医院获得性肺炎的预防

1、 改变胃排空及胃 液pH值的药物 有生物膜的装置 (气管插管, 鼻胃管) 既往应用抗生素 宿主因素 (免疫抑制, 烧伤) 消化道细菌定植 细菌误吸细菌吸入 医院获得性肺炎 水, 药物溶液及呼 吸治疗装置污染 感染控制措施不够 (洗手, 隔离衣, 手套) 医务人员不足 经胸种植 原发性菌血症 胃肠道细菌移位 细菌定植 (口咽, 胃, 鼻窦) 污染分泌物误吸/呼吸 机管路冷凝物/气雾剂 医院获得性肺炎 医院获得性肺炎发病机制医院获得性肺炎预防措施 避免不必要的抗生素使用 避免不必要的应激性溃疡预防 硫醣铝预防应激性溃疡 经口气管插管 洗必太口腔清洗 选择性胃肠道去污染 短疗程胃肠外抗生素使用 适当

2、洗手 避免气管插管/无创通气 缩短机械通气时间 半卧位 避免胃过度膨胀 声门下分泌物引流 避免频繁更换呼吸机管路/操作 引流呼吸机管路中的冷凝水 避免患者转运 避免意外拔管 细菌定植 (口咽, 胃, 鼻窦) 污染分泌物误吸/呼吸 机管路冷凝物/气雾剂 医院获得性肺炎 医院获得性肺炎发病机制医院获得性肺炎预防措施 避免不必要的抗生素使用 避免不必要的应激性溃疡预防 硫醣铝预防应激性溃疡 经口气管插管 洗必太口腔清洗 选择性胃肠道去污染 短疗程胃肠外抗生素使用 适当洗手 避免气管插管/无创通气 缩短机械通气时间 半卧位 避免胃过度膨胀 声门下分泌物引流 避免频繁更换呼吸机管路/操作 引流呼吸机管路

3、中的冷凝水 避免患者转运 避免意外拔管 Kress JP, Pohlman AS, OConnon MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-1477 Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol Weaning of Mechanical Ve

4、ntilation in Medical and Surgical Patients by Respiratory Care Practitioners and Nurses: Effect on Weaning Time and Incidence of Ventilator-Associated Pneumonia. Chest 2000; 118: 459-467 内科患者(p = 0.674) 9% 7% 0% 5% 10% 15% 20% MDVMP VAP发生率 Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, R

5、oby M. Protocol Weaning of Mechanical Ventilation in Medical and Surgical Patients by Respiratory Care Practitioners and Nurses: Effect on Weaning Time and Incidence of Ventilator-Associated Pneumonia. Chest 2000; 118: 459-467 外科患者(p = 0.061) 15% 6% 0% 5% 10% 15% 20% MDVMP VAP发生率 总计(p = 0.100) 12% 7

6、% 0% 5% 10% 15% 20% MDVMP VAP发生率 Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventila

7、tor-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313 P 72 h (n = 100) 插管后静脉 头孢呋肟1.5 g x 2 (n = 50) 对照组 (n = 50) 预防性抗生素 (n = 17) 未用抗生素 (n = 33) 12 (24%) 4 (23%) 21 (64%) P = 0.016 P = 0.007 早发性肺炎早发性肺炎 70% (26/37) 51.4% 58.2% 71.0% 0% 20% 40% 60% 80% 无VAP所有VAP迟发性VAP 输血患者比例 Shorr AF, Duh M-S, Ke

8、lly KM, et al: Red blood cell transfusion and ventilator-associated pneumonia. A potential link? Crit Care Med 2004; 32(3):666-674 Shorr AF, Duh M-S, Kelly KM, et al: Red blood cell transfusion and ventilator-associated pneumonia. A potential link? Crit Care Med 2004; 32(3):666-674 Cook D, Ricard JD

9、, Reeve B, et al: Ventilator circuit and secretion management strategies: A Franco-Canadian survey. Crit Care Med 2000; 28:35473554 不依从率 37.0% 推荐临床使用的措施 不依从率: 25.2% 效果不太显著的措施 不依从率: 45.6% Rello J, Lorente C, Bodi M, et al: Why physicians do not follow evidence-based guidelines for preventing ventilat

10、or-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661 OR 1.80 不依从率 37.0% 药物措施 不依从率: 57.4% 非药物措施 不依从率: 19.6% Rello J, Lorente C, Bodi M, et al: Why physicians do not follow evidence-based guidelines for preventing ventilator-associat

11、ed pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661 推荐临床使用的措施 不依从率: 38.9% 效果不太显著的措施 不依从率: 78.9% 推荐临床使用的措施 不依从率: 16.4% 效果不太显著的措施 不依从率: 23.4% Rello J, Lorente C, Bodi M, et al: Why physicians do not follow evidence-based guidelines for prevent

12、ing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661 完全不同意完全同意 19 Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Grou

13、p and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313 9.0 8.2 8.9 8.5 8.6 7.9 7.2 8.6 8.8 完全不同意完全同意 19 Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D,

14、 Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313 8.0 8.5 8.3 8.3 8.2 体位改变体位改变 Cook DJ, Meade MO, Ha

15、nd LE, et al: Toward understanding evidence uptake: Semirecumbency for pneumonia prevention. Crit Care Med 2002; 30:14721477 Babcock HM, Zack JE, Garrison T, et al: An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest, I

16、n Press Babcock HM, Zack JE, Garrison T, et al: An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest, In Press Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999; 340:627634 Kollef MH. The pr

17、evention of ventilator-associated pneumonia. N Engl J Med 1999; 340:627634 Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999; 340:627634 Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999; 340:627634 Dodek P, Keenan S, Cook D, Heyland D, Jac

18、ka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313 Dodek P, Keena

19、n S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004;

20、141: 305-313 Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneum

21、onia. Ann Intern Med 2004; 141: 305-313 Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systemic review. JAMA 2002; 288: 2151-2162 10.90.80.70.60.50.41.61.51.41.31.21.1 Favors high-intensityFavors low-intensity Relative Risk Hospital Mortality