Quenot Jean-Pierre, Ladoire Sylvain, Devoucoux Fabrice, Doise Jean-Marc, Cailliod Romain, Cunin Nicole, Aubé Hervé, Blettery Bernard, Charles Pierre Emmanuel
Department of Critical Care Medicine, Bocage University Hospital, Dijon, France.
Crit Care Med. 2007 Sep;35(9):2031-6. doi: 10.1097/01.ccm.0000282733.83089.4d.
To determine whether the use of a nurse-implemented sedation protocol could reduce the incidence of ventilator-associated pneumonia in critically ill patients.
Two-phase (before-after), prospective, controlled study.
University-affiliated, 11-bed medical intensive care unit.
Patients requiring mechanical ventilation for >or=48 hrs and sedative infusion with midazolam or propofol alone.
During the control phase, sedatives were adjusted according to the physician's decision. During the protocol phase, sedatives were adjusted according to a protocol developed by a multidisciplinary team including nurses and physicians. The protocol was based on the Cambridge scale, and sedation level was adjusted every 3 hrs by the nurses. Standard practices, including weaning from the ventilator and diagnosis of VAP, were the same during both study phases.
A total of 423 patients were enrolled (control group, n = 226; protocol group, n = 197). The incidence of VAP was significantly lower in the protocol group compared with the control group (6% and 15%, respectively, p = .005). By univariate analysis (log-rank test), only use of a nurse-implemented protocol was significantly associated with a decrease of incidence of VAP (p < .01). A nurse-implemented protocol was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model (hazard rate, 0.81; 95% confidence interval, 0.62-0.95; p = .03). The median duration of mechanical ventilation was significantly shorter in the protocol group (4.2 days; interquartile range, 2.1-9.5) compared with the control group (8 days; interquartile range, 2.2-22.0; p = .001), representing a 52% relative reduction. Extubation failure was more frequently observed in the control group compared with the protocol group (13% and 6%, respectively, p = .01). There was no significant difference in in-hospital mortality (38% vs. 45% in the protocol vs. control group, respectively, p = .22).
In patients receiving mechanical ventilation and requiring sedative infusions with midazolam or propofol, the use of a nurse-implemented sedation protocol decreases the rate of VAP and the duration of mechanical ventilation.
确定采用护士执行的镇静方案是否可降低重症患者呼吸机相关性肺炎的发生率。
两阶段（前后对照）前瞻性对照研究。
大学附属医院拥有11张床位的医疗重症监护病房。
需要机械通气≥48小时且仅使用咪达唑仑或丙泊酚进行镇静输注的患者。
在对照阶段，根据医生的决定调整镇静剂。在方案阶段，根据包括护士和医生在内的多学科团队制定的方案调整镇静剂。该方案基于剑桥量表，护士每3小时调整一次镇静水平。两个研究阶段的标准操作，包括脱机和VAP的诊断，均相同。
共纳入423例患者（对照组，n = 226；方案组，n = 197）。与对照组相比，方案组VAP的发生率显著更低（分别为6%和15%，p = 0.005）。通过单因素分析（对数秩检验），仅采用护士执行的方案与VAP发生率降低显著相关（p < 0.01）。在多变量Cox比例风险模型中，对简化急性生理学评分II进行调整后，发现护士执行的方案与较低的VAP发生率独立相关（风险率，0.81；95%置信区间，0.62 - 0.95；p = 0.03）。与对照组（8天；四分位间距，2.2 - 22.0；p = 0.001）相比，方案组机械通气的中位持续时间显著更短（4.2天；四分位间距，2.1 - 9.5），相对缩短了52%。与方案组相比，对照组拔管失败的发生率更高（分别为13%和6%，p = 0.01）。院内死亡率无显著差异（方案组与对照组分别为38%和45%，p = 0.22）。
在接受机械通气且需要使用咪达唑仑或丙泊酚进行镇静输注的患者中，采用护士执行的镇静方案可降低VAP发生率及机械通气持续时间。
