基于证据的预防呼吸机相关性肺炎集束化策略在新生儿的临床应用

Applying evidence-based prevention bundle strategies of ventilator-associated pneumonia in ventilatedneonates

【摘要】目的探讨在新生儿重症监护病房（ neonatal intensive care unit, NICU）对气管插管机械通气新生儿应用基于证据的预防新生儿呼吸机相关性肺炎（ ventilator-associated pneumonia, VAP） 集束化策略的临床效果。方法选择2016年1月至2017年12月本院NICU进行气管插管机械通气的新生儿进行回顾性分析，2016年1—12月纳入的病例应用传统常规方法预防VAP，为对照组；2017年1～12月纳入的病例应用基于证据的预防新生儿VAP集束化策略，为观察组。比较两组患儿在插管前咽拭子或痰培养为阴性，插管48h后至拔管48h内咽拭子或痰培养或气管插管末端培养任一项致病菌阳性的比例，以阳性例数／1000插管日表示；并采用多元回归分析呼吸道致病菌阳性率的影响因素。结果2016-2017年共纳入气管插管机械通气患儿1221例，对照组632例共插管798例次，观察组589例共插管720例次。观察组胎龄和出生体重小于对照组，超低出生体重儿、产前使用激素比例大于对照组，机械通气时间长于对照组，差异均有统计学意义（P〈0．05）。对照组致病菌阳性112例次，总插管时间3079d，阳性率为36．4例／1000插管日；观察组致病菌阳性72例次，总插管时间3475d，阳性率为20．7例／1000插管日，明显低于对照组（χ2=4．060，P=0．044）。多元回归分析结果显示，出生体重、日龄、机械通气时间和应用集束化策略是呼吸道致病菌阳性的影响因素。结论在NICU对气管插管机械通气新生儿采用基于证据的预防VAP集束化策略可以减少呼吸道致病菌入侵，今后的NICU护理工作中应越来越多地应用集束化策略对患儿进行护理。

Objective To study the clinical effect of evidence-based prevention strategies of ventilator-associated pneumonia （VAP） in newborns with endotracheal intubation in neonatal intensive care unit （NICU）. Method A retrospective analysis was carried out in neonates undergoing mechanical ventilation, who were admitted to the NICU of the hospital from 2016 to 2017. Intubated newborns from January 2016 to December 2016 were conducted with traditional method of preventing VAP and included as control group. While intubated newborns admitted from January 2017 to December 2017 with newly developed evidence-based prevention strategy for VAP were included as observation group. The positive rates of culture from swab or sputum or endotracheal intubation tube ends obtained within 48 hours after intubation and 48 hours after extubation were compared between groups. The neonates whose swab or sputum culture was negative before intubation were included. The positive rate was presented as the number of positive cases/1 000 intubation days . Result A total of 1 221 intubated infants were included, with 632 cases in the control group which were intubated 798 times, and 589 cases in the observation group which were intubated 720 times. The gestational age and birth weight of the observation group was lower than the control group. The rate of extremely low birth weight infant of the observation group was higher than that of the control group. The mechanical ventilation days were also longer in the observation group. The differences were statistically significant （ P 〈 0.05 ）. In the control group, the number of positive cases was 112 and the total intubation days were 3 079 days, the positive rate was 36.4 cases/1 000 intubation days. In the observation group, the number of positive cases was 72 and the total intubation days were 3 475 days, thepositive rate was 20.7 cases/1 000 intubation days. The positive rate of observation group was lower than the control group, the differences was statistically significant （ χ2 = 4. 060, P = 0. 044 ） . Conclusion Evidence-based neonatal VAP bundle can reduce the invasion of respiratory pathogenic bacteria in NICU. In the future work of NICU nursing, we should use bundle strategy to care for babies more and more, and the bundle should be supported by evidence.