Juneja Deven, Singh Omender, Javeri Yash, Arora Vikas, Dang Rohit, Kaushal Anjali
Department of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi, India.
Indian J Anaesth. 2011 Mar;55(2):122-8. doi: 10.4103/0019-5049.79889.
Implementation of evidence-based guidelines to prevent and manage ventilator-associated pneumonia (VAP) in the clinical setting may not be adequate. We aimed to assess the implementation of selected VAP prevention strategies, and to learn how VAP is managed by the intensivists practicing in the Indian Subcontinent. Three hundred 10-point questionnaires were distributed during an International Critical Care Conferenceheld at New Delhi in 2009. A total of 126 (42%) questionnaires distributed among delegates from India, Nepal and Sri Lanka were analyzed. Majority (96.8%) reported using VAP bundles with a high proportion including head elevation (98.4%), chlorhexidine mouthcare (83.3%), stress ulcer prophylaxis (96.8%), heat and moisture exchangers (HME, 92.9%), early weaning (94.4%), and hand washing (97.6%) as part of their VAP bundle. Use of subglottic secretion drainage (SSD, 45.2%) and closed suction systems (CSS, 74.6%) was also reported by many intensivists, whereas use of selective gut decontamination was reported by only 22.2%. Commonest method for sampling was endotracheal suction by 68.3%. Gram negative organisms were reported to be the most commonly isolated. Majority (39.7%) reported using proton pump inhibitors for stress ulcer prophylaxis and 84.1% believed that VAP contributed to increased mortality. De-escalating therapy was considered in patients responding to treatment by 57.9% and 65.9% considered adding empirical methicillin resistant Staphylococcus aureus (MRSA)coverage, while 63.5% considered adding nebulized antibiotics in certain high-risk patients. There was good concordance regarding VAP prophylaxis among the intensivists with a majority adhering to evidence-based guidelines. We could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of HME filters, SSD and CSS, where there still exists some practice variability and opportunities for improvement.
在临床环境中实施基于证据的预防和管理呼吸机相关性肺炎（VAP）的指南可能并不充分。我们旨在评估所选VAP预防策略的实施情况，并了解在印度次大陆执业的重症监护医生如何管理VAP。在2009年于新德里举行的一次国际重症监护会议期间分发了300份10分制问卷。共分析了分发给来自印度、尼泊尔和斯里兰卡代表的126份（42%）问卷。大多数（96.8%）报告使用VAP集束干预措施，其中很大一部分包括床头抬高（98.4%）、洗必泰口腔护理（83.3%）、应激性溃疡预防（96.8%）、热湿交换器（HME，92.9%）、早期撤机（94.4%）以及洗手（97.6%）作为其VAP集束干预措施的一部分。许多重症监护医生还报告使用声门下分泌物引流（SSD，45.2%）和密闭吸痰系统（CSS，74.6%），而只有22.2%报告使用选择性肠道去污。最常见的采样方法是经气管吸痰，占68.3%。据报告革兰氏阴性菌是最常分离出的细菌。大多数（39.7%）报告使用质子泵抑制剂预防应激性溃疡，84.1%认为VAP会导致死亡率增加。57.9%的医生在治疗有反应的患者时考虑降阶梯治疗，65.9%考虑增加经验性耐甲氧西林金黄色葡萄球菌（MRSA）覆盖，而63.5%考虑在某些高危患者中加用雾化抗生素。重症监护医生在VAP预防方面有良好的一致性，大多数人遵循基于证据的指南。我们可以识别出一些问题，如应激性溃疡预防药物的选择、HME过滤器的使用、SSD和CSS，在这些方面仍然存在一些实践差异和改进的机会。
