Eckert Matthew J, Davis Kimberly A, Reed R Lawrence, Esposito Thomas J, Santaniello John M, Poulakidas Stathis, Gamelli Richard L, Luchette Fred A
Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, 2160 S. First Avenue, Maywood, IL 60153, USA.
J Trauma. 2006 Jan;60(1):104-10; discussion 110. doi: 10.1097/01.ta.0000197376.98296.7c.
Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma.
A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed.
In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP.
Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.
先前的研究表明，与急诊科插管相比，创伤患者在院前（现场）插管后发生呼吸机相关性肺炎（VAP）的风险增加。然而，该人群未与住院患者插管情况进行比较，这使得数据解释变得困难。我们试图进一步研究创伤后发生VAP的预测因素。
对所有受伤后机械通气超过24小时的患者进行了为期10年的回顾性研究。
共识别出1628例患者，其中1213例（75%）为住院患者插管，415例为紧急插管（353例在急诊科，62例在现场）。总体而言，紧急插管的患者更年轻（p = 0.03），从更高的格拉斯哥昏迷量表评分（p = 0.0002）、更低的损伤严重度评分（p = 0.01）和更高的修正创伤评分（p < 0.0001）来看，损伤程度更低。尽管损伤严重程度较低，但紧急插管的患者更易发生肺炎，急诊科插管患者中有22%发生肺炎，现场插管患者中有15%发生肺炎，而住院患者的发生率为6.5%。与住院患者和急诊科患者组相比，现场插管后发生的肺炎更可能是社区获得性的（p < 0.0001），感染肠道革兰氏阴性杆菌的比例显著更低（p < 0.0001）。向前逻辑回归分析（VAP = 1）确定住院患者插管可预防VAP（比值比0.28，95%可信区间 = 0.2 - 0.4）。向后逻辑回归分析进一步确定现场气道（比值比2.29，95%可信区间 = 1.1 - 4.9）和急诊科气道（比值比3.61，95%可信区间 = 2.5 - 5.2）均可预测VAP。
与住院创伤患者群体相比，排除机械通气少于24小时的患者，在急诊科或现场插管的患者，尽管损伤严重程度相当或更低，但肺炎发生率更高。
