預(yù)防VAP：Bundle的作用課件

1、預(yù)防VAP: Bundle 的作用解放軍309醫(yī)院急救部 馬朋林預(yù)防VAP: Bundle 的作用解放軍309醫(yī)院急救部 內(nèi)容提要VAP流行病學(xué)1VAP預(yù)防Bundle2研究結(jié)果的啟示3內(nèi)容提要VAP流行病學(xué)1VAP預(yù)防Bundle2研究結(jié)果的啟Am J Respir Crit Care Med Vol 165. pp 867903, 2002確切的發(fā)生率尚未可知 Am J Respir Crit Care Med Vol 預(yù)防VAP：Bundle的作用課件Clinical practice guidelines for HAP and VAP in adults (Canada).Rotst

2、ein C, Can J Infect Dis Med Microbiol 2008;19(1):19-53.ICU VAP: 32.3%Clinical practice guidelines f 時(shí)間1997-2003 數(shù)據(jù)分析 Incidence of VAP： 16.9% of Patients 15.9/1000 MV-days法國11個(gè)ICU VAP監(jiān)測數(shù)據(jù)庫Crit Care Med 2009; 37:2545-2551 時(shí)間1997-2003 數(shù)據(jù)分析法國11個(gè)ICU VAVentilator-associated pneumonia in adults in developi

3、ng countries: a systematic review. InterJ Infect Dis (2008) 12, 505512Ventilator-associated pneumoniOutcomes Attributable to VAPCrit Care Med 2005; 33:21842193Outcomes Attributable to VAPCClinical and economic consequences of VAP: A systematic review. CCM 2005Patients who develop VAP incur$10,019in

4、additional hospital costs.Clinical and economic consequeAm 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 JYAm J Respir Crit Care Med 165.Crit Care Med 2

5、009; 37: 2709-291852項(xiàng)研究包含4882個(gè)VAP患者12465個(gè)非VAP對照者VAP導(dǎo)致死亡相對風(fēng)險(xiǎn)度（RR）1.27 (95%CI: 1.15-1.39, P0.01)Crit Care Med 2009; 37: 2709-Publication BiasI 2=69%Publication BiasI 2=69%研究的差異性分析研究的差異性分析For trauma patients N=9For ARDS patients N=4I 2=1.3%I 2=0%For trauma patients N=9For ARD病源微生物相關(guān)嗎？Am J Respir Crit C

6、are Med 165. pp 867903, 2002病源微生物相關(guān)嗎？Am J Respir Crit CareImpact of MRSA VAP on mortality : a systematic reviewEur Respir J 2008; 31: 625632Impact of MRSA VAP on mortalitCritical Care 2008, 12:R142Determinants and impact of MDR in pathogens causing VAPCritical Care 2008, 12:R142Det高危因素：病人群體高危因素：病人群體

7、病人性別Gender and sex hormone specific risk of ventilatorassociated pneumonia after critical illness or injuryDossett LA , S42 Surgical Forum Abstracts .J Am Coll Surg718 of 2,290 patients developed VAP(31%). Males were more likely to develop VAP (34%vs25%, p0.001), and this association remained after

8、adjusting for age and illness severity (OR1.5, 95% CI1.2-1.8, p0.001). 病人性別Gender and sex hormone speVentilator-Associated PneumoniaInsights From Recent Clinical Trials Kollef MH, CHEST 2005 , 128 ( 5 suppl 2) 583S-591S VariablesAdj OR (95% CI)p ValueTrauma admission1.68 (1.152.47)0.0079Male gender1

9、.54 (1.152.07)0.0042Duration of MV. d 1.50 (1.331.70) 0.0001Continuous sedation1.43 (1.071.92)0.0158EN within 48 h of MV2.65 (1.933.63) 0.0001Parenteral nutrition3.27 (2.244.75) 0.0001Ventilator-Associated Pneumoni病人年齡是問題嗎？Postgrad Med J 2006;82:172178. 病人年齡是問題嗎？Postgrad Med J 2006;8多器官功能障礙綜合征患者呼吸機(jī)相

