1 Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME, University Hospital of Nantes, Nantes, France.
Am J Respir Crit Care Med. 2013 Oct 15;188(8):958-66. doi: 10.1164/rccm.201301-0116OC.
Mechanical ventilation is associated with morbidity in patients with brain injury.
This study aims to assess the effectiveness of an extubation readiness bundle to decrease ventilator time in patients with brain injury.
Before-after design in two intensive care units (ICUs) in one university hospital. Brain-injured patients ventilated more than 24 hours were evaluated during two phases (a 3-yr control phase followed by a 22-mo intervention phase). Bundle components were protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia, and systematic approach to extubation. The primary endpoint was the duration of mechanical ventilation.
A total of 299 and 200 patients, respectively, were analyzed in the control and the intervention phases of this before-after study. The intervention phase was associated with lower tidal volume (P < 0.01), higher positive end-expiratory pressure (P < 0.01), and higher enteral intake in the first 7 days (P = 0.01). The duration of mechanical ventilation was 14.9 ± 11.7 days in the control phase and 12.6 ± 10.3 days in the intervention phase (P = 0.02). The hazard ratio for extubation was 1.28 (95% confidence interval [CI], 1.04-1.57; P = 0.02) in the intervention phase. Adjusted hazard ratio was 1.40 (95% CI, 1.12-1.76; P < 0.01) in multivariate analysis and 1.34 (95% CI, 1.03-1.74; P = 0.02) in propensity score-adjusted analysis. ICU-free days at Day 90 increased from 50 ± 33 in the control phase to 57 ± 29 in the intervention phase (P < 0.01). Mortality at Day 90 was 28.4% in the control phase and 23.5% in the intervention phase (P = 0.22).
The implementation of an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in patients with brain injury.
机械通气与颅脑损伤患者的发病率有关。
本研究旨在评估脱机准备包对减少颅脑损伤患者通气时间的效果。
在一家大学医院的两个重症监护病房（ICU）进行前后设计。在两个阶段评估通气超过 24 小时的颅脑损伤患者（3 年对照阶段后是 22 个月的干预阶段）。包裹组件为保护性通气、早期肠内营养、医院获得性肺炎的抗生素标准化治疗以及系统的拔管方法。主要终点为机械通气时间。
这项前后研究的对照和干预阶段分别分析了 299 名和 200 名患者。干预阶段的潮气量较低（P < 0.01），呼气末正压较高（P < 0.01），前 7 天的肠内摄入量较高（P = 0.01）。在对照阶段机械通气时间为 14.9 ± 11.7 天，在干预阶段为 12.6 ± 10.3 天（P = 0.02）。干预阶段的拔管风险比为 1.28（95%置信区间[CI]，1.04-1.57；P = 0.02）。多变量分析调整后的风险比为 1.40（95%CI，1.12-1.76；P < 0.01），倾向评分调整分析为 1.34（95%CI，1.03-1.74；P = 0.02）。90 天时 ICU 无天数从对照阶段的 50 ± 33 增加到干预阶段的 57 ± 29（P < 0.01）。90 天时的死亡率在对照阶段为 28.4%，在干预阶段为 23.5%（P = 0.22）。
实施基于证据的脱机准备包与减少颅脑损伤患者的通气时间有关。
