The impact of inspiratory pressure level on prevention of ventilator-associated pneumonia: A double-blind,randomized clinical trial

BackgroundAtelectasis and pneumonia are highly prevalent in patients under mechanical ventilation. Studies indicate that using ventilation with an open lung concept improves recovery, decreases ventilator-related pneumonia, decreases mortality and leads to faster weaning from the ventilator. Therefore, this study investigated the effect of higher airway pressure on ventilator-associated pneumonia.MethodsThis randomized clinical trial was conducted on 120 patients under mechanical ventilation. The patients were divided into two groups based on ventilator pressure: the control group (pressure level 20) and the intervention group (pressure level 30). Demographic data, disease severity, the incidence of ventilator-associated pneumonia, organ damage, days connected to the ventilator, length of hospitalization in ICU, and mortality were compared between the two groups.ResultsThere was no significant difference in demographic data and disease severity between the two groups. The average Clinical Pulmonary Infection Score in the intervention group was significantly lower than the control group (P = 0.02). The intervention group's average Sequential Organ Failure Assessment score was significantly lower than the control group (p = 0.016).ConclusionsHigh-pressure levels can decrease ventilator-associated pneumonia and organ failure. It is recommended that the study be repeated with a larger, more diverse population.     

An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects

STUDY OBJECTIVES: To determine whether an educational initiative could decrease rates of ventilator-associated pneumonia in a regional health-care system. SETTING: Two teaching hospitals (one adult, one pediatric) and two community hospitals in an integrated health system. DESIGN: Preintervention and postintervention observational study. PATIENTS: Patients admitted to the four participating hospitals between January 1, 1999, and June 30, 2002, who acquired ventilator-associated pneumonia. INTERVENTION: An educational program for respiratory care practitioners and ICU nurses emphasizing correct practices for the prevention of ventilator-associated pneumonia. The program included a self-study module on risk factors for, and strategies to prevent, ventilator-associated pneumonia and education-based in-services. Fact sheets and posters reinforcing the information were posted throughout the ICU and respiratory care departments. MEASUREMENTS AND RESULTS: Completion rates for the module were calculated by job title at each hospital. Rates of ventilator-associated pneumonia per 1,000 ventilator days were calculated for all hospitals combined and for each hospital separately. Overall 635 of 792 ICU nurses (80.1%) and 215 of 239 respiratory therapists (89.9%) completed the study module. There were 874 episodes of ventilator-associated pneumonia at the four hospitals during the 3.5-year study period out of 129,527 ventilator days. Ventilator-associated pneumonia rates for all four hospitals combined dropped by 46%, from 8.75/1,000 ventilator days in the year prior to the intervention to 4.74/1,000 ventilator days in the 18 months following the intervention (p < 0.001). Statistically significant decreased rates were observed at the pediatric hospital and at two of the three adult hospitals. No change in rates was seen at the community hospital with the lowest rate of study module completion among respiratory therapists (56%). CONCLUSIONS: Educational interventions can be associated with decreased rates of ventilator-associated pneumonia in the ICU setting. The involvement of respiratory therapy staff in addition to ICU nurses is important for the success of educational programs aimed at the prevention of ventilator-associated pneumonia.     

Variability in antibiotic prescribing patterns and outcomes in patients with clinically suspected ventilator-associated pneumonia

