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

2、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. Da

3、ily 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 by Respiratory Care Pra

4、ctitioners 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%MDVMPVAP发生率Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol Weaning of Mechanical Ventilation in Medical and Surgical Pat

5、ients 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发生率总计(p = 0.100)12%7%0%5%10%15%20%MDVMPVAP发生率Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere

6、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)插管后静脉头孢呋肟1.5 g x 2(n = 5

7、0)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 = 0.016P = 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, Kelly KM, et al: Red blood cell transfusion and ventilator-associated pneumonia. A potential link? Crit Care Med 2004; 32(3):666-

8、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 Care Med 2000; 28:354735

9、54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 ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661OR 1.80不依从率37.0

10、%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-associated 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:

11、 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 preventing 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19Dodek P,

12、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 Pneumonia. Ann Intern Med 2

13、004; 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 Practice Guideline for the

14、 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 al: An educational inte

15、rvention 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 comparison of effects. Chest, In

16、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; 340:627634Kollef 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 J,