk factors for the presence of these pathogens at enrollment were duration of hospital stay >or=48 hours before intensive care unit (ICU) admission (odds ratio, 2.37 [95% CI, 1.40-4.02]; P = .001] and prolonged duration of ICU stay before enrollment (odds ratio, 1.50 [95% CI, 1.17-1.93]; P = .002] per week. Fewer patients whose specimens grew either Pseudomonas or MDR organisms received appropriate empirical antibiotic therapy compared to those without these pathogens (68.5% vs 93.9%, P < .001). The isolation of high risk pathogens from respiratory secretions was associated with higher 28-day (relative risk, 1.59 [95% CI, 1.07-2.37]; P = .04] and hospital mortality (relative risk, 1.48 [95% CI, 1.05-2.07]; P = .05), and longer median duration of mechanical ventilation (12.6 vs 8.7 days, P = .05), ICU length of stay (16.2 vs 12.0 days, P = .05), and hospital length of stay (55.0 vs 41.8 days, P = .05). CONCLUSIONS: In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low. However, the presence of high risk pathogens is associated with worse clinical outcomes.     

改良集束化策略预防呼吸机相关性肺炎的临床研究

目的研究改良的集束化策略预防呼吸机相关性肺炎的效果。方法本院收治的机械通气≥5 d患者209例,随机分为对照组（94例）和试验组（115例）。对照组应用常规方法预防呼吸机相关性肺炎;试验组在对照组基础上采用改良的集束化策略。比较2组呼吸机相关性肺炎发生率、机械通气时间及ICU住院时间及痰病原学检查结果。结果试验组呼吸机相关性肺炎发生率较对照组明显下降,机械通气时间I、CU住院时间较对照组明显缩短。结论改良集束化策略能有效预防呼吸机相关性肺炎的发生。     

Impact of ureido/carboxypenicillin resistance on the prognosis of ventilator-associated pneumonia due to Pseudomonas aeruginosa

Introduction

Although Pseudomonas aeruginosa is a leading pathogen responsible for ventilator-associated pneumonia (VAP), the excess in mortality associated with multi-resistance in patients with P. aeruginosa VAP (PA-VAP), taking into account confounders such as treatment adequacy and prior length of stay in the ICU, has not yet been adequately estimated.

Methods

A total of 223 episodes of PA-VAP recorded into the Outcomerea database were evaluated. Patients with ureido/carboxy-resistant P. aeruginosa (PRPA) were compared with those with ureido/carboxy-sensitive P. aeruginosa (PSPA) after matching on duration of ICU stay at VAP onset and adjustment for confounders.

Results

Factors associated with onset of PRPA-VAP were as follows: admission to the ICU with septic shock, broad-spectrum antimicrobials at admission, prior use of ureido/carboxypenicillin, and colonization with PRPA before infection. Adequate antimicrobial therapy was more often delayed in the PRPA group. The crude ICU mortality rate and the hospital mortality rate were not different between the PRPA and the PSPA groups. In multivariate analysis, after controlling for time in the ICU before VAP diagnosis, neither ICU death (odds ratio (OR) = 0.73; 95% confidence interval (CI): 0.32 to 1.69; P = 0.46) nor hospital death (OR = 0.87; 95% CI: 0.38 to 1.99; P = 0.74) were increased in the presence of PRPA infection. This result remained unchanged in the subgroup of 87 patients who received adequate antimicrobial treatment on the day of VAP diagnosis.

Conclusions

After adjustment, and despite the more frequent delay in the initiation of an adequate antimicrobial therapy in these patients, resistance to ureido/carboxypenicillin was not associated with ICU or hospital death in patients with PA-VAP.     

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia

OBJECTIVE: To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. DESIGN: Prospective before-and-after study design. SETTING: A medical intensive care unit from a university-affiliated, urban teaching hospital. PATIENTS: Between April 1999 and January 2000, 102 patients were prospectively evaluated. INTERVENTIONS: Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. MEASUREMENTS AND MAIN RESULTS: The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 +/- 5.7 vs. 25.4 +/- 8.1, p =.798) and the clinical pulmonary infection scores (6.6 +/- 1.0 vs. 6.9 +/- 1.2, p =.105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p <.001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 +/- 5.1 days vs. 14.8 +/- 8.1 days, p <.001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p =.030). CONCLUSIONS: The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.     

Diagnostic techniques for ventilator-associated pneumonia: Conflicting results from two trials

Citation

A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006, 355:2619–2630 [1].

Background

Critically ill patients who require mechanical ventilation are at risk for ventilator-associated pneumonia. Current data are conflicting as to the optimal diagnostic approach in patients who have suspected ventilator-associated pneumonia.

Methods

Objective

To compare the quantitative culture of bronchoalveolar-lavage fluid and nonquantitative culture of endotracheal aspirate in critically ill patients with suspected ventilator-associated pneumonia, testing the hypothesis that bronchoscopy with quantitative culture would be associated with lower mortality rates and less use of antibiotics.

Design

Multi-center non-blinded randomized controlled trial.

Setting

28 intensive care units (ICUs) across Canada and the United States.

Subjects

740 immunocompetent critically ill adult patients with suspected ventilator-associated pneumonia after 4 days in the ICU. Patients known to be colonized or infected with Pseudomonas species or methicillin-resistant Staphylococcus aureus were excluded.

Intervention

Using a 2-by-2 factorial design, subjects were randomly assigned to a) undergo bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid or endotracheal aspiration with nonquantitative culture of the aspirate, and to b) receive empirical combination antibiotic therapy or monotherapy. Empirical antibiotic therapy was initiated in all patients until culture results were available, at which point a protocol of targeted therapy was used for discontinuing or reducing the dose or number of antibiotics, or for resuming antibiotic therapy to treat a pre-enrollment condition if the culture was negative.

