预防急性肺损伤：方案指导下限制大潮气量通气和不当输血。

Toward the prevention of acute lung injury: protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion.

作者信息

Yilmaz Murat, Keegan Mark T, Iscimen Remzi, Afessa Bekele, Buck Curtis F, Hubmayr Rolf D, Gajic Ognjen

机构信息

Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.

出版信息

Crit Care Med. 2007 Jul;35(7):1660-6; quiz 1667. doi: 10.1097/01.CCM.0000269037.66955.F0.

DOI:10.1097/01.CCM.0000269037.66955.F0

PMID:17507824

Abstract

OBJECTIVE

We evaluated the effect of two quality improvement interventions (low tidal volume ventilation and restrictive transfusion) on the development of acute lung injury in mechanically ventilated patients.

DESIGN

Observational cohort study.

SETTING

Three intensive care units in a tertiary academic center.

PATIENTS

We included patients who were mechanically ventilated for > or =48 hrs excluding those who refused research authorization or had preexisting acute lung injury or pneumonectomy.

INTERVENTIONS

Multifaceted interdisciplinary intervention consisting of Web-based teaching, respiratory therapy protocol, and decision support within computerized order entry.

MEASUREMENTS AND MAIN RESULTS

Of 375 patients who met the inclusion and exclusion criteria, 212 were ventilated before and 163 after the interventions. Baseline characteristics were similar between the two groups except for a lower frequency of sepsis (27% vs. 17%, p = .030), trend toward lower median glucose level (140 mg/dL, interquartile range 118-168 vs. 132 mg/dL, interquartile range 113-156, p = .096), and lower frequency of pneumonia (27% vs. 20%, p = .130) during the second period. We observed a large decrease in tidal volume (10.6-7.7 mL/kg predicted body weight, p < .001), in peak airway pressure (31-25 cm H2O, p < .001), and in the percentage of transfused patients (63% to 38%, p < .001) after the intervention. The frequency of acute lung injury decreased from 28% to 10% (p < .001). The duration of mechanical ventilation decreased from a median of 5 (interquartile range 4-9) to 4 (interquartile range 4-8) days (p = .030). When adjusted for baseline characteristics in a multivariate logistic regression analysis, protocol intervention was associated with a reduction in the frequency of new acute lung injury (odds ratio 0.21, 95% confidence interval 0.10-0.40).

CONCLUSIONS

Interdisciplinary intervention effectively decreased large tidal volumes and unnecessary transfusion in mechanically ventilated patients and was associated with a decreased frequency of new acute lung injury.

摘要

目的

我们评估了两种质量改进干预措施（低潮气量通气和限制性输血）对机械通气患者急性肺损伤发生情况的影响。

设计

观察性队列研究。

地点

一所三级学术中心的三个重症监护病房。

患者

我们纳入了机械通气时间≥48小时的患者，排除了拒绝研究授权或已有急性肺损伤或接受过肺切除术的患者。

干预措施

多方面的跨学科干预，包括基于网络的教学、呼吸治疗方案以及计算机医嘱录入中的决策支持。

测量指标及主要结果

在375例符合纳入和排除标准的患者中，212例在干预前接受通气，163例在干预后接受通气。两组的基线特征相似，但在第二个时间段，脓毒症发生率较低（27%对17%，p = 0.030），血糖中位数有降低趋势（140mg/dL，四分位间距118 - 168对132mg/dL，四分位间距113 - 156，p = 0.096），肺炎发生率较低（27%对20%，p = 0.130）。干预后，我们观察到潮气量大幅下降（从预计体重的10.6降至7.7mL/kg，p < 0.001），气道峰压下降（从31降至25cm H₂O，p < 0.001），输血患者百分比下降（从63%降至38%，p < 0.001）。急性肺损伤的发生率从28%降至10%（p < 0.001）。机械通气时间从中位数5天（四分位间距4 - 9）降至4天（四分位间距4 - 8）（p = 0.030）。在多变量逻辑回归分析中对基线特征进行调整后，方案干预与新发急性肺损伤频率的降低相关（比值比0.21，95%置信区间0.10 - 0.40）。