呼吸机捆绑式治疗的探讨课件

呼吸机捆绑式治疗的探讨

AReviewoftheVentilatorBundle来自美国的报道

Question什么是捆绑?WhatisaBundle??ANSWERBUNDLE:同时综合运用一组有效的治疗手段优于运用单一治疗手段.

Agroupofinterventionsrelatedtoadiseaseprocess,that,whenexecutedtogether,resultinbetteroutcomesthanwhenimplementedindividually.关于呼吸机捆绑1.升高床头30-45度ElevatingHeadofBedto30-45degrees2.每日间歇停止使用镇静药物DailySedationVacations3.每日评价拔管指征DailyAssessmentofReadinesstoExtubate4.预防消化道溃疡PepticUlcerProphylaxis5.预防深静脉血栓DVTProphylaxis1.升高床头30-45度1.升高床头30-45度

目的:减少呼吸机相关肺炎

GOAL:ReduceVentilator-AssociatedPneumonia(VAP)根据随机实验:Drakulovicetal.Lancet.1999:354:1851-58升高床头30-45度

潜在并发症PotentialComplications休克病人低血压HypotensioninShock可压迫股部血管装置MayCompromiseFemoralDevices须经常调换姿势MayRequireFrequentRepositioning其他?....Others?....2.每日间歇停止使用镇静剂DailySedationVacations

2.每日间隔应用镇静药物

DailySedationVacations

目的:减少通气时间及ICU入住时间

GOALS:DecreaseDurationofVentilationandLengthofICUStayBasedonRandomizedStudy:Kressetal.NEJM.2000:342:1471-72.每日间歇使用镇静剂

DailySedationVacations

潜在并发症PotentialComplications中心静脉管,气管插管或其他装置意外脱出Accidentalremovalofendotrachealtubes,centrallines,otherequipment3.每日评价拔管指征DailyAssessmentofReadinesstoExtubate

3.每日评价拔管指征

DailyAssessmentofReadinesstoExtubate

目的:减少通气时间及ICU入住时间

GOALS:DecreaseDurationofVentilationandLengthofICUStay基于以下随机实验BasedonRandomizedStudies:Elyetal.NEJM.1996:335:1864-9.Estebanetal.NEJM.1995;332:345-50.Elyetal

NEJM.1996;335:1864-9.

Estebanetal

NEJM.1995;332:345-60ElyDailySB

NoDailySB

每日自主呼吸无每日自主呼吸

4.5days* 6.0daysEsteban

multipleSB

oncedailySBIMV

PS

多次

每日一次 5days 4days 3days* 3days*

*P<0.053.每日评价拔管指征

DailyAssessmentofReadinesstoExtubate

潜在并发症PotentialComplications-中心静脉管,气管插管或其他装置意外脱出Accidentalremovalofendotrachealtubes,centrallines,otherequipment4.预防消化道溃疡

PepticUlcerProphylaxis

4.溃疡预防PepticUlcerProphylaxis

矛盾与问题:-机械通气患者PUD的发病率?-相互矛盾的研究结果-Meta-分析推荐使用-PUD可增加VAP风险-谁是最佳?ControversiesandQuestions:-IncidenceofPUDinventilatedpatients?-Conflictingstudies-Meta-analyseshavebeenusedforrecommendations-PUDmayincreasetheriskofVAP-Whichmedicationsarebest?4.溃疡预防PepticUlcerProphylaxis

ASHP诊治规范1.患者接受机械通气>48小时

Patientsreceivingmechanicalventilationfor>48hours2.患者存在凝血异常

Patientswithcoagulopathy3.入院前一年内曾有过消化道出血

Patientswithh/oGIbleedingw/in1yearofadmission4.有至少两项以下危险因素

Patientswithatleasttwoofthefollowingriskfactors -败血症

Sepsis -ICU时间超过1周

ICUstayofmorethan1week -出血6天或以上

Occultbleedinglasting6daysormore -应用大剂量皮质激素

Useofhigh-dosecorticosteroids**Medicationchoiceinstitution-specificIHI-对此干预未给出指征Doesnotspecifypatientselectionforthisintervention-未特别强调某项治疗Doesnotspecifymedication4.溃疡预防

PepticUlcerProphylaxis

潜在并发症PotentialComplications-增加VAP和其他感染的风险IncreaseriskofVAPandotherinfections

(MHKollef.CritCareMed.2004;32:1395-1405.)5.预防深静脉血栓

DVTProphylaxis

目的:预防静脉血栓形成

GOAL:PreventionofThromboembolicEvents基于以下随机实验BasedonRandomizedStudies:Summary:ACCP.CHEST.2004;126:338S-400S.5.预防深静脉血栓DVTProphylaxis

ACCP诊治规范

最严重的患者处于中至高度风险中1. 有出血危险者:低分子或小剂量肝素2. 有出血危险者:机械压迫装置避免使用阿斯匹林MostCriticallyILLPatientsareatModeratetoHighRisk1. Withoutriskofbleeding:eitherlow-molecularorlowdoseunfractionatedheparin2. Withriskofbleeding:mechanicalcompressiondevicesalone3. AspirinshouldbeavoidedIHI

呼吸机捆绑VentilatorBundle…abundleisacohesiveunit.Thestepsmustallbecompletedtosucceed;the“allornone”featureisthesourceofthebundle’spower…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…eachelementin…everypatient….每个病人,每项措施均要落实OurLadyofLourdesHospital,Binghampton,NewYork,USA290DaysWithaVAPRateofZero(March2004toJanuary2005)290天未发生VAPUniversityofRochester/StrongHealthRochester,NewYork,USA>300DaysWithaVAPRateofZero大于300天未出现VAP呼吸机捆绑降低VAP的报道DominicanHospital >97daysSantaCruz,CASt.Vincent’sHospital >255daysBirmingham,ALVirginiaMasonMedicalCenter >180daysSeattle,WAUniversityofTexasMDAnderson 50%reduction Houston,TXNavalMedicalCenter >150daysSanDiego,CAOurLadyofLourdes 290daysBinghampton,NYUniversityofRochester/Strong >300daysRochester,NY

IHI

呼吸机捆绑VentilatorBundle捆绑的证据及应用-院内应用捆绑治疗可降低VAP-非随机实验;无其他观察指标-IHI现在强调VAP;VAP捆绑或呼吸机捆绑?-DVT和PUD预防治疗对VAP并无特异性预防作用BUNDLEEVIDENCEandAPPLICATION-HospitalsusingbundleshavereportedgreatreductionsinVAP-non-randomized;nootheroutcomes-IHInowemphasizesVAP;VAPBUNDLEorVentilatorBundle?-DVTandPUDProphylaxisarenotspecifictopreventionofVAPIHI

呼吸机捆绑的解释VentilatorBundle

Interpretation

Pros积极的-较好的总结Goodsummary-好的开端Goodstaringpoint-所有措施均在至少一次随机临床实验的基础上AllinterventionsbasedonatleastonerandomizedtrialCons负面的-有些方面相互矛盾Someareascontroversial-缺乏技术细节Detailslacking(whichpatients,when,otherspe