Thomas Bradley W, Maxwell Robert A, Dart Benjamin W, Hartmann Elizabeth H, Bates Dustin L, Mejia Vicente A, Smith Philip W, Barker Donald E
Department of Surgery, University of Tennessee College of Medicine-Chattanooga Unit, Chattanooga, Tennessee, USA.
Am Surg. 2011 Aug;77(8):998-1002.
Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients' medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients (P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.
呼吸机相关性肺炎（VAP）是重症监护病房（ICU）中常见的问题，尽管其发病率尚无确切定论。本研究旨在比较外科重症监护医师判定的VAP发病率与医院感染控制部门（ICS）检测到的VAP发病率。对入住外科重症监护病房的创伤和手术患者在5个月的时间内进行前瞻性VAP评估。收集的数据包括外科重症监护医师使用美国疾病控制与预防中心（CDC）的VAP标准进行的临床VAP（SIS-VAP）评估。作为医院VAP监测项目的一部分，ICS也会使用相同的CDC VAP标准对这些患者的病历进行VAP（ICS-VAP）审查。所有疑似患有VAP的患者均接受支气管肺泡灌洗（BAL）。然后将SIS-VAP和ICS-VAP与BAL-VAP进行比较。在研究期间，有329名患者入住ICU。其中133名患者插管时间超过48小时，构成了我们的研究人群。62名患者接受了89次BAL评估以确定是否存在VAP。38名（28.5%）患者被诊断为SIS-VAP。11名（8.3%）患者被确定为ICS-VAP（P<0.001）。根据BAL标准，VAP的发病率为23.3%。与BAL相比，SIS-VAP的敏感性为61.3%，ICS-VAP的敏感性为29%。医院管理部门报告的VAP发生率明显不如医生报告的准确，且严重低估了VAP的发病率。宣称VAP是外科和创伤重症患者的零容忍事件似乎是一种谬论。
