Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
JAMA Intern Med. 2014 May;174(5):751-61. doi: 10.1001/jamainternmed.2014.359.
Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality.
To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation.
PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language.
Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria.
Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non-cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis.
Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing.
There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non-cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited.
Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.
在大多数医院，使用葡萄糖酸氯己定进行常规口腔护理是接受机械通气患者的标准护理。这一政策基于荟萃分析表明降低呼吸机相关性肺炎的风险，但这些荟萃分析可能存在误导，因为它们没有区分心脏手术和非心脏手术研究，将开放性研究与双盲研究混为一谈，并且对患者为中心的结果（如机械通气时间、住院时间和死亡率）重视不够。
评估常规口腔护理用氯己定对接受机械通气的患者患者为中心的结果的影响。
PubMed、Embase、CINAHL 和 Web of Science，从建立之初到 2013 年 7 月，无日期或语言限制。
比较氯己定与安慰剂在接受机械通气的成年人中的随机临床试验。在 171 个独特的引文，16 项研究，包括 3630 名患者符合纳入标准。
由 2 名研究人员独立识别、评估偏倚风险并提取合格试验。差异通过共识解决。我们将研究分为心脏手术和非心脏手术以及开放性研究与双盲研究。使用随机效应荟萃分析对合格研究进行汇总。
呼吸机相关性肺炎、死亡率、机械通气时间、重症监护病房和住院时间、抗生素处方。
心脏手术患者随机接受氯己定治疗的下呼吸道感染更少（相对风险 [RR]，0.56 [95% CI，0.41-0.77]），但非心脏手术患者双盲研究中呼吸机相关性肺炎的风险无显著差异（RR，0.88 [95% CI，0.66-1.16]）。心脏手术研究中氯己定与安慰剂之间的死亡率无显著差异（RR，0.88 [95% CI，0.25-2.14]），而非心脏手术研究中死亡率略有升高（RR，1.13 [95% CI，0.99-1.29]）。机械通气时间或重症监护病房住院时间无显著差异。关于住院时间和抗生素处方的数据有限。
常规口腔护理用葡萄糖酸氯己定可预防心脏手术患者的医院获得性肺炎，但可能不会降低非心脏手术患者呼吸机相关性肺炎的风险。氯己定的使用对这两个人群的患者为中心的结果都没有影响。鼓励非心脏手术患者常规口腔护理用葡萄糖酸氯己定的政策需要重新评估。
