Risk factors for ventilator-associated pneumonia in trauma patients:A descriptive analysis

BACKGROUND:We sought to evaluate the risk factors for developing ventilator-associated pneumonia(VAP)and whether the location of intubation posed a risk in trauma patients.METHODS:Data were retrospectively reviewed for adult trauma patients requiring intubation for>48 hours,admitted between 2010 and 2013.Patients’demographics,clinical presentations and outcomes were compared according to intubation location(prehospital intubation[PHI]vs.trauma room[TRI])and presence vs.absence of VAP.Multivariate regression analysis was performed to identify predictors of VAP.RESULTS:Of 471 intubated patients,332 patients met the inclusion criteria(124 had PHI and208 had TRI)with a mean age of 30.7±14.8 years.PHI group had lower GCS(P=0.001),respiratory rate(P=0.001),and higher frequency of head(P=0.02)and chest injuries(P=0.04).The rate of VAP in PHI group was comparable to the TRI group(P=0.60).Patients who developed VAP were 6 years older,had significantly lower GCS and higher ISS,head AIS,and higher rates of polytrauma.The overall mortality was 7.5%,and was not associated with intubation location or pneumonia rates.In the early-VAP group,gram-positive pathogens were more common,while gram-negative microorganisms were more frequently encountered in the late VAP group.Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.CONCLUSION:In trauma,the risk of developing VAP is multifactorial.However,the location of intubation and presence of chest injury could play an important role.

Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A Meta-analysis

Objective： Ventilator associated pneumonia （VAP） has been shown to be associated with significant morbidity and mortality（ Chastre and Fagon, 2002; klompas, 2007） among mechanically venti- lated patients in the intensive care unit （ICU）, with the incidence ranging from 9% to 27% ; crude mortality ranges from 25% to 50%.1-3 A meta-analysis of published studies was undertaken to combine information regarding the effect of subglottic secretion drainage （SSD） on the incidence of ventilated associated pneumonia in adult ICU patients. Methods： Reports of studies on SSD were identified by searching the PUBMED, EMBASE, and COCHRANCE LIBRARY databases （December 30, 2010）. Randomized trials of SSD compared to usual care in adult mechanically ventilated ICU patients were included in this meta-analysis. Results： Ten RCTs with 2,314 patients were identified. SSD significantly reduced the incidence of VAP [ relative risk （RR） =0.52, 95% confidence interval （C/）： 0.42-0.64, P〈0.000 01]. When SSD was compared with the control groups, the overall RR for ICU mortality was 1.00 （95% CI, 0.84-1.19） and for hospital mortality was 0.95 （95% CI, 0. 80-1.13）. Overall, the subglottic drainage effect on the days of mechanical ventilation was -1.52 days （95% CI, -2.94 to -0.11） and on the ICU length of stay （LOS） was -0.81days （95% CI, -2.33 to -0.7）. Conclusions： In this meta-analysis, when an endotracheal tube （ETT） with SSD was compared with an ETT without SSD, there was a highly significant reduction in the VAP rate of approxi- mately 50%. Time on mechanical ventilation （MV） and the ICU LOS may be reduced, but no reduction in ICU or hospital mortality has been observed in published trials,

Pseudomonas aeruginosa ventilator associated pneumonia: improved outcomes with earlier follow-up

It is not clear what is the appropriate timing to follow-up patients with ventilator-associated pneumonia (VAP) and Clinical Pulmonary Infe- ction Score >6 between days 3-5 of an appro- priate antibiotic treatment. We studied 122 patients with Pseudomonas aeruginosa VAP. A follow-up respiratory sample was collected on days three or five ( “day-three” and “day-five” group ) and treatment was modified 48h later. Molecular typing identified super-infections or persistence. For serial data another respiratory sample was collected, on day three from the “day-five” group and on day five from the “day-three” group. Sixty patients, in the “day- three” group compared to 62 in the “day-five” group, had reduced fourteen-day mortality ( 18.3% and 38.7%;p=0.01 ) and fewer days in intensive care unit (17.2 ± 4.3 compared to 27.3 ± 4.7, p6, improved fourteen-day mortality and shorter duration of stay in health-care facilities were observed with earlier follow-up.

