醫(yī)院獲得性肺炎的預(yù)防

1、改變胃排空及胃液ph值的藥物有生物膜的裝置(氣管插管, 鼻胃管)既往應(yīng)用抗生素宿主因素(免疫抑制, 燒傷)消化道細(xì)菌定植細(xì)菌誤吸細(xì)菌吸入醫(yī)院獲得性肺炎水, 藥物溶液及呼吸治療裝置污染感染控制措施不夠(洗手, 隔離衣, 手套)醫(yī)務(wù)人員不足經(jīng)胸種植原發(fā)性菌血癥胃腸道細(xì)菌移位細(xì)菌定植(口咽, 胃, 鼻竇)污染分泌物誤吸/呼吸機(jī)管路冷凝物/氣霧劑醫(yī)院獲得性肺炎醫(yī)院獲得性肺炎發(fā)病機(jī)制醫(yī)院獲得性肺炎預(yù)防措施避免不必要的抗生素使用避免不必要的應(yīng)激性潰瘍預(yù)防硫醣鋁預(yù)防應(yīng)激性潰瘍經(jīng)口氣管插管洗必太口腔清洗選擇性胃腸道去污染短療程胃腸外抗生素使用適當(dāng)洗手避免氣管插管/無創(chuàng)通氣縮短機(jī)械通氣時(shí)間半臥位避免胃過度膨脹聲

2、門下分泌物引流避免頻繁更換呼吸機(jī)管路/操作引流呼吸機(jī)管路中的冷凝水避免患者轉(zhuǎn)運(yùn)避免意外拔管細(xì)菌定植(口咽, 胃, 鼻竇)污染分泌物誤吸/呼吸機(jī)管路冷凝物/氣霧劑醫(yī)院獲得性肺炎醫(yī)院獲得性肺炎發(fā)病機(jī)制醫(yī)院獲得性肺炎預(yù)防措施避免不必要的抗生素使用避免不必要的應(yīng)激性潰瘍預(yù)防硫醣鋁預(yù)防應(yīng)激性潰瘍經(jīng)口氣管插管洗必太口腔清洗選擇性胃腸道去污染短療程胃腸外抗生素使用適當(dāng)洗手避免氣管插管/無創(chuàng)通氣縮短機(jī)械通氣時(shí)間半臥位避免胃過度膨脹聲門下分泌物引流避免頻繁更換呼吸機(jī)管路/操作引流呼吸機(jī)管路中的冷凝水避免患者轉(zhuǎn)運(yùn)避免意外拔管15% (18/118)27% (32/118)kress jp, pohlman as,

3、 oconnon mf, hall jb. daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. n engl j med 2000; 342: 1471-1477marelich gp, murin s, battistella f, inciardi j, vierra t, roby m. protocol weaning of mechanical ventilation in medical and surgical patients

4、 by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. chest 2000; 118: 459-467內(nèi)科患者(p = 0.674)9%7%0%5%10%15%20%mdvmpvap發(fā)生率marelich gp, murin s, battistella f, inciardi j, vierra t, roby m. protocol weaning of mechanical ventilation in

5、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%mdvmpvap發(fā)生率總計(jì)(p = 0.100)12%7%0%5%10%15%20%mdvmpvap發(fā)生率dodek p, keenan s, cook d, heyland d, jac

6、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: 305-313p 72 h(n = 100)

7、插管后靜脈頭孢呋肟1.5 g x 2(n = 50)對(duì)照組(n = 50)預(yù)防性抗生素(n = 17)未用抗生素(n = 33)12 (24%)4 (23%)21 (64%)p = 0.016p = 0.007早發(fā)性肺炎早發(fā)性肺炎70% (26/37)51.4%58.2%71.0%0%20%40%60%80%無vap所有vap遲發(fā)性vap輸血患者比例shorr af, duh m-s, kelly km, et al: red blood cell transfusion and ventilator-associated pneumonia. a potential link? crit c

8、are med 2004; 32(3):666-674shorr 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):666-674cook d, ricard jd, reeve b, et al: ventilator circuit and secretion management strategies: a franco-canadian survey. crit

9、care med 2000; 28:35473554不依從率37.0%推薦臨床使用的措施不依從率: 25.2%效果不太顯著的措施不依從率: 45.6%rello j, lorente c, bodi m, et al: why physicians do not follow evidence-based guidelines for preventing ventilator-associated pneumonia? a survey based on the opinions of an international panel of intensivists. chest 2002; 1

10、22:656661or 1.80不依從率37.0%藥物措施不依從率: 57.4%非藥物措施不依從率: 19.6%rello j, lorente c, bodi m, et al: why physicians do not follow evidence-based guidelines for preventing ventilator-associated pneumonia? a survey based on the opinions of an international panel of intensivists. chest 2002; 122:656661推薦臨床使用的措施不

11、依從率: 38.9%效果不太顯著的措施不依從率: 78.9%推薦臨床使用的措施不依從率: 16.4%效果不太顯著的措施不依從率: 23.4%rello j, lorente c, bodi m, et al: why physicians do not follow evidence-based guidelines for preventing ventilator-associated pneumonia? a survey based on the opinions of an international panel of intensivists. chest 2002; 122:65

12、6661完全不同意完全同意19dodek 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 pne

13、umonia. ann intern med 2004; 141: 305-3139.08.28.98.58.67.97.28.68.8完全不同意完全同意19dodek 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 pr

14、actice guideline for the prevention of ventilator-associated pneumonia. ann intern med 2004; 141: 305-3138.08.58.38.38.2cook dj, meade mo, hand le, et al: toward understanding evidence uptake: semirecumbency for pneumonia prevention. crit care med 2002; 30:14721477babcock hm, zack je, garrison t, et

15、 al: an educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. chest, in pressbabcock hm, zack je, garrison t, et al: an educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a compariso

16、n of effects. chest, in presskollef mh. the prevention of ventilator-associated pneumonia. n engl j med 1999; 340:627634kollef mh. the prevention of ventilator-associated pneumonia. n engl j med 1999; 340:627634桿菌和流感病毒的疫苗桿菌和流感病毒的疫苗kollef mh. the prevention of ventilator-associated pneumonia. n engl j med 1999; 340:627634kollef mh. the prevention of ventilator-associated pneumonia. n engl j med 1999; 340:627634dodek p, keenan s, cook d, heyland d, jacka m, hand l, muscedere