机械通气患者呼吸机相关性肺炎的病例对照研究

Mechanical ventilation patients with ventilator-associated pneumonia:a case-control study

目的探索机械通气患者发生呼吸机相关性肺炎(VAP)的危险因素,为医疗机构降低VAP的发生率提供参考依据。方法采用回顾性病例对照的方法,收集2020年1月—2021年4月入住重症医学科(ICU)接受机械通气>48 h、年龄>18岁的患者资料。根据诊断标准确定20例VAP患者作为病例组,在同期住院患者筛选性别、年龄与病例匹配的20例未发生VAP患者为对照组,并对两组间各项临床指标进行统计分析。结果两组患者在接受机械通气前入院诊断情况、是否手术和合并慢性阻塞性肺炎、APACHEⅡ评分、置管地点比较差异均无统计学意义(P>0.05);机械通气时白细胞、C反应蛋白、降钙素原比较差异无统计学意义(P>0.05)。与对照组相比,病例组住院总日数、住ICU天数、机械通气时间、吸痰护理次数、抗生素使用天数明显增加(均P<0.05)。其中ICU中VAP以耐碳青霉烯类鲍曼不动杆菌(占比70%)感染为主;环境卫生学监测发现,患者周围环境、护士站及使用后的消毒物品均检出鲍曼不动杆菌,说明医务人员手卫生依从性差及环境消毒不彻底也是导致院内VAP发生的原因之一。病例组住院总费用中位数为145207元,对照组为60745.48元,VAP造成的平均经济损失为84461.52元/例。病例组各项医疗费用均高于对照组,比较差异有统计学意义(P<0.05)。结论机械通气期间不适当的诊治、环境消毒不到位、手卫生依从性差可能是造成医疗机构VAP发生的主要原因。

Objective To explore the risk factors of ventilator-associated pneumonia(VAP)in patients with mechanical ventilation,and provide a reference basis for medical institutions to reduce the occurrence of VAP.Methods A retrospective casecontrol method was used to collect data of patients who hospitalized in intensive care unit(ICU)from January 2020 to April 2021,received mechanical ventilation>48 h and were>18 years old.According to the diagnostic criteria,20 patients with VAP infection were enrolled as the case group.During the same period,20 non-infected patients who matched sex,age with case group patients were enrolled as the control group,and the clinical indicators between the two groups were statistically analyzed.Results There were no significant differences between the two groups in terms of admission diagnosis,surgery and chronic obstructive pulmonary disease,APACHEII score and place of intubation before mechanical ventilation(P>0.05).There were no significant differences in white blood cell,C-reactive protein and procalctionin,CRP and PCT during the mechanical ventilation period(P>0.05).Compared with the control group,the length of stay in hospital,the length of stay in ICU,the time of mechanical ventilation,number of sputum suction nursing,and the days of antibiotic use increased significantly(all P<0.05).Among them,Acinetobacter baumannii resistant to carbapenem in ICU(accounting for 70%)was the main cause of VAP infection.The environmental hygiene monitoring found that Acinetobacter baumannii was detected in the patient’s surrounding environment,the nurse station and the disinfected items after use,indicating that the low hand hygiene compliance of medical staff and the incomplete disinfection of the environment were also the causes of VAP infection in the hospital.The median of total cost of hospitalization in the case group was 145207 yuan,while that in the control group was 60745.48 yuan.The average economic loss caused by VAP infection was 84461.52 yuan each case.The medical expenses of the case group were higher than those of the control group,with a statistically significant difference(P<0.05).Conclusions Improper diagnosis and treatment during the mechanical ventilation period,poor environmental disinfection,low hand hygiene compliance of medical staff are probably the main reasons for the occurrence of VAP in this institution.