预防VAP ：Bundle 的作用马朋林教授.ppt

预防VAP:Bundle 的作用,解放军309医院急救部 马朋林,内容提要,Am J Respir Crit Care Med Vol 165.pp 867903,2002,确切的发生率尚未可知,Clinical practice guidelines for HAP and VAP in adults(Canada).,Rotstein C,Can J Infect Dis Med Microbiol 2008;19(1):19-53.,ICU VAP:32.3%,时间1997-2003 数据分析 Incidence of VAP：16.9%of Patients 15.9/1000 MV-days,法国11个ICU VAP监测数据库,Crit Care Med 2009;37:2545-2551,Ventilator-associated pneumonia in adults in developing countries:a systematic review.,InterJ Infect Dis(2008)12,505512,Outcomes Attributable to VAPCrit Care Med 2005;33:21842193,Clinical and economic consequences of VAP:A systematic review.CCM 2005,Patients who develop VAP incur$10,019in additional hospital costs.,Am J Respir Crit Care Med 165.pp 867903,2002,ICU ventilated patients with VAP have a 2-to 10-fold higher risk of death compared with patients without pneumonia.,Mortality:VAPChastre J and Fagon JY,Crit Care Med 2009;37:2709-2918,52项研究包含4882个VAP患者12465个非VAP对照者,VAP导致死亡相对风险度（RR）1.27(95%CI:1.15-1.39,P0.01),Publication Bias,I 2=69%,研究的差异性分析,For trauma patients N=9,For ARDS patients N=4,I 2=1.3%,I 2=0%,病源微生物相关吗？,Am J Respir Crit Care Med 165.pp 867903,2002,Impact of MRSA VAP on mortality:a systematic review,Eur Respir J 2008;31:625632,Critical Care 2008,12:R142,Determinants and impact of MDR in pathogens causing VAP,高危因素：病人群体,病人性别,Gender and sex hormone specific risk of ventilatorassociated pneumonia after critical illness or injuryDossett LA,S42 Surgical Forum Abstracts.J Am Coll Surg,718 of 2,290 patients developed VAP(31%).Males were more likely to develop VAP(34%vs25%,p0.001),and this association remained after adjusting for age and illness severity(OR1.5,95%CI1.2-1.8,p0.001).,Ventilator-Associated PneumoniaInsights From Recent Clinical Trials,Kollef MH,CHEST 2005,128(5 suppl 2)583S-591S,病人年龄是问题吗？,Postgrad Med J 2006;82:172178.,多器官功能障碍综合征患者呼吸机相关性肺炎的危险因素分析,ChinJ Emerg Med,November 2006,l115(111):1010,A Prospective Study of Ventilator-Associated Pneumonia in Children,Pediatrics 2009;123:1108-1115,机械通气时间,Kollef MH,CHEST 2005,128(5 suppl 2)583S-591S,A prospective study in 23 Italian ICUs724 critically ill patients(MV 24 hours)VAP:mean rate of 23%;5%:MV for 1 day 69%:MV for 30 days Am Rev Respir Dis 1989;140:302305.,Respiratory Medicine(2007)101,762767,Epidemiology of VAP in a Long-Term Acute Care Hospital,A total of 23 CDC-defined cases of VAP occurred in 19 patients during 13,746 ventilator days.The cumulative VAP incidence was 14.6%(23 of 157 admissions),and the incidence rate was 1.67 cases/1,000 ventilator-days,which was a 56%reduction from theVAP rate of 3.8 cases per 1,000 ventilator-days before the implementation of a VAP-bundle approach.,Infect Control Hosp Epidemiol 2009;30:319-324,MV 时间VAP发生率并非线性相关,Day 3:2.2%increaseDay 7:3.3%increaseDay:15:1.5%decreaseVAP higher risk days:4-7 MV days,Crit Care Med 2009;37:2545-2551,VAP 高危因素,Crit Care Med 2009;37:2545-2551,Continuous Aspiration of Subglottic Secretions in the Prevention of VAP in the Postoperative Period of Major Heart Surgery CHEST 2008;134:938946,VAP 高危因素分析,机体抗感染能力低下,不恰当操作,Story from Current VAP Epidemiological Analysis,一双不干净的手，对一群缺乏抵抗能力的患者实施不规范的操作，导致呼吸机相关性肺炎的发生。