Ventilator associated pneumonia following liver transplantation:Etiology,risk factors and outcome

AIM: To determine the incidence, etiology, risk factors and outcome of ventilator-associated pneumonia(VAP) in patients undergoing orthotopic liver transplantation(OLT).METHODS: This retrospective study considered 242 patients undergoing deceased donor OLT. VAP was diagnosed according to clinical and microbiological criteria. RESULTS: VAP occurred in 18(7.4%) patients, with an incidence of 10 per 1000 d of mechanical ventilation(MV). Isolated bacterial etiologic agents were mainly Enterobacteriaceae(79%). Univariate logistic analysis showed that model for end-stage liver disease(MELD) score, pre-operative hospitalization, treatment with terlipressin, Child-Turcotte-Pugh score, days of MV and red cell transfusion were risk factors for VAP. Multivariateanalysis, considering significant risk factors in univariate analysis, demonstrated that pneumonia was strongly associated with terlipressin usage, pre-operative hospitalization, days of MV and red cell transfusion. Mortality rate was 22% in the VAP group vs 4% in the group without VAP. CONCLUSION: Our data suggest that VAP is an important cause of nosocomial infection during postoperative period in OLT patients. MELD score was a significant risk factor in univariate analysis. Multiple transfusions, treatment with terlipressin, preoperative hospitalization rather than called to the hospital while at home and days of MV constitute important risk factors for VAP development.

The Diagnostic and Prognostic Value of Serum Procalcitonin among Ventilator Associated Pneumonia Patients

Ventilator-associated pneumonia (VAP) is a complication in as many as 28% of patients who receive mechanical ventilation. Studies have consistently shown that a delay in diagnosis and treatment increases the mortality risk. The aim of this work was to clarify the role of the serum procalcitonin (PCT) in the diagnosis and the prognosis of ventilator associated pneumonia. Methods: Forty two VAP patients, 20 non VAP-ICU (on mechanical ventilation) admitted patients and 20 healthy control subjects of similar age and sex were included in the study. PCT levels in serum samples were measured in all subjects. Results: There was a highly statistically significant difference (p value 0.001) between VAP patients on one side and non VAP-ICU patients and healthy control subjects on the other side regarding the mean values of PCT. Also, the mean values of PCT were statistically significantly higher (p 0.001) among died VAP group than the survivor VAP group. There was a statistically positive correlation (p = 0.449), CRIP (R = 0.403) and SOFA (R = 0.437)) and initial PCT serum levels. Conclusions: This study found that the increased PCT serum level is an important diagnostic tool for VAP and the PCT serum levels can predict the outcome of VAP patients. We recommend other larger studies to augment our findings.

Ventilator Associated Pneumonia in an Intensive Care Unit

The aim of this prospective study was to evaluate the incidence, etiologic agents and mortality rate of ventilator-associated pneumonia (VAP). In a six-month period, cases who were 18 years or older, dependent on mechanical ventilator for more than 3 days and without pulmonary infection on first admission were included in this study. In all cases, body temperature recordings, blood and urine culture, microbiological analyses of endotracheal aspirates, and chest X-rays were obtained and used to identify VAP. Apache II scores on admission, duration of mechanical ventilation, length of intensive care unit (ICU) stay and mortality were recorded. This study included 45 cases and 22 developed VAP (48%). The incidence of VAP was 25.34 per 1000 ventilator days. Univariate analyses showed that duration of mechanical ventilation, length of ICU stay, coma and tracheotomy were associated with the development of VAP. The mortality rate of cases with VAP (72.7%) was significantly higher than cases without VAP (39.1%). The most frequent microorganisms were Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella pneumoniae. In our study, VAP was a very common and important complication of mechanical ventilation and mortality was very high. To reduce mortality, minimize morbidity, shorten the length of stay, and reduce costs, defined risk factors for VAP should be recognized and an effective infection control program for the prevention of VAP should be implemented. Surveillance results should be evaluated regularly and necessary precautions should be taken.

Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer

Patients undergoing major oncological surgery for head and neck cancer （SHNC） have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia （VAP） in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6~0 （n = 95） in patients who required more than 48 h of mechanical ventilation. Staphylococcus （37.7%）, Enterobacteriaceae （32.1%）, Pseudomonas （20.8%）, and Haemophilus （16.9~） were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively （P = 0.006）. Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively （P 〈 0.001）. The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.

Risk factors and clinical responses of pneumonia patients with colistin-resistant Acinetobacter baumannii-calcoaceticus

BACKGROUND Nosocomial infections with carbapenem-resistant Acinetobacter baumanniicalcoaceticus complex(ABC)strains are great problem for intensive care units.ABC strains can develop resistance to all the antibiotics available.Carbapenem resistance is common and colistin resistance is rare in our country.Knowing the risk factors for colistin resistance is important since colistin seems to be the only remaining therapeutic option for the patients with pneumonia due to extensively drug resistant ABC for our country.AIM To investigate the comparison of clinical responses and outcomes between pneumonia patients with colistin-susceptible and-resistant Acinetobacter sp.Strains.METHODS During the study period,108 patients with pneumonia due to colistin-susceptible strains and 16 patients with colistin-resistant strains were included retrospectively.Continuous variables were compared with the Mann-Whitney U test,and categorical variables were compared using Pearson’s chi-square test or Fisher’s Exact chi-square test for two groups.A binary logistic regression model was developed to identify the potential independent factors associated with colistin resistance in patients with colistin-resistant strains.RESULTS High Acute Physiology and Chronic Health Evaluation II scores(OR=1.9,95%CI:1.4-2.7;P<0.001)and prior receipt of teicoplanin(OR=8.1,95%CI:1.0-63.3;P=0.045)were found to be independent risk factors for infection with colistin-resistant Acinetobacter sp.Different combinations of antibiotics including colistin,meropenem,ampicillin/sulbactam,amikacin and trimethoprim/sulfamethoxazole were used for the treatment of patients with colistin-resistant strains.Although the median duration of microbiological cure(P<0.001)was longer in the colistin-resistant group,clinical(P=0.703),laboratory(P=0.277),radiological(P=0.551),microbiological response(P=1.000)and infection related mortality rates(P=0.603)did not differ between the two groups.Among the patients with infections due to colistin-resistant strains,seven were treated with antibiotic combinations that included sulbactam.Clinical(6/7)and microbiological(5/7)response rates were quite high in these patients.CONCLUSION The optimal therapy regimen is unclear for colistin-resistant Acinetobacter sp.infections.Although combinations with sulbactam seems to be more effective in our study patients,data supporting the usefulness of combinations with sulbactam is very limited.

Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients： A Retrospective Study on Propensity Score Matching Method

Background： Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia （VAP） in trauma patients. Methods： This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy （de-escalation group） or non-de-escalation therapy （non-de-escalation group）. Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation. Results： Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups （28.6% vs. 23.8%, P = 0.620）. The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group （11 [8-13] vs. 14 [8-19] days, P = 0.045）. The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group （6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively）. Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE Ⅱ） score, high injury severity score, multi-drug resistant （MDR） infection, and inappropriate initial antibiotics were associated with patients＇ 28-day mortality, while high APACHEⅡ score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation. Conclusions： De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.

Microscopic examination of intracellular organisms in bronchoalveolar lavage fluid for the diagnosis of ventilator-associated pneumonia：a prospective multi-center study

