Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington 98104, USA.
Surg Infect (Larchmt). 2011 Oct;12(5):339-44. doi: 10.1089/sur.2010.074. Epub 2011 Sep 20.
We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP.
The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007-July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥ 10⁴ colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis.
Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003).
Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration.
我们之前曾报道过在创伤患者中，无论是在院前（PH）场所还是在急诊科插管，呼吸机相关性肺炎（VAP）的发生率相似。对接受连续质量评估的 PH 插管的亚组进行了重新检查，以确定与 VAP 相关的插管因素。
该亚组源自 2007 年 7 月至 2008 年 7 月期间在一级创伤中心入院前连续成年创伤患者的现有数据集。记录的插管细节包括球囊面罩通气（BVM）和气道内物质的存在。VAP 的诊断首选通过定量支气管肺泡灌洗（BAL）培养（≥10⁴ 个菌落形成单位表示感染）。通过单变量分析比较 VAP 患者和无 VAP 患者的基线数据、损伤特征和插管情况。
197 名患者中有详细数据，平均入院后 6.0±0.7 天发生 32 例（16.2%）VAP。两组的基线特征相似，但 VAP 组糖尿病更为常见（4[12.5%]比 5[3.0%]；p=0.02）。VAP 患者钝性损伤发生率较高（28[87.5%]比 106[64.2%]；p=0.01），损伤严重程度评分较高（33.1±2.8 比 23.0±1.0；p=0.0002）和胸部简明损伤评分（2.6±0.3 比 1.5±0.1；p=0.002）。VAP 患者格拉斯哥昏迷量表评分较低（7.9±0.9 比 9.9±0.4；p=0.04），BVM 使用较多（18[56.3%]比 56[34.0%]；p=0.02）。呕吐的 10 例（31.3%）患者发生 VAP，而仅有 4 例（12.5%）气道内有血液的患者发生 VAP（p=0.003）。
与意识障碍和更大的损伤严重程度一样，吸入可能使创伤患者易发生 VAP。前瞻性研究应重点关注与插管相关的吸入物的质量和时间，以确定是否可以通过新的干预措施来预防吸入物或降低吸入物后发生 VAP 的风险。
