蛛网膜下腔出血后感染并发症的危险因素王宁.ppt

蛛网膜下腔出血后感染并发症的危险因素InfectiouscomplicationsofaneurysmalSAH,王宁首都医科大学宣武医院神经外科ICU2009-06-21,目录,动脉瘤破裂造成的临床级联反应感染性并发症的危险因素及对预后的影响肺炎在肺部并发症的状况？肺部并发症的预防与控制,动脉瘤破裂造成的临床级联反应,Ahighermortalityandmorbiditydisease,ThemortalityrateforSAHinthe1966CooperativeStudyonIntracranialAneurysmswas50%at29days33%inarecentanalysisofin-hospitaldeathsamongSAHpatientsadmittedthroughanemergencydepartment,Naturehistory,IntheprospectiveCooperativeAneurysmStudy,rebleedingwasmaximal(4%)onthefirstdayafterSAHandthenconstantatarateof1%perdayto2%perdayoverthesubsequent4weeks.Severalprospectivefollow-upcohortshavedemonstratedthattheriskofrebleedingwithconservativetherapyisbetween20%and30%forthefirstmonthafterhemorrhageandthenstabilizesatarateof3%peryear.,并发症是影响预后的重要因素,ThefactorsthatstronglyinfluenceoutcomeafterSAH,Patientfactors:theseverityofinitialhemorrhage,age,sex,timetotreatment,andmedicalco-morbiditiessuchasuntreatedandtreatedhypertension,atrialfibrillation,congestiveheartfailure,coronaryarterydisease,andrenaldisease.Aneurysmfactors:size,locationintheposteriorcirculation,andpossiblymorphology.Institutionalfactorsincludetheavailabilityofendovascularservices,thevolumeofSAHpatientstreated,andthetypeoffacilityinwhichthepatientisfirstevaluated.CrossDT.Mortalityratesaftersubarachnoidhemorrhage:variationsaccordingtohospitalcasevolumein18states.JNeurosurg.2019;99:810817.,Vasospasm,Angiographicvasospasmisseenin30%to70%ofpatientsIncontemporaryseries,15%to20%ofsuchpatientssufferstrokeordieofvasospasmdespitemaximaltherapyLookedatanotherway,vasospasmappearstoaccountfornearly50%ofthedeathsinpatientssurvivingtotreatmentafterSAHLongstrethWT.Clinicalcourseofspontaneoussubarachnoidhemorrhage:apopulation-basedstudyinKingCounty,Washington.Neurology.1993;43:712718.,Hydrocephalus,Acutehydrocephalus(ventricularenlargementwithin72hours)isreportedtooccurin20%to30%ofpatients.Chronicventriculomegalyrequiringpermanentshuntingproceduresisreportedatratesof18%to26%ofsurvivingpatients.,Seizures,Morerecentretrospectivereviewsreportalowfrequencyofseizuresrangingfrom6%to18%.Delayedseizuresoccurredin7%ofpatientsinanotherseries.,Balanceofwaterandelectrolytes,ThereportedincidenceofhyponatremiaafterSAHrangesfrom10%to30%.,感染性并发症的危险因素及对预后的影响,两种手术方式治疗动脉瘤并发症分布,Wartenberg,KatjaE.IMPACTOFNOSOCOMIALINFECTIOUSCOMPLICATIONSAFTERSUBARACHNOIDHEMORRHAGE.Neurosurgery.201962(1),8087,Wartenberg,KatjaE.IMPACTOFNOSOCOMIALINFECTIOUSCOMPLICATIONSAFTERSUBARACHNOIDHEMORRHAGE.Neurosurgery.201962(1),8087,神经原性肺水肿（Neurogenicpulmonaryedema）,TheincidenceofNPEwas8%(39of477patients).MostpatientswithNPEwereseverelyimpairedandallofthempresentedwithradiologicallyseverehemorrhagePatientswithNPEshowedpoorneurologicoutcome(Glasgowoutcomescale1to3in25%vs.77%ofpatients)MuroiC.Neurogenicpulmonaryedemainpatientswithsubarachnoidhemorrhage.JNeurosurgAnesthesiol.2019Jul;20(3):188-92,亚低温治疗增加感染,GasserS,etal.Long-termhypothermiainpatientswithseverebrainedemaafterpoor-gradesubarachnoidhemorrhage:feasibilityandintensivecarecomplications.JNeurosurgAnesthesiol.2019;15(3):240-8,ClinicaldataofHypothermia,NICU患者发生SAP的危险因素,RuedigerHilker.MD,etal.Stroke,2019;34:975-981,SAP的临床危险因素,RDziewas,etal.JNeurolNeurosurgPsychiatry2019;75:852856.,如何有效控制肺感染并发症?,临床经验性治疗与细菌病原学治疗关系,经验性抗菌素与对病原菌敏感抗菌素治疗的结合和统一,Tracheostomy,Earlytracheostomyafterintubationhasalsobeenshown：Toreduceratesofpneumonia,Todecreasemortality,ToshortenboththelengthofICUstayandthedurationofmechanicalventilationinapopulationofmedicalICUpatientsRumbakMJ:Aprospective,randomized,studycomparingearlypercutaneousdilationaltracheotomytoprolongedtranslaryngealintubation(delayedtracheotomy)incriticallyillmedicalpatients.CritCareMed32:16891694,2019,抗菌素应用之外的抗感染措施,ElevatingtheheadofthebedUprightpositioningduringfeedingLimitingthedurationofmechanicalventilationareimportantfactorsinreducingtheincidenceofventilator-associatedpneumonia.Dailysedationinterruptionandweaningtrialshavealsobeenshowntolimitthedurationofmechanicalventilation.Restrictedbloodtransfusions,Tightglucosecontrolarerecommendedmeasurestopreventventilator-associatedpneumoniaAmericanThoracicSociety,InfectiousDiseasesSocietyofAmerica:Guidelinesforthemanagementofadultswithhospital-acquired,ventilator-associated,andhealthcare-associatedpneumonia.AmJRespirCritCareMed171:388416,2019,Neuroscience-specificintensivecareunitsthatarestaf