Background The presence of intracellular organisms （ICOs） in polymorphonuclear leukocytes obtained from bronchoalveolar lavage fluid （BALF） is a possible method for rapid diagnosis of ventilator-associated pneumonia （VAP）.However,the validity of this diagnostic method remains controversial and the diagnostic thresholds reported by investigators were different.Our objective was to evaluate the accuracy of quantification of ICOs in BALF for the diagnosis of VAP,and to detect the best cutoff percentage of PMNs containing ICOs （PIC） in the microscopic examination of BALF for the diagnosis of VAP.Methods This was a prospective multi-center study conducted in 4 ICUs in Wuhan,China,which involved 181 patients suspected of first episode of VAP.BALF was obtained from all enrolled patients.The BALF samples underwent quantitative culture,cytological and bacteriological analysis to detect the culture results,PIC values and the morphological features of microorganisms.Definite diagnosis of VAP was based on pre-set criteria.The receiver-operating characteristic curve was used to detect the best cutoff point for PIG to diagnose VAP,and the diagnostic accuracy was calculated.Moreover,quantitative culture and Gram＇s stain of BALF were adopted to diagnose VAP,and their diagnostic accuracy was evaluated as well.Results There were 102 patients definitely diagnosed with VAP （VAP group）,and 60 patients definitely diagnosed without VAP （no VAP group）.We found that ICOs were present in 96.08％ （98 out of 102） of VAP patients and 20.00％ （12 out of 60） of no VAP patients.The PICs were significantly higher （（9.53±6.65）％ vs.（0.52±1.33）％,P＜0.01） in VAP group.In our study,the best cutoff point for PIC to diagnose VAP was 1.5％,which had a sensitivity of 94.12％,a specificity of 88.33％,a positive predictive value （PPV） of 93.20％ and a negative predictive value （NPV） of 89.83％.The area under the receiveroperating characteristic curve was 0.956 （95％ confidence interval,0.925-0.986; P＜0.01）.When the positive quantitative culture results of BALF were used to diagnose VAP,the sensitivity,specificity,PPV and NPV were 65.69％,95.00％,95.71％ and 61.96％,respectively.Whereas they were 70.59％,76.67％,83.72％ and 60.53％,respectively,when the positive Gram＇s stain results of BALF were used to diagnose VAP.The concordance between the results of Gram＇s stain and quantitative cultures was poor,only 32.10％ （52 out of 162） was totally right,and 17.28％ （28 out of 162） was partially right.Conclusions PIC＞1.5％ has good diagnostic performance in the microscopic examination of BALF for the diagnosis of VAP.However,Gram＇s stain is not reliable for the early application of antibiotic therapy,due to the poor bacteriological predictive value.

The Association of Pneumonia with Clinical Outcome in Patients with Inhalation Injury

Introduction: Inhalation injury is a particularly lethal form of thermal burn injury, and is associated with increased morbidity and mortality. Pneumonia is a common complication of inhalation injury, due to the increased susceptibility of lungs that have been stripped of their biologic defense mechanisms, as well as the general susceptibility of the burn population to infections. While older series suggest that pneumonia is associated with worse mortality and morbidity, recent reports suggest that this may not be the case in all populations. Methods: We attempted to clarify the impact of pneumonia in terms of mortality, length of mechanical ventilation, need for tracheostomy, and discharge disposition, in patients admitted with inhalation injury by performing a retrospective review of patients admitted to a regional burn center 2002-2009. Burn registry and electronic chart review were used to obtain demographic, clinical and outcome data. Univariate and multivariate analysis was used to compare outcomes in patients who developed pneumonia versus those who did not. Results: The study cohort comprised 166 patients, of whom 21 (13%) were diagnosed with pneumonia. Development of pneumonia was not predicted by age, surface area burned or other complications such as acute respiratory distress syndrome. Surprisingly, pneumonia was associated with reduced inpatient mortality (p = 0.006). However, patients who developed pneumonia were also more likely to have prolonged ventilator dependence (19 vs 5 days,

Natural History, Outcomes and Antibiotic Treatment for Ventilator-Associated Tracheobronchitis in Critical Ill Patients