10、關(guān)性肺炎的危險(xiǎn)因素分析ChinJ Emerg Med, November 2006 , l115 (111):1010多器官功能障礙綜合征患者呼吸機(jī)相關(guān)性肺炎的危險(xiǎn)因素分析ChiA Prospective Study of Ventilator-Associated Pneumonia in ChildrenPediatrics 2009;123:1108-1115A Prospective Study of Ventila機(jī)械通氣時(shí)間VariablesAdj OR (95% CI)p ValueTrauma admission1.68 (1.152.47)0.0079Male gender1

11、.54 (1.152.07)0.0042Duration of MV. d 1.50 (1.331.70) 0.0001Continuous sedation1.43 (1.071.92)0.0158EN within 48 h of MV2.65 (1.933.63) 0.0001Parenteral nutrition3.27 (2.244.75) 24 hours) VAP: mean rate of 23%; 5% : MV for 1 day 69%: MV for 30 days Am Rev Respir Dis 1989;140:302305.A prospective stu

12、dy in 23 ItalRespiratory Medicine (2007) 101, 762767Respiratory Medicine (2007) 10Epidemiology of VAP in a Long-Term Acute Care HospitalA 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

13、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;30:319-324Epidemiology of VAP in a LongMV 時(shí)間VAP發(fā)生率并非線性相關(guān)Day 3: 2.2% increaseDa

14、y 7: 3.3% increaseDay:15: 1.5% decreaseVAP higher risk days: 4-7 MV days Crit Care Med 2009; 37:2545-2551MV 時(shí)間VAP發(fā)生率并非線性相關(guān)Day 3: VAP 高危因素Crit Care Med 2009; 37:2545-2551VAP 高危因素Crit Care Med 2009; 37Continuous Aspiration of Subglottic Secretions in the Prevention of VAP in the Postoperative Period o

15、f Major Heart Surgery CHEST 2008; 134:938946Continuous Aspiration of Subgl醫(yī)源性因素宿主因素操作污染創(chuàng)傷患者胃液PH升高，返流存在基礎(chǔ)疾病老年患者鎮(zhèn)靜過度 男性患者M(jìn)V 高危時(shí)間高SOFA患者VAP 高危因素分析機(jī)體抗感染能力低下不恰當(dāng)操作醫(yī)源性因素宿主因素操作污染創(chuàng)傷患者胃液PH升高，返流存在基礎(chǔ)Story from Current VAP Epidemiological Analysis一雙不干凈的手，對一群缺乏抵抗能力的患者實(shí)施不規(guī)范的操作，導(dǎo)致呼吸機(jī)相關(guān)性肺炎的發(fā)生。結(jié)果：花了大把的錢！增加了死亡風(fēng)險(xiǎn)！Story

16、 from Current VAP Epidemi內(nèi)容提要VAP流行病學(xué)1VAP 預(yù)防Bundle2研究結(jié)果的啟示3內(nèi)容提要VAP流行病學(xué)1VAP 預(yù)防Bundle2研究結(jié)果的Prevention measures of VAPCrit Care Med 2009Prevention measures of VAPCritIHI呼吸機(jī)Bundle內(nèi)容 1、床頭抬高 2、每日喚醒+脫機(jī)試驗(yàn) 3、消化性潰瘍預(yù)防 4、深靜脈血栓預(yù)防Institute of healthcare Improvement 2004IHI呼吸機(jī)Bundle內(nèi)容 1、床頭抬高I捆綁是 有” 或 無”的策略, 要麼不用, 要

17、麼全部應(yīng)用以取得治療的成功。 每個(gè)病人, 每項(xiàng)措施均要落實(shí)Bundle 策略捆綁是 有” 或 無”的策略, 要麼不用, 要麼全部應(yīng)用Reports from Lady of Lourdes Hospital, Binghampton, New York, USA290 Days With a VAP Rate of ZeroReports from Lady of Lourdes Bundle 降低VAP的報(bào)道()Dominican Hospital： 97 daysSt. Vincents Hospital 255 daysVirginia Mason Center 180 daysUniv