STUDY OBJECTIVES: To describe the variation in clinical practice strategies for the treatment of suspected ventilator-associated pneumonia (VAP) in a population of critically ill patients, and to determine whether initial empiric treatment with certain antibiotics, monotherapy vs combination antibiotic therapy, or appropriate vs inappropriate antibiotic therapy is associated with survival, length of hospital stay, or days free of antibiotics. DESIGN: Prospective, observational cohort study. SETTING: Medical-surgical ICUs of two university-affiliated tertiary medical centers. PATIENTS: Between May 1, 1998, and August 1, 2000, we screened 7,030 ICU patients and identified 156 patients with clinically suspected VAP. Patients were followed up until death or discharge from the hospital. RESULTS: The mean age was 62 years, mean APACHE (acute physiology and chronic health evaluation) II score was 14, and mortality was 34%. Combination antibiotic therapy was used in 53% of patients. Piperacillin-tazobactam, fluoroquinolones, vancomycin, cephalosporins, and aminoglycosides were the most commonly employed antibiotics. Initial empiric antibiotics were deemed appropriate in 92% of patients. The predominant organisms isolated from respiratory secretions included Pseudomonas aeruginosa and Staphylococcus aureus. Patients had lower in-hospital mortality rates if their initial treatment regimen included an antipseudomonal penicillin plus beta-lactamase inhibitor (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.21 to 0.80; p = 0.009). There was also a strong trend toward reduced mortality rates in patients treated with aminoglycosides (HR, 0.43; 95% CI, 0.16 to 1.11; p = 0.08). Specific antibiotic therapy was not associated with length of hospital stay or days free of antibiotics. Outcomes were similar for patients treated with monotherapy vs combination therapy, and for patients who received initial appropriate vs inappropriate therapy. CONCLUSIONS: Patients with clinically suspected VAP who receive initial empiric therapy with antipseudomonal penicillins plus beta-lactamase inhibitors, and possibly aminoglycosides, have lower in-hospital mortality rates when compared with those who are not treated with these antibiotics. These agents should be considered for the initial empiric therapy of VAP.     

血必净对严重脓毒症并发呼吸机相关性肺炎发病率的影响

目的观察血必净注射液对严重脓毒症患者呼吸机相关性肺炎发生的影响。方法严重脓毒症并发呼吸衰竭需要机械通气的成年住院患者100名，随机分为血必净治疗组和常规对照组，观察两组病人呼吸机相关性肺炎的发生率，28天病死率，ICU住院时间，呼吸机治疗时间以及抗生素使用天数。结果血必净治疗组呼吸机相关性肺炎的发生率，病死率降低，ICU住院时间，呼吸机治疗时间以及抗生素使用天数缩短，有统计学差异。结论血必净可以降低严重脓毒症患者发生呼吸机相关性肺炎的发病率。     

National Infection Control Program in Turkey: The healthcare associated infection rate experiences over 10 years

BackgroundThe prevalence of healthcare associated infection (HAI) is generally higher in countries with limited resources than developed countries. To address the high prevalence of HAI, Turkish Ministry of Health introduced a national infection control program in 2005.MethodsDevice associated (DA)-HAIs routinely surveyed included ventilator associated events, urinary catheter associated urinary tract infection and central line associated blood stream infection. Rates in DA-HAI were examined from 2008 to 2017 by type of hospitals, bed capacity, and geographic location of hospitals.ResultsAll DA-HAIs declined significantly from 2008 to 2017 nationally for ventilator associated events from 16.69 to 4.86 per 1,000 device days (IRR = 0.29, P < .0001), catheter associated urinary tract infection from 4.98 to 1.59 per 1,000 catheter days (IRR = 0.31, P < .0001) and central line associated blood stream infection from 5.65 to 2.82 per 1,000 catheter days (IRR = 0.47, P < .0001). The rates for DA-HAIs declined significantly in hospitals with ≥200 beds and <200 bed capacity and in all 4 type of hospitals. By 2017 all DA-HAI had significantly improved across all regions.ConclusionsThe introduction of a new national surveillance system supported by a national infection control program has significantly reduced 3 major DA-HAIs that are associated with risk of treatment failure and death. The next critical step in sustaining this crucial improvement will require timely feedback to hospitals using technology and continued buy-in from clinicians for their commitment to safety associated with DA-HAIs using aspirational DA-HAI rates.     