We assessed incidence and outcomes of patients with ventilator-associated respiratory infections (VARI) due to tracheobronchitis (VAT) and pneumonia (VAP), including length of intensive care unit (ICU) stay and ventilator days. We also examined pathogens, rate of progression from VAT to VAP, and impact of antibiotic therapy for VAT. Data analysis included 234 patients, 100 patients (43%) had at least moderate (+++) bacterial growth in their semi-quantitative endotracheal aspirate (SQ-ETA) cultures. VAT and VAP were each diagnosed in 34 (15%) patients. Staphylococcus aureus was the most common pathogen isolated and had the highest rate of progression from VAT to VAP. Seven (21%) of the 34 patients were diagnosed with VAT that later progressed to VAP in averaged 3 days. Patients diagnosed with VAT had significantly more ventilator days (9 vs 6, p p < 0.001) and hospital days (22 vs 17, p < 0.001). No significant difference was observed in the clinical outcomes of the 25 VAT patients with timely, appropriate antibiotics compared to the 9 VAT patients who did not receive timely appropriate antibiotics. VAT was a risk factor for increased ventilator days, longer length of ICU and hospital stay. The time window from VAT to VAP allowed physicians to identify the pathogens and sensitivity profile needed to treat VAT with appropriate antibiotics. Data from well-designed studies were needed to assess the impact of early, appropriate antibiotic therapy for VAT, the choice of antibiotics, as well as the duration and route of administration.

纤维支气管镜肺泡灌洗液中sTREM-1、IL-32及PCT水平对呼吸机相关性肺炎病情及预后判断的价值

目的:探讨纤支镜支气管肺泡灌洗液中可溶性髓系细胞触发受体-1(sTREM-1)、白细胞介素32(IL-32)及降钙素原(PCT)水平与呼吸机相关肺炎(VAP)患者病情及预后判断的价值。方法:选取确诊的53例VAP患者作为VAP组;另选取同期实施机械通气但是未发生VAP的56例患者作为对照组。记录两组患者肺泡灌洗液中sTREM-1、IL-32、PCT水平、CPIS评分、APACHEⅡ评分,并探究其与患者病情和预后的相关性。结果:VAP组患者肺泡灌洗液sTREM-1、IL-32、PCT水平及CPIS评分、APACHEⅡ评分均高于对照组(P<0.05);VAP组患者肺泡灌洗液的sTREM-1、IL-32、PCT水平与CPIS评分正相关(r=0.614、0.603、0.621,P<0.05);VAP组患者肺泡灌洗液的sTREM-1、IL-32、PCT水平与APACHEⅡ评分正相关(r=0.414、0.463、0.409,P<0.05);53例VAP患者,经过28 d治疗,死亡17例、存活36例,死亡的VAP患者肺泡灌洗液sTREM-1、IL-32、PCT水平及CPIS评分、APACHEⅡ评分均高于存活组(P<0.05);肺泡灌洗液sTREM-1、IL-32、PCT水平预测VAP患者不良预后结局的受试者工作曲线下面积(AUC)分别为0.900、0.862、0.917。结论:VAP患者肺泡灌洗液中sTREM-1、IL-32、PCT水平升高,并且与患者肺部感染程度、病情危重程度正相关,对于预测患者不良结局具有较高的价值。

FOCUS-PDCA模式对ICU重症患者呼吸机相关性肺炎的影响

目的分析发现-组织领导-明确情况-分析了解-改进方案(find organize clarify understand select,FOCUS)-计划-执行-检查-行动(plan do check act,PDCA)模式对重症监护室(intensive care unit,ICU)重症患者呼吸机相关性肺炎(ventilator associated pneumonia,VAP)的影响。方法选取2022年10月—2023年9月菏泽市牡丹人民医院ICU接受机械通气治疗的重症患者120例,根据干预时间将其分为2组,即2022年10月—2023年3月60例患者作为对照组,2023年4—9月60例患者作为研究组。对照组接受常规干预措施预防VAP,研究组在此基础上,采用FOCUS-PDCA模式预防VAP。比较2组患者机械通气时间、住院时间、住院费用、一次性脱机成功率与VAP发生率。结果与对照组相比,研究组机械通气时间、住院时间更短(P<0.05),住院费用更低(P<0.05)。研究组一次性脱机成功率为96.67%,高于对照组的85.00%(χ^(2)=4.904,P<0.05);VAP发生率为1.67%,低于对照组的13.33%(χ^(2)=4.324,P<0.05)。结论FOCUS-PDCA模式能够有效降低ICU重症患者VAP的发生率,缩短机械通气时间与住院时间,节省住院费用,提高一次性脱机成功率,具有临床应用价值。

