三级重症监护病房中改变气管插管气囊管理对呼吸机相关性肺炎抗生素使用的影响。

Influence of changing endotracheal tube cuff management on antibiotic use for ventilator-associated pneumonia in a tertiary intensive care unit.

作者信息

Darvall Jai N, Thevarajan Irani, Iles Simon, Rechnitzer Thomas, Spelman Tim, Harley Nerina

机构信息

Intensive Care Unit and Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia.

Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.

出版信息

Crit Care Resusc. 2017 Sep;19(3):247-253.

PMID:28866975

Abstract

BACKGROUND

Routine deflation of the endotracheal tube (ETT) cuff of critically ill patients receiving MV is common in Australia and New Zealand. Literature about ventilatorassociated pneumonia (VAP) and antibiotic use rates with different ETT cuff maintenance practices is lacking.

OBJECTIVE

To determine the impact of a change in ETT cuff maintenance from a minimal leak technique to pressure manometry on the administration of antibiotics for VAP.

DESIGN, SETTING AND PARTICIPANTS: A prospective, pre- post observational study conducted in a metropolitan tertiary referral intensive care unit. We analysed data from 178 patients receiving MV for > 48 hours during 13 weeks of minimal leak test ETT cuff technique (pre-intervention, n = 92) or 13 weeks of cuff pressure manometry (postintervention, n = 86), separated by 3 weeks' "wash-out".

MAIN OUTCOME MEASURES

Primary outcome was the number of patients receiving antibiotics for the indication of VAP. Secondary outcomes were incidence of ventilatorassociated surveillance events, lengths of stay (LOSs) and mortality.

RESULTS

Antibiotics were administered for VAP in 24 patients (26.1%) in the pre-intervention period compared with 11 post-intervention patients (12.8%). The univariate antibiotic administraion rate per 100 ventilation days was 15.3% (95% CI, 12.6%-18.4%) v 6.8% (95% CI, 4.9%- 9.3%), and the incident rate ratio (IRR) was 0.45 (95% CI, 0.31-0.64); P < 0.001). After adjustment for ventilation duration, IRR was 0.55 (95% CI, 0.24-1.27); P = 0.160. The ventilator-associated complication incidence rate was lower in the post-intervention group (11.4% v 16.3%; IRR, 0.70 [95% CI, 0.51-0.95]; P = 0.018). After adjustment for duration of MV, IRR was 0.66 (95% CI, 0.25-1.70); P = 0.387. Antibiotic administration for VAP was associated with increased ICU and hospital LOSs, but not with mortality.

CONCLUSIONS

ETT cuff pressure manometry is associated with a reduced rate of antibiotic administration for a diagnosis of VAP compared with a minimal leak test technique.

摘要

背景

在澳大利亚和新西兰，接受机械通气（MV）的重症患者常规放气气管内导管（ETT）套囊很常见。目前缺乏关于不同ETT套囊维护方法与呼吸机相关性肺炎（VAP）及抗生素使用率的文献。

目的

确定ETT套囊维护方法从最小漏气技术改为压力测定法对VAP抗生素使用的影响。

设计、设置和参与者：在一家大都市三级转诊重症监护病房进行的一项前瞻性前后观察研究。我们分析了178例接受MV超过48小时患者的数据，在13周的最小漏气试验ETT套囊技术（干预前，n = 92）或13周的套囊压力测定法（干预后，n = 86）期间，中间间隔3周的“洗脱期”。

主要观察指标

主要结局是因VAP指征接受抗生素治疗的患者数量。次要结局是呼吸机相关监测事件的发生率、住院时间（LOS）和死亡率。

结果

干预前期有24例患者（26.1%）因VAP接受抗生素治疗，干预后为11例患者（12.8%）。每100个通气日的单变量抗生素给药率分别为15.3%（95%CI，12.6%-18.4%）和6.8%（95%CI，4.9%-9.3%），发病率比（IRR）为0.45（95%CI，0.31-0.64）；P<0.001）。在调整通气持续时间后，IRR为0.55（95%CI，0.24-1.27）；P = 0.160。干预后组的呼吸机相关并发症发生率较低（11.4%对16.3%；IRR，0.70[95%CI，0.51-0.95]；P = 0.018）。在调整MV持续时间后，IRR为0.66（95%CI，0.25-1.70）；P = 0.387。因VAP使用抗生素与ICU和医院住院时间延长相关，但与死亡率无关。