Device-related infections in a pediatric intensive care unit: The Jordan University of Science and Technology experience

To estimate the prevalence of the most frequent infections related to device utilization and their antimicrobial sensitivity panel, and to investigate the overall incidence of device associated infection rates per 1000 device days, at the pediatric intensive care unit of the Jordan University of Science and Technology.This is a retrospective study from a single pediatric intensive care unit. Data were collected in relation to bloodstream infections associated with central venous catheters, pneumonia associated with ventilator endotracheal tubes, and urinary tract infections associated with Foley catheters, between January 2013 and December 2018, according to the center of disease control and prevention protocols.During the 5-year study, 3195 patients were admitted to the pediatric intensive care unit for a total of 16,487 days. Forty-six patients (1.4%) developed 55 infections, with a median incidence rate of 7.4, 3.7, and 0.7 per 1000 days for central line associated infections, ventilator associated pneumonia, and catheter associated infections, respectively. The commonest isolated microorganisms were gram-negative bacteria in 89.1% of cases, and fungi in 10.9% of cases. Among the resistant bacterial isolates, 59.2% were multidrug resistant, and 32.6% were extended spectrum beta lactamase producers Klebsiella pneumoniae and Eschericia coli. High infection rates were related to Acinetobacter baumannii and K pneumoniae, associated with high resistance to cephalosporins. Susceptibility was highest to tigecycline and imipenem at 42.9% and 32.7% respectively.Microbial isolates are commonly associated with healthcare device insertions in pediatric intensive care unit, invasive bacterial infections associated with critical morbidity and mortality. Further studies on device associated infections are recommended for regional profiling purposes.     

Impact of humidification systems on ventilator-associated pneumonia: a randomized multicenter trial

RATIONALE AND OBJECTIVES: The respective influence on the incidence of ventilator-associated pneumonia of currently available systems used for warming and humidifying the gases delivered to mechanically ventilated patients, that is, heated humidifiers and heat and moisture exchanger filters, remains controversial. METHODS: We addressed this question in a multicenter randomized study comparing heated humidifiers (with heated circuits) and filters in an unselected population of 369 intensive care patients receiving mechanical ventilation for more than 48 h. MAIN MEASUREMENTS AND RESULTS: The diagnosis of pneumonia was confirmed according to strict microbiologic criteria. There was no difference in pneumonia rate between the two groups (53 of 184 [28.8%] versus 47 of 185 [25.4%] for humidifiers versus filters; p = 0.48), or in the incidence density of pneumonia (27.4/1,000 ventilatory days versus 25.3/1,000 ventilatory days for humidifiers versus filters; p = 0.76). The mean duration of mechanical ventilation did not differ between the two groups (14.9 +/- 15.1 versus 13.5 +/- 16.3 days for humidifiers versus filters, p = 0.36). Endotracheal tube occlusion occurred, respectively, in five patients and one patient in the humidifier and filter groups (p = 0.12). Intensive care mortality was identical in the two groups (about 33%). CONCLUSION: These results suggest that both heated humidifiers and heat and moisture exchanger filters can be used with no significant impact on the incidence of ventilator-associated pneumonia and that other criteria may justify their choice.     

呼吸机相关性肺炎的好发因素及病原学分析

目的分析急诊内科ICU呼吸机相关性肺炎的好发因素及病原学、药敏情况。方法分析本院急诊内科ICU近4年来收治的48例呼吸机相关性肺炎患者的好发因素、病原学药敏结果。结果呼吸机相关性肺炎的好发因素:年龄、呼吸机使用时间延长、APACHEII评分增高、低蛋白血症、抗生素及激素的使用、肠内营养返流,进行计数统计,P0.05,有统计学差异。呼吸机相关性肺炎主要以革兰氏阴性杆菌(65.4%)为主,其次为革兰氏阳性球菌(21.8%),现在真菌(12.8%)感染日益增多。结论使用呼吸机的患者需注意避免呼吸机相关性肺炎的好发因素,一旦发生呼吸机相关性肺炎,可经验性使用革兰氏阴性杆菌敏感的抗生素,同时及时的病原培养药敏检查。     

