呼吸机bundle疗效观察

呼吸机治疗BUNDLE效果观察,让临床重新思考,海南医学院附属医院ICU 胡志华,BUNDLE的概述,VAP BUNDLE的内容和实施,VAP BUNDLE 疗效新发现,VAP BUNDLE 的展望,定义集束化（BUNDLE）策略,定义：集束化治疗策略是指为了提高护理指南的可行性和依从性，为针对某种问题而制定的一系列（一般为3-5个）有循证支持的联合护理措施。 呼吸机相关性肺炎集束 中心静脉导管相关性感染集束 感染性休克集束,集束化的实施,当患者在难以避免的风险下治疗时，由医护人员提供的一系列安全有效的医疗护理干预的集合。,集束化治疗,循证医学,医疗护理措施,综合方案,BUNDLE的概述,VAP BUNDLE 疗效新发现,VAP BUNDLE的内容和实施,VAP BUNDLE 的展望,VAP的简介,定义 呼吸机相关性肺炎(ventilator - associated pneumonia ,VAP) ： 指患者在建立人工气道(气管插管或切开) 并机械通气48 h 以后或撤机拔管后48 h 以内所发生的医院获得性肺炎。是一种严重的院内感染和并发症，也是ICU 内最常见的感染之一。,VAP 的发病情况,国外有文献报导接受机械通气的患者VAP发病率达46%，病死率高达50-69%,而79.2 %的VAP 发生在开始机械通气的4d内。国内调查表明VAP的发病率为18.53%，病死率为32.5%。ICU住院时间延长4.3-6.1天，住院时间延长了4-9天。国外数据：每个病人平均多花了约40000美元。,VAP BUNDLE 的内容,抬高床头30-45氯已定口腔清洁中断镇静药的输注自主呼吸试验预防消化道溃疡预防深静脉血栓,VAP BUNDLE 的实施,管理流程,组建呼吸机质量控制小组,制订质量管理目标和相关规定,明确目标责任,集束化管理策略应用效果分析,集束化管理措施,从 VAP BUNDLE 得到益处,降低VAP的发生率、降低入住ICU天数、降低病死亡率；实现医护队伍的沟通、协助，促进医疗质量的持续改进，实现教育、审计、反馈和流程的重建等1-9,1. Klompas M. Ventilator-associated pneumonia: is zero possible? Clin Infect Dis. 2010;51(10):1123-1126.2. Youngquist P, Carroll M, Farber M, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf. 2007;33(4):219-225.3. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243-248.4. Talbot TR, Carr D, Parmley CL, et al. Sustained reduction of ventilator-associated pneumonia rates using real-time course correction with a ventilator bundle compliance dashboard. Infect Control Hosp Epidemiol. 2015;36(11):1261-1267.5. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32(4):305-314.6. Bouadma L, Deslandes E, Lolom I, et al. Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis. 2010;51 (10):1115-1122.7. Marra AR, Cal RG, Silva CV, et al. Successful prevention of ventilator-associated pneumonia in an intensive care setting. Am J Infect Control. 2009; 37(8):619-625.8. Burger CD, Resar RK. “Ventilator bundle” approach to prevention of ventilator-associated pneumonia. Mayo Clin Proc. 2006;81(6):849-850.9. Bird D, Zambuto A, ODonnell C, et al. Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg. 2010;145(5):465-470.,问 题,10. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, FerrerM. Supine body position as a risk factor for nosocomial pneumonia in mechanicall ventilated patients: a randomised trial. Lancet. 1999;354(9193):1851-1858.11. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med. 2006;34(2):396-402.12. Keeley L. Reducing the risk of ventilator-acquired pneumonia through head of bed elevation. Nurs Crit Care. 2007;12(6):287-294.13. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301 (20):2120-2128.14. Miano TA, Reichert MG, Houle TT, MacGregor DA, Kincaid EH, Bowton DL. Nosocomial pneumonia risk and stress ulcer prophylaxis: a comparison of pantoprazole vs ranitidine in cardiothoracic surgery patients. Chest. 2009;136 (2):440-447.15. Sasabuchi Y, Matsui H, Lefor AK, Fushimi K, Yasunaga H. Risks and benefits of stress ulcer prophylaxis for patients with severe sepsis. Crit Care Med. 2016;44(7):e464-e469.16. Price R, MacLennan G, Glen J; SuDDICU Collaboration. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ. 2014;348:g2197.Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014;174(5):751-761.18Kress JP, Pohlman AS, OConnor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-1477.19. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-134.20. Mehta S, Burry L, Cook D, et al; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):1985-1992.,也有文献报道预防应激性溃疡可能提高VAP风险，氯已定口腔清洁与潜在高死亡率有关10-20,BUNDLE 的概述,VAP BUNDLE的内容和实施,VAP BUNDLE的展望,VAP BUNDLE 疗效新发现,JAMA Internal Medicine Published online July 18, 2016,IMPORTANCE 背景,JAMA Internal Medicine Published online July 18, 2016,呼吸机集束化治疗包括床头抬高，中断镇静药输注，自主呼吸试验，深静脉血栓预防，消化道溃疡预防以及氯已定口腔护理均得到普遍实施，但是各项措施的绝对与相对作用尚不清楚。,OBJECTIVE 目的,评价呼吸机集束化治疗措施及联合使用与呼吸机相关事件（VAEs）、拔管时间、机械通气期间病死率、出院时间及住院死亡之间的相关性。,JAMA Internal Medicine Published online July 18, 2016,设计、场景和对象,这项回顾性队列研究包括了布里格姆及妇女医院2009年1月1日至2013年12月31日连续收治的接受至少3天机械通气的所有5539名患者。,JAMA Internal Medicine Published online July 18, 2016,MAIN OUTCOMES AND MEASURES 主要预后和指标,呼吸机相关事件、拔管存活时间与机械通气期间病死率，以及出院时间与住院死亡的风险比（HR）。效应模型采用Cox比例风险回归以及Fine-Gray竞争风险模型，并对患者人口统计学特征、合并症、病房类型、疾病严重程度、近期操作、过程指标禁忌症，每日临床状态指标以及年份进行校正。,JAMA Internal Medicine Published online July 18, 2016,结 果,表1 患者特征,JAMA Internal Medicine Published online July 18, 2016,a: 包括对没有接受连续注射镇静剂患者的记录。,表2. 每年实施护理措施对通气天数的比率,JAMA Internal Medicine Published online July 18, 2016,表3. 护理措施与呼吸机相关事件（VAEs）之间的关联a,.11,0.55 (0.27-1.14),.05,0.60 (0.36-1.00),.42,0.87 (0.61-1.23),氯已定口腔护理,.02,7.69 (1.44-41.10),.20,1.62 (0.78-3.35),.19,1.34 (0.87-2.07),应激性溃疡,.90,1.13 (0.16-7.78),.96,0.96 (0.26-3.56),.51,0.78 (0.38-1.62),血栓,预防,.52,0.79 (0.39-1.60),.05,0.60 (0.37-1.00),.001,0.55 (0.40-0.76),自主呼吸试验,.63,0.82 (0.37-1.82),.88,1.04 (0.61-1.78),.76,0.95 (0.67-1.35),中断镇静