呼吸机相关性肺炎在创伤性脑损伤患者中的发生率、危险因素及对预后的影响：一项大型、多中心、前瞻性、观察性纵向研究的分析。

Incidence, Risk Factors, and Effects on Outcome of Ventilator-Associated Pneumonia in Patients With Traumatic Brain Injury: Analysis of a Large, Multicenter, Prospective, Observational Longitudinal Study.

机构信息

Department of Anesthesia and Intensive Care Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova.

School of Medicine and Surgery, University of Milan-Bicocca, Milan; Center for Biostatistics for Clinical Epidemiology, University of Milano-Bicocca, Monza.

出版信息

Chest. 2020 Dec;158(6):2292-2303. doi: 10.1016/j.chest.2020.06.064. Epub 2020 Jul 4.

DOI:10.1016/j.chest.2020.06.064

PMID:32634435

Abstract

BACKGROUND

No large prospective data, to our knowledge, are available on ventilator-associated pneumonia (VAP) in patients with traumatic brain injury (TBI).

RESEARCH QUESTION

To evaluate the incidence, timing, and risk factors of VAP after TBI and its effect on patient outcome.

STUDY DESIGN AND METHODS

This analysis is of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury data set, from a large, multicenter, prospective, observational study including patients with TBI admitted to European ICUs, receiving mechanical ventilation for ≥ 48 hours and with an ICU length of stay (LOS) ≥ 72 hours. Characteristics of patients with VAP vs characteristics of patients without VAP were compared, and outcome was assessed at 6 months after injury by using the Glasgow Outcome Scale Extended.

RESULTS

The study included 962 patients: 196 (20.4%) developed a VAP at a median interval of 5 days (interquartile range [IQR], 3-7 days) after intubation. Patients who developed VAP were younger (median age, 39.5 [IQR, 25-55] years vs 51 [IQR, 30-66] years; P < .001), with a higher incidence of alcohol abuse (36.6% vs 27.6%; P = .026) and drug abuse (10.1% vs 4.2%; P = .009), more frequent thoracic trauma (53% vs 43%; P = .014), and more episodes of respiratory failure during ICU stay (69.9% vs 28.1%; P < .001). Age (hazard ratio [HR], 0.99; 95% CI, 0.98-0.99; P = .001), chest trauma (HR, 1.4; 95% CI, 1.03-1.90; P = .033), histamine-receptor antagonist intake (HR, 2.16; 95% CI, 1.37-3.39; P = .001), and antibiotic prophylaxis (HR, 0.69; 95% CI, 0.50-0.96; P = .026) were associated with the risk of VAP. Patients with VAP had a longer duration of mechanical ventilation (median, 15 [IQR, 10-22] days vs 8 [IQR, 5-14] days; P < .001) and ICU LOS (median, 20 [IQR, 14-29] days vs 13 [IQR, 8-21] days; P < .001). However, VAP was not associated with increased mortality or worse neurological outcome. Overall mortality at 6 months was 22%.

INTERPRETATION

VAP occurs less often than previously described in patients after TBI and has a detrimental effect on ICU LOS but not on mortality and neurological outcome.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02210221; URL: www.clinicaltrials.gov.

摘要

背景

据我们所知，尚无关于创伤性脑损伤（TBI）患者呼吸机相关性肺炎（VAP）的大型前瞻性数据。

研究问题

评估 TBI 后 VAP 的发生率、时间和危险因素及其对患者预后的影响。

研究设计和方法

这是对协作欧洲神经创伤功效研究中创伤性脑损伤数据集的分析，该数据集来自一项大型、多中心、前瞻性、观察性研究，包括入住欧洲 ICU 的 TBI 患者，接受机械通气时间≥48 小时，入住 ICU 时间≥72 小时。比较 VAP 患者与无 VAP 患者的特征，并在损伤后 6 个月使用格拉斯哥预后量表扩展版评估预后。

结果

研究共纳入 962 例患者：196 例（20.4%）在插管后中位数 5 天（四分位距 [IQR]，3-7 天）时发生 VAP。发生 VAP 的患者年龄较小（中位数年龄，39.5 [IQR，25-55] 岁 vs 51 [IQR，30-66] 岁；P<.001），酒精滥用（36.6% vs 27.6%；P=.026）和药物滥用（10.1% vs 4.2%；P=.009）发生率较高，胸部创伤更常见（53% vs 43%；P=.014），ICU 期间呼吸衰竭发作更频繁（69.9% vs 28.1%；P<.001）。年龄（风险比 [HR]，0.99；95%CI，0.98-0.99；P=.001）、胸部创伤（HR，1.4；95%CI，1.03-1.90；P=.033）、组胺受体拮抗剂摄入（HR，2.16；95%CI，1.37-3.39；P=.001）和抗生素预防（HR，0.69；95%CI，0.50-0.96；P=.026）与 VAP 风险相关。发生 VAP 的患者机械通气时间较长（中位数，15 [IQR，10-22] 天 vs 8 [IQR，5-14] 天；P<.001）和 ICU 入住时间较长（中位数，20 [IQR，14-29] 天 vs 13 [IQR，8-21] 天；P<.001）。然而，VAP 与死亡率或神经预后恶化无关。6 个月时的总体死亡率为 22%。