呼吸机相关肺炎患者病原菌分布及血清miR-101-3p、斯钙素1的检测分析

目的 探究呼吸机相关肺炎(ventilator-associated pneumonia,VAP)患者病原菌分布及血清微小RNA-101-3p(microRNA-101-3p,miR-101-3p)、斯钙素1(stanniocalcin 1,STC1)表达水平在VAP诊断中的临床意义。方法 选取2020年1月至2023年4月在安徽医科大学附属六安医院进行机械通气治疗,发生VAP的患者121例作为VAP组,未发生VAP的患者87例为非VAP组,同期健康体检者83例为对照组。采集VAP组患者下呼吸道分泌物进行病原菌鉴定;测定所有研究对象的血清STC1、降钙素原(procalcitonin,PCT)、C反应蛋白(C-reactive protein,CRP)、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)、miR-101-3p水平。采用Pearson法分析血清miR-101-3p、STC1与炎症因子PCT、CRP、TNF-α的相关性;采用受试者操作特征曲线(receiver operating characteristic curve,ROC曲线)分析血清miR-101-3p、STC1对VAP的诊断价值。结果 121例VAP患者共检测分离出病原菌218株,其中革兰氏阴性菌124株(56.88%),革兰氏阳性菌86株(39.45%),真菌8株(3.67%);VAP组的血清miR-101-3p、PCT、CRP、TNF-α水平均显著高于非VAP组和对照组(P<0.05),STC1水平显著低于非VAP组和对照组(P<0.05);VAP患者的血清miR-101-3p水平与PCT、CRP、TNF-α呈正相关(P<0.05),STC1水平与PCT、CRP、TNF-α呈负相关(P<0.05);ROC曲线显示血清miR-101-3p、STC1单独及联合诊断VAP患者的曲线下面积(area under curve,AUC)分别为0.766、0.750、0.841,联合诊断价值高于二者单独诊断(Z二者联合-miR-101-3p=2.275、P=0.023,Z二者联合-STC1=2.856、P=0.004)。结论 VAP患者以革兰氏阴性菌感染为主,血清miR-101-3p呈高表达、STC1呈低表达,血清miR-101-3p、STC1联合诊断对于VAP的发生具有一定的诊断价值。

血清ChE、Syndecan-1水平对AECOPD合并呼吸机相关性肺炎患者病情及预后的评估价值

目的 分析血清胆碱酯酶(ChE)、多配体蛋白聚糖-1(Syndecan-1)水平对慢性阻塞性肺疾病急性加重期(AECOPD)合并呼吸机相关性肺炎(VAP)患者病情及预后的评估价值。方法 选取2022年1月至2024年1月淮安市第五人民医院收治的AECOPD合并VAP患者132例(设为AECOPD合并VAP组),另选择同期COPD稳定期患者70例(设为COPD稳定期组)和同期体检健康者70例(设为对照组),比较3组血清ChE、Syndecan-1水平。根据急性生理和慢性健康评分系统Ⅱ(APACHEⅡ)评分将AECOPD合并VAP患者分为低危VAP组(42例)、中危VAP组(44例)、高危VAP组(46例),分析血清ChE、Syndecan-1水平与AECOPD合并VAP患者APACHEⅡ评分的相关性。根据28 d预后分为死亡组(52例)和存活组(80例),比较3组ChE、Syndecan-1水平,并收集AECOPD合并VAP患者基线资料,绘制受试者工作特征(ROC)曲线,分析CHE、Syndecan-1水平评估AECOPD合并VAP患者不良预后的价值。结果 血清ChE水平AECOPD合并VAP组低于COPD稳定期组低于对照组,血清Syndecan-1水平AECOPD合并VAP组高于COPD稳定期组高于对照组(P <0.05),低、中、高危VAP组血清ChE水平依次降低,Syndecan-1水平依次降低(P <0.05)。AECOPD合并VAP患者APACHEⅡ评分与血清ChE水平呈负相关,与血清Syndecan-1水平呈正相关(P <0.05)。APACHEⅡ评分增加、降钙素原升高、Syndecan-1升高为AECOPD合并VAP患者不良预后的独立危险因素,第1秒用力呼气容积占预计值百分比升高、ChE升高为独立保护因素(P <0.05)。血清ChE联合Syndecan-1水平评估AECOPD合并VAP患者不良预后的曲线下面积为0.882,大于血清ChE、Syndecan-1水平单独评估的0.800、0.794(P <0.05)。结论 血清ChE水平降低和Syndecan-1升高与AECOPD合并VAP患者病情加重和预后不良有关,血清ChE联合Syndecan-1水平评估AECOPD合并VAP患者预后的价值较高。

