口腔去定植对重症患者呼吸机相关性肺炎发生率的影响

Effect of oral decontamination on bacterial colonization to prevent ventilator-associated pneumonia in critically ill patients

目的探讨口腔去定植对重症患者呼吸机相关性肺炎发生率的影响。方法选择2014年1月至2018年1月普宁华侨医院重症医学科收治的进行机械通气的重症患者582人,随机分为对照组(n=289)和治疗组(n=293);对照组进行常规口腔护理(不使用洗必泰),治疗组用0.12%的洗必泰将医用棉球浸湿,对患者口腔进行清洁,包括患者前后咽部、牙龈、舌头以及口腔黏膜,每日4次。比较两组患者呼吸机相关性肺炎的发生状况、持续时间、ICU住院时间和肺部感染评分,以及血常规、体温、C反应蛋白(CRP)、血清淀粉样蛋白A(SAA)、血清降钙素原(PCT)、白细胞介素-6(IL-6)、IL-8、IL-10、TNF-α水平,比较两组患者下呼吸道分泌物病原菌分布。结果治疗组患者的VAP发生率、ICU住院时间、机械通气时间均显著低于对照组,两组比较差异有统计学意义(P<0.05);VAP的发生时间(10.62±4.96)d,显著晚于对照组(8.31±5.38)d,差异有统计学意义(P<0.05)。两组患者干预前临床肺部感染评分(CPIS)比较差异无统计学意义(P>0.05),治疗后治疗组入组48 h和72 h的CPIS分别为(3.87±0.89)、(2.59±0.74)分,明显低于对照组的(6.57±0.92)、(6.31±0.82)分,差异有统计学意义(P<0.05)。两组患者干预前血常规和感染相关生物标志物指标水平比较差异无统计学意义,治疗后治疗组患者白细胞计数、中性粒细胞百分比、CRP、SAA、PCT水平明显低于对照组,差异有统计学意义(P<0.05)。所有患者下呼吸道分泌物共检出病原菌541株,其中革兰阴性菌355株,占65.6%;革兰阳性菌171株,占31.6%;真菌15株,占2.8%。结论口腔去定植是预防VAP的有效方法,能有效降低VAP的发生率,延迟VAP的发生,缩短患者的机械通气时间及ICU住院时间。

Objective To explore the effect of oral decontamination on bacterial colonization to prevent ventilator-associated pneumonia in critically ill patients.Methods A total of 582 critically ill patients who were treated in the hospital from Jan2014 to Jan 2018 were enrolled in the study and randomly divided into the control group with 289 cases and treated group with293 cases.The control group received standard oral care(without chlorhexidine),while the treated group received oral decontamination on bacterial colonization with 0.12%chlorhexidine to wash front and back pharyngeal,gingiva,tongue and oral mucosa,four times a day during the ICU stay.The incidence of infection was compared between the two groups of patients,the constituent ratios of pathogens isolated from the critically ill patients were observed,and the blood routine,levels of C-reactive protein(CRP),serum amyloid A(SAA),serum procalcitonin(PCT),interleukin-6(IL-6),IL-8,IL-10 and TNF-αwere observed and compared between the two groups of patients.Results The incidence rate of VAP,length of stay in ICU and duration of mechanical ventilation in the treated group were significantly lower than those in the control group(P<0.05).The onset time of VAP was significantly later than that of control group(P<0.05).CPIS of the two groups before intervention showed no statistical significance(P>0.05),while CPIS of the treatment group after 48 h and 72 h were(3.87±0.89)and(2.59±0.74)points,respectively,which were significantly lower than those of the control group(6.57±0.92)and(6.31±0.82)points,with statistical significance(P<0.05).The white blood cell counts,neutrophilic granulocyte percentage,CRP,SAA,PCT of control group was significantly higher than those in the treated group(P<0.05).Totally 541 strains of pathogens were isolated from lower respiratory tract excretion of critically ill patients,including 355(65.6%)strains of gram-negtive bacteria,171(31.6%)strains of gram-positive bacteria,and 15(2.8%)strains of fungi.Conclusion Oral decontamination on bacterial colonization was an effective way to prevent the VAP,which may reduce the incidence of VAP,delay the onset time of VAP,shorten the time of mechnical ventilation and hospital stay.