Multidrug-resistant Pseudomonas aeruginosa and mortality in mechanically ventilated ICU patients

BackgroundThe link between bacterial resistance and prognosis remains controversial. Predominant pathogen causing ventilator-associated pneumonia (VAP) is Pseudomonas aeruginosa (Pa), which has increasingly become multidrug resistant (MDR). The aim of this study was to evaluate the relationship between MDR VAP Pa episodes and 30-day mortality.MethodsFrom a longitudinal prospective French multicenter database (2010-2016), Pa VAP onset and physiological data were recorded. MDR was defined as non-susceptibility to at least 1 agent in 3 or more antimicrobial categories. To analyze if MDR episodes were associated with greater in-hospital 30-day mortality, we performed a multivariate survival analysis using the multivariate nonlinear frailty model.ResultsA total of 230 patients presented 286 Pa VAP. A maximum of 3 episodes per patient was observed; 73 episodes were MDR and 213 were susceptible. In the multivariate model, factors independently associated with 30-day mortality included hospitalization in the 6 months preceding the first episode (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.50-3.60; P = .0002), chronic renal failure (HR, 2.34; 95% CI, 1.15-4.77; P = .0196), and Pa VAP recurrence (HR, 2.29; 95% CI, 1.79-4.87; P = .032). Finally, MDR Pa VAP was not associated with death (HR, 0.87; 95% CI; 0.52-1.45; P = .59).ConclusionsThis study did not identify a relationship between the resistance profile of Pseudomonas aeruginosa and mortality.     

Guidelines-concordant empiric antimicrobial therapy and mortality in patients with severe community-acquired pneumonia requiring mechanical ventilation

Background

Community-acquired pneumonia (CAP) has high morbidity and mortality among adults. Several clinical guidelines recommend prompt administration of combined antimicrobial therapy. However, the association between guidelines concordance and mortality in patients with severe pneumonia remains unclear. The present study aimed to examine the impact of guidelines-concordant empiric antimicrobial therapy on 7-day mortality in patients with extremely severe pneumonia who required mechanical ventilation at admission, using a nationwide inpatient database in Japan.

Appropriateness and delay to initiate therapy in ventilator-associated pneumonia.

Inappropriate therapy (IT) and delayed initiation of appropriate therapy (DIAT) result in inadequate therapy in patients with ventilator-associated pneumonia (VAP). The aim of the current study was to assess the impact of DIAT in VAP. A total of 76 mechanically ventilated patients with bacteriologically confirmed VAP were prospectively evaluated in the intensive care unit of six hospitals in Buenos Aires, Argentina. Appropriate therapy was defined as coverage of all the identified pathogens by the antimicrobial therapy administered at the time of VAP clinical diagnosis. The clinical pulmonary infection score was measured during the 3 days before, at the onset and during the days which followed the onset of VAP. A total of 24 patients received adequate therapy; mortality was 29.2%. The remaining 52 patients received either IT (n = 16) or DIAT (n = 36); the mortality was 63.5% combined, and 75.0 and 58.3% for IT and DIAT, respectively (statistically significant compared with adequate therapy). Inappropriate therapy and delayed initiation of appropriate therapy increased the mortality of ventilator-associated pneumonia. Patients with inappropriate therapy and/or delayed initiation of appropriate therapy had a more gradual increase in clinical pulmonary infection score than those receiving adequate therapy, and this increase was found to occur prior to the time of the clinical diagnosis. In conclusion, these findings might provide the rationale for a trial of earlier initiation of therapy, based on clinical grounds in an effort to improve the outcome of patients with ventilator-associated pneumonia.     

