Joshi N, Localio A R, Hamory B H
Department of Medicine, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey.
Am J Med. 1992 Aug;93(2):135-42. doi: 10.1016/0002-9343(92)90042-a.
To develop a scoring system for stratifying patients in intensive care units (ICUs) by risk of developing nosocomial pneumonia (NP) and to identify the time period associated with the highest risk.
Two hundred and three patients 18 years of age or older and residing in the ICU for 72 hours or more were followed until development of NP or death or for 48 hours after discharge from the ICU. After the identification of independent risk factors for NP, a scoring system was developed to arrive at a predictive risk index for NP.
Twenty-six (12.8%) patients developed NP. The presence of a nasogastric (NG) tube [odds ratio (OR) = 6.48, 95% confidence intervals (CI) = 2.11 to 19.82], upper abdominal/thoracic surgery (OR = 4.34, 95% CI = 1.43 to 13.14), and bronchoscopy (OR = 2.95, 95% CI = 1.02 to 8.52), most commonly performed for respiratory toilet, were identified as independent risk factors on multivariate analysis. The risks associated with endotracheal intubation and altered consciousness, although not independently significant, were highest when these factors were present for 1 to 4 days after the 72 hours required for study entry (endotracheal intubation, OR = 2.2 to 2.5; altered consciousness, OR = 1.4 to 2.0). The risk then declined; ORs of less than 1 were observed at 7 days. The risk associated with the NG tube was highest during the first 6 days (OR = 6.0 to 19.5). Although a subsequent decrease in risk was observed, the OR was still greater than 2 at 7 days. To obtain a predictive risk index for NP, a scoring system was developed using a multivariate model. This system has a sensitivity of 85% and a specificity of 66% in predicting NP in this ICU population.
ICU patients can be stratified into high- and low-risk groups for NP using a bedside scoring system. Endotracheal intubation, altered mental status, and NG tube are associated with the highest risk of NP during the first 1 to 6 days of their presence after 72 hours of stay in the ICU. After this time period, the risk associated with these factors decreases. Bronchoscopy may be an independent risk factor for NP that has not been previously recognized. This procedure, often done in the ICU for respiratory toilet, may be an avoidable risk in this group of patients.
建立一种评分系统，用于根据重症监护病房（ICU）患者发生医院获得性肺炎（NP）的风险进行分层，并确定风险最高的时间段。
对203例年龄在18岁及以上且在ICU住院72小时或更长时间的患者进行随访，直至发生NP或死亡，或在从ICU出院后48小时。在确定NP的独立危险因素后，开发了一种评分系统以得出NP的预测风险指数。
26例（12.8%）患者发生NP。鼻胃管（NG）的存在[比值比（OR）=6.48，95%置信区间（CI）=2.11至19.82]、上腹部/胸部手术（OR =4.34，95%CI =1.43至13.14）以及支气管镜检查（OR =2.95，95%CI =1.02至8.52，最常用于呼吸道清理）在多因素分析中被确定为独立危险因素。气管插管和意识改变相关的风险，虽然并非独立显著，但在研究入组所需的72小时后的1至4天内存在这些因素时风险最高（气管插管，OR =2.2至2.5；意识改变，OR =1.4至2.0）。然后风险下降；在7天时观察到OR小于1。与NG管相关的风险在最初6天内最高（OR =6.0至19.5）。虽然随后观察到风险降低，但在7天时OR仍大于2。为了获得NP的预测风险指数，使用多变量模型开发了一种评分系统。该系统在预测该ICU人群的NP时灵敏度为85%，特异度为66%。
使用床边评分系统可将ICU患者分为NP的高风险和低风险组。气管插管、精神状态改变和NG管在入住ICU 72小时后的最初1至6天内与NP的最高风险相关。在此时间段之后，与这些因素相关的风险降低。支气管镜检查可能是一种先前未被认识到的NP独立危险因素。该操作常在ICU中用于呼吸道清理，在这组患者中可能是一种可避免的风险。