18、ersity of Texas 50% reductionNaval Medical Center 150 daysOur Lady of Lourdes 290 daysUniversity of Rochester 300 days Bundle 降低VAP的報(bào)道()DoVAP in a Military Deployed Setting: The Impact of an Aggressive Infection Control Program（ J Trauma. 2008;64:S123S128）VAP in a Military Deployed SetShorr A F, Kol

19、lef M H Chest 2005;128:583S-591SVAP 預(yù)防Bundle 研究結(jié)果Shorr A F, Kollef M H Chest 2Implementing quality improvements in the intensive care unit:Ventilator bundle as an example. Crit Care Med 2009; 37:305309Implementing quality improvemePotential for publication biasFirst, all of the peer-reviewed papers

20、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/1

21、000MV days in the period after implementation of the bundle . Potential for publication biasConclusion:Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundles effectiveness or cost-effectiveness. Conclusion:Lack of methodologi呼吸機(jī) Bundle臨床依從性分析（N=166）2

22、005.6-2008.6 總數(shù)達(dá) 標(biāo)（例/%） 未達(dá)標(biāo)（例/%）措施1 措施2 措施3 措施43 天5635/ 62.519（33.9） 0（0） 0（0） 5（8.9） 4-7天9521/ 22.161（64.2） 8（8.4） 12（12.6） 18（18.9） 7天151/ 6.714（93.3） 5（33.3） 8（53.3） 5（33.3）總體16657/ 34.394（56.6） 13（7.8） 20（12.0） 28（16.9）措施1：床頭抬高30；措施2：每日喚醒+脫機(jī)試驗(yàn)；措施3：潰瘍性潰瘍預(yù)防；措施4：深靜脈血栓預(yù)防 呼吸機(jī) Bundle臨床依從性分析（N=166）2005

23、.Bundle 應(yīng)用前后對照研究對照組干預(yù)組例數(shù)71166男性例數(shù)（%）48 (67.6)114 (68.6)年齡（XS）58.7916.8654.4818.32APACHE評分（XS）13.54.7512.65.56MV時(shí)間（XSD，天）5.925.65.156.13 天（例數(shù)/%）20（28.2）56（33.7） 4-7天（例數(shù)/%）43（60.6）95（57.2） 7天（例數(shù)/%）8（11.2）15（9.1）VAP例數(shù)（%）15（21.1）34（20.5）VAP例數(shù)/1000MV日33.739.528天病死率（例數(shù)/%）12（16.9）33（19.8）Bundle 應(yīng)用前后對照研究對照組

24、干預(yù)組例數(shù)71166男性內(nèi)容提要VAP流行病學(xué)1VAP 預(yù)防Bundle2研究結(jié)果的啟示3內(nèi)容提要VAP流行病學(xué)1VAP 預(yù)防Bundle2研究結(jié)果的Bundle 內(nèi)容的間的邏輯聯(lián)系VAPSedation誤吸營養(yǎng)SBT血栓MV timeMortalityBundle 內(nèi)容的間的邏輯聯(lián)系VAPSedation誤吸營Bundle內(nèi)容中確切有效措施 1、床頭抬高 2、每日喚醒+脫機(jī)試驗(yàn) 3、消化性潰瘍預(yù)防 4、深靜脈血栓預(yù)防Institute of healthcare Improvement 2004Bundle內(nèi)容中確切有效措施 1、床頭抬高1、床頭抬高問題 簡單的操作，但高度差的依從性1、床頭

25、抬高問題 簡單的操作，但高度差的依從性預(yù)防VAP：Bundle的作用課件原因：不能保持30-45度位置原因：不能保持30-45度位置Factors impacting on patient positionNurse preference with average angle 23Negative correlation between angle and severity of illnessSpecific groups e.g. raised ICP and spinal injuryProcedures requiring supine positionPatient preferenceFactors impacting on patient p2. 每日喚醒-脫機(jī)2. 每日喚醒-脫機(jī)僅強(qiáng)調(diào)Wake-up不夠 計(jì)劃鎮(zhèn)靜提高M(jìn)V患者的舒適性 提高M(jìn)V有效性 避免過度鎮(zhèn)靜 僅強(qiáng)調(diào)Wake-up不夠 計(jì)劃鎮(zhèn)靜Depth of Sedation assessed by