Epidemiology and microbiology of hospital-acquired pneumonia

Hospital-acquired pneumonia (HAP) is the second most common nosocomial infection in the critically ill patient and is associated with the greatest mortality and increased morbidity and cost of care. The major risk factor for the development of HAP in intensive care is the occurrence of intubation and mechanical ventilation, giving rise to the term ventilator-associated pneumonia (VAP). Incidence of VAP varies in different populations of critically ill patients and generally ranges from 9 to 20%, with an overall rate of 10 to 15 cases per 1,000 ventilator days. The cumulative risk of developing VAP is ~1% per day of mechanical ventilation (MV). The crude mortality rate of VAP is 60% and the estimates of attributable risk range from 27 to 43%. Mortality from VAP is influenced by host factors, the virulence of the pathogens, and the adequacy of initial antimicrobial therapy. The etiologic agents for VAP differ according to the population studied, duration of hospital stay, time after intubation, and prior antimicrobial therapy. Risk factors include nonmodifiable factors like age, chronic obstructive pulmonary disease, severe head trauma, and multiple trauma, and modifiable factors like large volume gastric aspiration, duration of MV, elevated gastric pH, histamine type 2 blocker therapy, ventilator circuit change frequency, self-extubation, and reintubation. The impact that diagnosis using invasive diagnostic techniques may have on the epidemiological characteristics of VAP are unknown, but may potentially reduce problems resulting from misclassification of this entity.     

Quantitative culture of endotracheal aspirate and BAL fluid samples in the management of patients with ventilator-associated pneumonia: a randomized clinical trial

OBJECTIVE:

To compare 28-day mortality rates and clinical outcomes in ICU patients with ventilator-associated pneumonia according to the diagnostic strategy used.

METHODS:

This was a prospective randomized clinical trial. Of the 73 patients included in the study, 36 and 37 were randomized to undergo BAL or endotracheal aspiration (EA), respectively. Antibiotic therapy was based on guidelines and was adjusted according to the results of quantitative cultures.

RESULTS:

The 28-day mortality rate was similar in the BAL and EA groups (25.0% and 37.8%, respectively; p = 0.353). There were no differences between the groups regarding the duration of mechanical ventilation, antibiotic therapy, secondary complications, VAP recurrence, or length of ICU and hospital stay. Initial antibiotic therapy was deemed appropriate in 28 (77.8%) and 30 (83.3%) of the patients in the BAL and EA groups, respectively (p = 0.551). The 28-day mortality rate was not associated with the appropriateness of initial therapy in the BAL and EA groups (appropriate therapy: 35.7% vs. 43.3%; p = 0.553; and inappropriate therapy: 62.5% vs. 50.0%; p = 1.000). Previous use of antibiotics did not affect the culture yield in the EA or BAL group (p = 0.130 and p = 0.484, respectively).

CONCLUSIONS:

In the context of this study, the management of VAP patients, based on the results of quantitative endotracheal aspirate cultures, led to similar clinical outcomes to those obtained with the results of quantitative BAL fluid cultures.     

The impact of serum vancomycin levels and minimum inhibitory concentrations of methicillin-resistant Staphylococcus aureus on mortality in patients with nosocomial pneumonia

BACKGROUND:

Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) infections; however, treatment failure is not uncommon, even when the minimum inhibitory concentration (MIC) of the MRSA strain is within the susceptible range for vancomycin.

OBJECTIVE:

To describe the relationship between molecular markers such as the mecA and agrII genes, serum vancomycin levels and vancomycin MICs, and the 30-day mortality rate of patients with nosocomial MRSA pneumonia in an intensive care unit (ICU).

METHODS:

The present study was a prospective cohort study including all patients with MRSA hospital-acquired pneumonia or ventilator-associated pneumonia who were admitted to the ICU of a tertiary care hospital between June 2009 and December 2011. The MIC for vancomycin was determined using the E-test and broth microdilution methods. Variables analyzed included age, sex, comorbid conditions, serum vancomycin trough concentration, the Acute Physiology and Chronic Health Evaluation II (APACHE) score and the presence of the agrII gene. The primary outcome was mortality at 30 days.

