呼吸機捆綁式治療的探討課件

呼吸機捆綁式治療的探討

AReviewoftheVentilatorBundle來自美國的報道

Question什么是捆綁?WhatisaBundle??ANSWERBUNDLE:同時綜合運用一組有效的治療手段優(yōu)于運用單一治療手段.

Agroupofinterventionsrelatedtoadiseaseprocess,that,whenexecutedtogether,resultinbetteroutcomesthanwhenimplementedindividually.關于呼吸機捆綁1.升高床頭30-45度ElevatingHeadofBedto30-45degrees2.每日間歇停止使用鎮(zhèn)靜藥物DailySedationVacations3.每日評價拔管指征DailyAssessmentofReadinesstoExtubate4.預防消化道潰瘍PepticUlcerProphylaxis5.預防深靜脈血栓DVTProphylaxis1.升高床頭30-45度1.升高床頭30-45度

目的:減少呼吸機相關肺炎

GOAL:ReduceVentilator-AssociatedPneumonia(VAP)根據隨機實驗:Drakulovicetal.Lancet.1999:354:1851-58升高床頭30-45度

潛在并發(fā)癥PotentialComplications休克病人低血壓HypotensioninShock可壓迫股部血管裝置MayCompromiseFemoralDevices須經常調換姿勢MayRequireFrequentRepositioning其他?....Others?....2.每日間歇停止使用鎮(zhèn)靜劑DailySedationVacations

2.每日間隔應用鎮(zhèn)靜藥物

DailySedationVacations

目的:減少通氣時間及ICU入住時間

GOALS:DecreaseDurationofVentilationandLengthofICUStayBasedonRandomizedStudy:Kressetal.NEJM.2000:342:1471-72.每日間歇使用鎮(zhèn)靜劑

DailySedationVacations

潛在并發(fā)癥PotentialComplications中心靜脈管,氣管插管或其他裝置意外脫出Accidentalremovalofendotrachealtubes,centrallines,otherequipment3.每日評價拔管指征DailyAssessmentofReadinesstoExtubate

3.每日評價拔管指征

DailyAssessmentofReadinesstoExtubate

目的:減少通氣時間及ICU入住時間

GOALS:DecreaseDurationofVentilationandLengthofICUStay基于以下隨機實驗BasedonRandomizedStudies:Elyetal.NEJM.1996:335:1864-9.Estebanetal.NEJM.1995;332:345-50.Elyetal

NEJM.1996;335:1864-9.

Estebanetal

NEJM.1995;332:345-60ElyDailySB

NoDailySB

每日自主呼吸無每日自主呼吸

4.5days* 6.0daysEsteban

multipleSB

oncedailySBIMV

PS

多次

每日一次 5days 4days 3days* 3days*

*P<0.053.每日評價拔管指征

DailyAssessmentofReadinesstoExtubate

潛在并發(fā)癥PotentialComplications-中心靜脈管,氣管插管或其他裝置意外脫出Accidentalremovalofendotrachealtubes,centrallines,otherequipment4.預防消化道潰瘍

PepticUlcerProphylaxis

4.潰瘍預防PepticUlcerProphylaxis

矛盾與問題:-機械通氣患者PUD的發(fā)病率?-相互矛盾的研究結果-Meta-分析推薦使用-PUD可增加VAP風險-誰是最佳?ControversiesandQuestions:-IncidenceofPUDinventilatedpatients?-Conflictingstudies-Meta-analyseshavebeenusedforrecommendations-PUDmayincreasetheriskofVAP-Whichmedicationsarebest?4.潰瘍預防PepticUlcerProphylaxis

ASHP診治規(guī)范1.患者接受機械通氣>48小時

Patientsreceivingmechanicalventilationfor>48hours2.患者存在凝血異常

Patientswithcoagulopathy3.入院前一年內曾有過消化道出血

Patientswithh/oGIbleedingw/in1yearofadmission4.有至少兩項以下危險因素

Patientswithatleasttwoofthefollowingriskfactors -敗血癥

Sepsis -ICU時間超過1周

ICUstayofmorethan1week -出血6天或以上

Occultbleedinglasting6daysormore -應用大劑量皮質激素

Useofhigh-dosecorticosteroids**Medicationchoiceinstitution-specificIHI-對此干預未給出指征Doesnotspecifypatientselectionforthisintervention-未特別強調某項治療Doesnotspecifymedication4.潰瘍預防

PepticUlcerProphylaxis

潛在并發(fā)癥PotentialComplications-增加VAP和其他感染的風險IncreaseriskofVAPandotherinfections

(MHKollef.CritCareMed.2004;32:1395-1405.)5.預防深靜脈血栓

DVTProphylaxis

目的:預防靜脈血栓形成

GOAL:PreventionofThromboembolicEvents基于以下隨機實驗BasedonRandomizedStudies:Summary:ACCP.CHEST.2004;126:338S-400S.5.預防深靜脈血栓DVTProphylaxis

ACCP診治規(guī)范

最嚴重的患者處于中至高度風險中1. 有出血危險者:低分子或小劑量肝素2. 有出血危險者:機械壓迫裝置避免使用阿斯匹林MostCriticallyILLPatientsareatModeratetoHighRisk1. Withoutriskofbleeding:eitherlow-molecularorlowdoseunfractionatedheparin2. Withriskofbleeding:mechanicalcompressiondevicesalone3. AspirinshouldbeavoidedIHI

呼吸機捆綁VentilatorBundle…abundleisacohesiveunit.Thestepsmustallbecompletedtosucceed;the“allornone”featureisthesourceofthebundle’spower…捆綁是’有”或’無”的策略,要麼不用,要麼全部應用以取得治療的成功…eachelementin…everypatient….每個病人,每項措施均要落實OurLadyofLourdesHospital,Binghampton,NewYork,USA290DaysWithaVAPRateofZero(March2004toJanuary2005)290天未發(fā)生VAPUniversityofRochester/StrongHealthRochester,NewYork,USA>300DaysWithaVAPRateofZero大于300天未出現(xiàn)VAP呼吸機捆綁降低VAP的報道DominicanHospital >97daysSantaCruz,CASt.Vincent’sHospital >255daysBirmingham,ALVirginiaMasonMedicalCenter >180daysSeattle,WAUniversityofTexasMDAnderson 50%reduction Houston,TXNavalMedicalCenter >150daysSanDiego,CAOurLadyofLourdes 290daysBinghampton,NYUniversityofRochester/Strong >300daysRochester,NY

IHI

呼吸機捆綁VentilatorBundle捆綁的證據及應用-院內應用捆綁治療可降低VAP-非隨機實驗;無其他觀察指標-IHI現(xiàn)在強調VAP;VAP捆綁或呼吸機捆綁?-DVT和PUD預防治療對VAP并無特異性預防作用BUNDLEEVIDENCEandAPPLICATION-HospitalsusingbundleshavereportedgreatreductionsinVAP-non-randomized;nootheroutcomes-IHInowemphasizesVAP;VAPBUNDLEorVentilatorBundle?-DVTandPUDProphylaxisarenotspecifictopreventionofVAPIHI

呼吸機捆綁的解釋VentilatorBundle

Interpretation

Pros積極的-較好的總結Goodsummary-好的開端Goodstaringpoint-所有措施均在至少一次隨機臨床實驗的基礎上AllinterventionsbasedonatleastonerandomizedtrialCons負面的-有些方面相互矛盾Someareascontroversial-缺乏技術細節(jié)Detailslacking(whichpatients,when,otherspe