结果：花了大把的钱！增加了死亡风险！,内容提要,Prevention measures of VAP,Crit Care Med 2009,IHI呼吸机Bundle内容,1、床头抬高 2、每日唤醒+脱机试验 3、消化性溃疡预防 4、深静脉血栓预防,Institute of healthcare Improvement 2004,捆绑是 有”或 无”的策略,要麽不用,要麽全部应用以取得治疗的成功。每个病人,每项措施均要落实,Bundle 策略,Reports from Lady of Lourdes Hospital,Binghampton,New York,USA,290 Days With a VAP Rate of Zero,Bundle 降低VAP的报道(www.ihi.org),Dominican Hospital：97 daysSt.Vincents Hospital 255 daysVirginia Mason Center 180 daysUniversity of Texas 50%reductionNaval Medical Center 150 daysOur Lady of Lourdes 290 daysUniversity of Rochester 300 days,VAP in a Military Deployed Setting:The Impact of an Aggressive Infection Control Program（J Trauma.2008;64:S123S128）,Shorr A F,Kollef M H Chest 2005;128:583S-591S,VAP 预防Bundle 研究结果,Implementing quality improvements in the intensive care unit:Ventilator bundle as an example.,Crit Care Med 2009;37:305309,Potential for publication bias,First,all of the peer-reviewed papers reported positive results and none reported negative ones.A recent story in a nonpeer-reviewed trade publication questioned the effectiveness of bundle implementation in a trauma ICU,where the VAP rate actually increased directionally from 10 cases/1000 MV days in the period before to 11.9 cases/1000MV days in the period after implementation of the bundle.,Conclusion:,Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundles effectiveness or cost-effectiveness.,呼吸机 Bundle临床依从性分析（N=166）2005.6-2008.6,措施1：床头抬高30；措施2：每日唤醒+脱机试验；措施3：溃疡性溃疡预防；措施4：深静脉血栓预防,Bundle 应用前后对照研究,内容提要,Bundle 内容的间的逻辑联系,VAP,Sedation,误吸,营养,SBT,血栓,MV timeMortality,Bundle内容中确切有效措施,1、床头抬高 2、每日唤醒+脱机试验 3、消化性溃疡预防 4、深静脉血栓预防,Institute of healthcare Improvement 2004,1、床头抬高问题,简单的操作，但高度差的依从性,原因：不能保持30-45度位置,Factors impacting on patient position,Nurse preference with average angle 23Negative correlation between angle and severity of illnessSpecific groups e.g.raised ICP and spinal injuryProcedures requiring supine positionPatient preference,2.每日唤醒-脱机,仅强调Wake-up不够,计划镇静提高MV患者的舒适性 提高MV有效性 避免过度镇静,Depth of Sedation assessed by Motor Activity Level,Crit Care Med 2007;35:393401,A total of 111 subjects(40%)received one or more ratings of oversedation,and 211(76.2%)received one or more ratings of undersedation,计划镇静内容,设计方案与目标监测、调整、目标维持每日唤醒镇静撤离,缩短机械通气天数,Changes in sedation management in German intensive care units between 2002 and 2006:A national follow-up survey,Critical Care 2007,11:R124,Wake-up plus SBT,每日一次可能不够,Lancet 2008;371:12634,总结1：VAP,VAP是ICU 最主要的HAP 发生率：10-30例/1000MV天 高危因素：MV时间、食道返流、年龄、机体免疫状态、不规范的与MV相关的医护操作。VAP对预后影响：增加MV时间和医疗费用，可能增加死亡风险。,总结2：呼吸机Bundle,是预防VAP有效的手段之一IHI呼吸机Bundle临床依从性、措施间的逻辑联系以及临床有效性存在争议。优化呼吸机Bundle将具有重要的临床意义。,Thank you for your attention,