RESULTS:

Thirty-six (42.4%) patients died within 30 days of the index MRSA culture. A multiple regression analysis that included the variables of MIC (determined using the E-test or broth microdilution methods), APACHE II score, serum vancomycin level and the presence of agrII revealed that only the APACHE II score was related to the 30-day mortality rate (P=0.03). Seven patients (9.0%) with isolates exhibiting an MIC ≥1.5 μg/mL according to the E-test method died, and nine patients (11.6%) survived (P=0.76). Of the patients for whom MICs were determined using the broth microdilution method, 11 (14.1%) patients with MICs of 1.0 μg/mL died, and 16 (20.5%) survived (P=0.92). The median APACHE II score of survivors was 22.5, and the median score of nonsurvivors was 25.0 (P=0.03). The presence of the agrII gene was not related to the 30-day mortality rate.

CONCLUSIONS:

Patients with severe hospital-acquired pneumonia presented with MRSA isolates with low to intermediate vancomycin MICs in the ICU setting. At the Hospital de Clínicas de Porto Alegre (Porto Alegre, Brazil), the 30-day mortality rate was high, and was similar among patients with severe hospital-acquired pneumonia infected with MRSA isolates that exhibited MICs of ≤1.5 μg/mL determined using the E-test method and ≤1.0 μg/mL determined using the broth microdilution method in those who achieved optimal serum vancomycin levels. The APACHE II scores which provides an overall estimate of ICU mortality were independently associated with mortality in the present study, regardless of the MICs determined. Molecular markers, such as the agrII gene, were not associated with higher mortality in the present study.     

慢性阻塞性肺疾病患者呼吸机相关肺炎的病原菌特点与临床分析

目的 探讨慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)患者呼吸机相关肺炎(ventilator-associated pneumonia,VAP)的病原菌分布与临床特点.方法 回顾分析对我院呼吸科及重症监护病房COPD并呼吸衰竭患者行插管机械通气发生VAP的52例患者的下呼吸道分泌物、肺泡灌洗液等标本进行细菌培养和药敏实验,并分析临床特点.结果 COPD并VAP的主要病原菌依次是铜绿假单胞菌(25.6%)、肺炎克雷伯菌(15.8%)、耐甲氧西林金黄色葡萄球菌(15.8%)、鲍曼不动杆菌(13.4%)和大肠埃希菌(8.5%),以革兰阴性杆菌为主.结论 COPD并VAP病原菌对常见抗生素耐药性较高,机械通气术前抗生素应用者,VAP的病原菌高度耐药,病死率较高;抗生素治疗应用降阶梯方法病死率较低;迟发性(4 d后)VAP与早发性(4 d内)VAP病死率差异无统计学意义.     

Factors influencing survival in patients with multidrugresistant Acinetobacter baumannii infection

Multidrug-resistant (MDR) Acinetobacter baumannii (Acb) is a rapidly emerging pathogen in healthcare settings. The aim of this study was to evaluate the predictors of poor outcome in patients with MDR Acb. This is the first report documenting factors influencing survival in patients with MDR Acb in this tertiary hospital. This study is a prospective of the hospital epidemiology database. A total of 73 patients with 84 Acb isolates were obtained between August 2009 and October 2010 in this hospital. In the present study, the 30-day mortality rate was 39.7%. Of 84 Acb isolates, 50 (59%) were MDR, nine (11%) were pan-resistant, and 25 (30%) were non-MDR. The non-MDR isolates were used as the control group. The factors significantly associated with multidrug resistance included previous surgeries, presence of comorbidity (renal disease), use of more than two devices, parenteral nutrition, and inappropriate antimicrobial therapy. Significant predictors of 30-day mortality in the univariate analysis included pneumonia, diabetes mellitus, renal disease, use of more than two devices, and inappropriate antimicrobial therapy administered within two days of the onset of infection. The factors associated with mortality in patients with MDR Acb infection in this study were: age ≥ 60 years, pneumonia, diabetes mellitus, renal disease, use of more than two invasive procedures, and inappropriate antimicrobial therapy. Vigilance is needed to prevent outbreaks of this opportunistic and deadly pathogen.     

Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients

Seventy-eight (24%) episodes of nosocomial pneumonia (NP) were detected in 322 consecutive mechanically ventilated patients admitted to a 1,000-bed teaching hospital from April 1987 through May 1988 to assess the incidence, risk, and prognosis factors of NP acquired during mechanical ventilation (MV). The risk and prognosis factors for developing NP during MV were studied using both univariate and multivariate statistical techniques. Multivariate analysis selected the following variables significantly associated with a higher risk for developing ventilator-associated pneumonia: more than one intubation during MV (p = 0.000012), a prior episode of aspiration of gastric content (p = 0.00018), a MV period longer than 3 days (p = 0.015), the presence of chronic obstructive pulmonary disease (COPD) (p = 0.048), and the use of positive end-expiratory pressure (PEEP) during MV (p = 0.092). The presence of an ultimately or rapidly fatal underlying disease (p = 0.0018), worsening of acute respiratory failure caused by pneumonia (p = 0.0096), the presence of septic shock (p = 0.016), an inappropriate antibiotic treatment (p = 0.02), and the type of intensive care unit (ICU) hospitalization (noncardiac surgery and nonsurgical ICU compared with post-cardiac surgery ICU) (p = 0.08) were those factors selected by a stepwise logistic regression analysis as independently worsening the prognosis. The overall fatality rate was 23% (73 of 322). The mortality of patients with NP was higher (33%; 26 of 78; p less than 0.01) when compared with fatality rates of patients without NP (19%; 47 of 244).(ABSTRACT TRUNCATED AT 250 WORDS)     

硫糖铝和抑酸剂预防应激性溃疡对机械通气患者发生呼吸机相关性肺炎影响的Meta分析

 目的 比较硫糖铝和抑酸剂预防应激性溃疡对ICU机械通气患者发生呼吸机相关性肺炎(VAP)的影响。方法 计算机检索PubMed、EMbase、Cochrane Library、万方数据库、中国期刊全文数据库和手工检索从建库至2013年3月硫糖铝和抑酸剂预防ICU机械通气患者应激性溃疡的RCT研究,按Cochrane协作网推荐的系统评价员手册5.2.3文献质量评价标准评价纳入研究质量,用RevMan 5.2软件进行Meta分析。结果 共纳入15项RCT研究,总样本量为2883例,硫糖铝组1315例,抑酸剂组1568例。Meta分析结果显示:硫糖铝组较抑酸剂组能显著降低VAP的发生率(RR=0.81,95%CI 0.7~0.95 ,P=0.008),对上消化道出血发生率的影响差异无统计学意义(RR=0.96,95%CI 0.59~1.58,P=0.88),两组患者机械通气时间、ICU留治时间、ICU病死率均差异无统计学意义 (P值均>0.05)。结论 应用硫糖铝可降低ICU机械通气患者VAP的发生率,对消化道出血的发生率、机械通气时间、ICU留治时间、ICU病死率无明显影响。     

The relationship between frequency of ventilator circuit changes and infectious hazard.

The relationship between frequency of ventilator circuit changes and risk of ventilator-associated pneumonia was studied using 2 independent approaches. The first was an in-use aerosol contamination study with patients on 8-hour, 16-hour, or 24-hour ventilator changing schedules. The second approach was a study comparing the incidence of pneumonia in patients on ventilators for 2 one-year periods when the ventilator circuit changing time differed. In-use aerosol sampling of 513 ventilator treatment periods showed bacterial contamination greater than 100 organisms per aerosol in 1.8 per cent of 8-hour cycles, in 2.5 per cent of 16-hour cycles, and in 5.4 per cent of 24-hour cycles. These differences were not significant. The incidence of ventilator-associated pneumonia was the same for one-year periods when ventilator circuits were changed either every 8 or every 24 hours. It was concluded that changing ventilator circuits every 24 hours provides adequate protection from ventilator-associated pneumonia.