Outcome

The primary outcome was 28-day mortality. Secondary outcomes included ICU and hospital survival, duration of mechanical ventilation, response to clinical and microbiologic treatment, discontinuation of antibiotics after culture results known, and other measures of antibiotic use.

Results

There was no significant difference in 28-day mortality rate between the bronchoalveolar-lavage group and the endotracheal-aspiration group (18.9% and 18.4%, respectively; P = 0.94). The bronchoalveolar-lavage group and the endotracheal-aspiration group also had similar rates of targeted therapy (74.2% and 74.6%, respectively; P = 0.90), days alive without antibiotics (10.4 +/- 7.5 and 10.6 +/- 7.9, P = 0.86), and maximum organ-dysfunction scores (mean [+/- SD], 8.3 +/- 3.6 and 8.6 +/- 4.0; P = 0.26). The two groups did not differ significantly in the length of stay in the ICU or hospital.

Conclusion

Two diagnostic strategies for ventilator-associated pneumonia – bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid and endotracheal aspiration with nonquantitative culture of the aspirate – are associated with similar clinical outcomes and similar overall use of antibiotics.

Trial Registration

(Current Controlled Trials number, ISRCTN51767272.)     

刷牙冲洗法口腔护理在ICU患者经口气管插管中的效果研究

目的 探究刷牙冲洗法口腔护理在重症监护(ICU)患者经口气管插管中的效果。方法 选择2017年1月至2018年12月我院ICU监护治疗经口气管插管行机械通气的128例患者作为研究对象。采用随机数字表法将所选患者分为试验组和对照组,各64例。对照组给予传统口腔护理,试验组采用刷牙冲洗法对患者口腔进行护理。统计和比较患者呼吸机相关性肺炎(VAP)发生及口腔异味程率,此外统计患者口腔并发症的发生情况。结果 经刷牙冲洗法口腔护理后试验组VAP发生率明显低于对照组[12.5% vs 29.7%,P<0.05];经刷牙冲洗法口腔护理后试验组口腔异味率明显低于对照组[20.3% vs 57.8%,P<0.05];主要口腔并发症由口腔炎症、口腔溃疡及真菌感染,经刷牙冲洗法口腔护理后试验组并发症的发生率明显低于对照组[4.7% vs 17.2%,P<0.05]。结论 ICU患者经口气管插管后采用刷牙冲洗法口腔护理可有效清除细菌移位,降低VAP的发生及口腔异味,值得在临床推广使用。     

Ventilator-associated pneumonia: breaking the vicious circle of antibiotic overuse

OBJECTIVE: To assess the rate of appropriateness of empirical antimicrobial therapy for ventilator-associated pneumonia, to evaluate de-escalation in patients with ventilator-associated pneumonia treated according to local pathway, and to identify the bacteria responsible for recurrence of ventilator-associated pneumonia. DESIGN: Prospective observational study during a 36-month period. SETTING: Medical-surgical intensive care unit of a university hospital. PATIENTS: One hundred and fifteen patients hospitalized in an intensive care unit developing ventilator-associated pneumonia with positive cultures. The patients with ventilator-associated pneumonia were treated with limited-spectrum antibiotics (i.e., without activity against Pseudomonas aeruginosa) if they had no prior hospitalization (within 21 days) or prior administration of antibiotics (within 10 days). Quantitative cultures obtained by bronchoscopy or tracheal aspiration were used to reassess empirical therapy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A limited-spectrum therapy was used in 79 patients (69%). Empirical antimicrobial therapy was appropriate in 100 patients (85%). The mortality rate was significantly higher in the patients in whom empirical therapy was inappropriate than in those in whom treatment was appropriate (47 vs. 20%, p=.04). De-escalation was done in respectively 26% and 72% of patients with early- and late-onset ventilator-associated pneumonia, whereas treatment was escalated in 27 patients (23%). Ventilator-associated pneumonia episodes were recurrent in 22 cases, including eight episodes due to high-risk bacteria. CONCLUSIONS: A rational empirical antimicrobial therapy for ventilator-associated pneumonia using limited-spectrum antibiotics is possible if local ecology and patient medical history and clinical status are considered. In addition, de-escalation is feasible in 42% of patients. This integrative approach may reduce the emergence of resistant bacteria, which in turns reduces the need for broad-spectrum antibiotics, breaking the vicious circle of antibiotic overuse.     

改进吸痰法在气管插管机械通气患者中的应用效果观察

目的探讨改进吸痰法在气管插管机械通气患者中的应用效果观察。方法将行气管插管机械通气的120例患者,按照随机数字表法分为试验组和对照组,每组各60例,试验组采用改进吸痰法,包括气管导管内（浅部）吸痰、气管导管外（深部）及气囊上方吸痰3部分;对照组采用常规吸痰法。两周后观察两组患者气道黏膜损伤及呼吸机相关性肺炎（ventilator-associated pneumonia,VAP）的发生情况。结果试验组和对照组患者气道黏膜损伤发生率比较,差异具有统计学意义（1.7%vs16.7%,χ2=8.107,P〈0.01）;试验组和对照组患者VAP的发生率比较,差异具有统计学意义（3.3%vs18.3%,χ2=6.988,P〈0.01）。结论改进吸痰法在气管插管机械通气患者中的应用,不仅降低了患者气道黏膜的损伤,同时还降低了VAP的发生,值得临床推广应用。