Leone Marc, Bourgoin Aurélie, Giuly Elsa, Antonini François, Dubuc Myriam, Viviand Xavier, Albanèse Jacques, Martin Claude
Intensive Care Unit and Trauma Center, Nord Hospital, Marseilles University Hospital System, Marseilles School of Medicine, Marseilles, France.
Crit Care Med. 2002 Aug;30(8):1741-6. doi: 10.1097/00003246-200208000-00011.
Ventilator-associated pneumonia is said to be associated with an increased mortality or a prolonged intensive care unit stay. In multiple trauma, the use of selective digestive decontamination has been reported to decrease morbidity and mortality associated with pneumonia. We performed a study to evaluate the attributable morbidity and mortality of ventilator-associated pneumonia in multiple trauma patients with head trauma treated with selective digestive decontamination.
Prospective, matched-paired, case-control study.
Intensive care unit at a tertiary university hospital.
During a 6-yr period, 324 consecutive multiple trauma patients with head trauma requiring mechanical ventilation for >48 hrs were prospectively followed for the development of VAP. Case-control matching criteria were as follows: 1) age difference within 5 yrs, 2) Glasgow coma scale within five categories, 3) injury severity score within 5 points, 4) APACHE II score within 5 points, 5) ventilation of control patients for at least as long as the cases. The selective digestive decontamination regimen was used in all patients (cases and controls): polymixin E, gentamicin, and amphotericin B. Systemic cefazolin (1 g three times a day) was given for the first 3 days of intensive care unit stay.
Analysis was performed on 58 pairs that were matched with 100% of success The most common isolates recovered were Staphylococcus aureus (39%) and Haemophilus influenzae (22%). High-risk pathogens were rarely isolated: Pseudomonas aeruginosa (5.1%), Acinetobacter species (8.6%), and methicillin-resistant S. aureus (6.7%). The duration of mechanical ventilation and intensive care unit stay were increased in case patients (11.6 +/- 1.7 and 22.7 +/- 2.9 days, respectively) compared with control patients (9.4 +/- 1.3 and 16.8 +/- 2.9 days, respectively; p <.0006). Mortality was similar in both case (17%) and control (24%) patients.
Ventilator-associated pneumonia did not seem to increase mortality of multiple trauma patients with head trauma who received selective digestive decontamination. Whether or not this conclusion applied to trauma patients not receiving selective digestive decontamination should be evaluated in further studies.
呼吸机相关性肺炎被认为与死亡率增加或重症监护病房住院时间延长有关。在多发伤患者中，据报道使用选择性消化道去污可降低与肺炎相关的发病率和死亡率。我们开展了一项研究，以评估接受选择性消化道去污治疗的头部外伤多发伤患者中呼吸机相关性肺炎的可归因发病率和死亡率。
前瞻性、配对、病例对照研究。
一所三级大学医院的重症监护病房。
在6年期间，对324例连续的头部外伤多发伤患者进行前瞻性随访，这些患者需要机械通气超过48小时以观察呼吸机相关性肺炎的发生情况。病例对照匹配标准如下：1）年龄相差5岁以内；2）格拉斯哥昏迷量表处于五个类别以内；3）损伤严重程度评分相差5分以内；4）急性生理与慢性健康状况评分系统II相差5分以内；5）对照患者的通气时间至少与病例患者一样长。所有患者（病例组和对照组）均采用选择性消化道去污方案：多黏菌素E、庆大霉素和两性霉素B。在重症监护病房住院的前3天给予全身性头孢唑林（每日3次，每次1 g）。
对成功匹配率为100%的58对患者进行了分析。分离出的最常见病原体为金黄色葡萄球菌（39%）和流感嗜血杆菌（22%）。很少分离出高危病原体：铜绿假单胞菌（5.1%）、不动杆菌属（8.6%）和耐甲氧西林金黄色葡萄球菌（6.7%）。与对照患者相比，病例患者的机械通气时间和重症监护病房住院时间延长（分别为11.6±1.7天和22.7±2.9天，而对照患者分别为9.4±1.3天和16.8±2.9天；p<0.0006）。病例组（17%）和对照组（24%）患者的死亡率相似。
对于接受选择性消化道去污治疗的头部外伤多发伤患者，呼吸机相关性肺炎似乎并未增加其死亡率。这一结论是否适用于未接受选择性消化道去污治疗的创伤患者，应在进一步研究中进行评估。