FOCUS-PDCA质量管理模式在冠状动脉旁路移植术患者健康教育中的应用效果

目的评价FOCUS-PDCA质量管理模式在冠状动脉旁路移植术(CABG)患者健康教育中的应用效果。方法2022年1—6月方便选取住院择期接受CABG的患者560例,分为对照组和研究组各280例。对照组接受常规健康教育,研究组接受FOCUS-PDCA模式的健康教育。比较两组患者接受不同教育方案的预后效果。结果健康教育后,研究组患者肠道排气时间和住院总时间分别为(1.93±0.44)d和(11.51±3.41)d,均低于对照组的(2.12±0.53)和(13.75±4.16);研究组患者出院前6 min最大步行距离为(478.31±28.40)m,大于对照组的(451.23±30.82)m;研究组患者出院时冠心病相关知识、感知控制力和自我管理行为评分分别为(17.72±1.62)分、(30.75±3.13)分和(102.12±18.57)分,均高于对照组的(15.33±1.78)分、(27.19±3.27)分、和(94.15±20.09)分;术后研究组患者肺不张发生率和呼吸机相关肺炎(VAP)发生率分别9.3%和3.2%,明显低于对照组的15.0%和7.1%,差异均有统计学意义(P<0.05)。结论在冠状动脉旁路移植术患者围术期实施FOCUS-PDCA管理模式的健康教育,可降低术后肺部并发症发生率,改善术后心肺耐力,促进患者术后康复,同时能提升患者对疾病知识掌握度、控制信念、自我管理水平。

Muscular tissue desaturation and pneumonia in patients receiving lung cancer surgery:a cohort study

Background:Post-operative pneumonia(POP)is a common complication of lung cancer surgery,and muscular tissue oxygenation is a root cause of post-operative complications.However,the association between muscular tissue desaturation and POP in patients receiving lung cancer surgery has not been specifically studied.This study aimed to investigate the potential use of intra-operative muscular tissue desaturation as a predictor of POP in patients undergoing lung cancer surgery.Methods:This cohort study enrolled patients(≥55 years)who had undergone lobectomy with one-lung ventilation.Muscular tissue oxygen saturation(SmtO_(2))was monitored in the forearm(over the brachioradialis muscle)and upper thigh(over the quadriceps)using a tissue oximeter.The minimum SmtO_(2)was the lowest intra-operative measurement at any time point.Muscular tissue desaturation was defined as a minimum baseline SmtO_(2)of<80%for>15 s.The area under or above the threshold was the product of the magnitude and time of desaturation.The primary outcome was the association between intra-operative muscular tissue desaturation and POP within seven post-operative days using multivariable logistic regression.The secondary outcome was the correlation between SmtO_(2)in the forearm and that in the thigh.Results:We enrolled 174 patients.The overall incidence of muscular desaturation(defined as SmtO_(2)<80%in the forearm at baseline)was approximately 47.1%(82/174).The patients with muscular desaturation had a higher incidence of pneumonia than those without desaturation(28.0%[23/82]vs.12.0%[11/92];P=0.008).The multivariable analysis revealed that muscular desaturation was associated with an increased risk of pneumonia(odds ratio:2.995,95%confidence interval:1.080-8.310,P=0.035)after adjusting for age,American Society of Anesthesiologists status,Assess Respiratory Risk in Surgical Patients in Catalonia score,smoking,use of peripheral nerve block,propofol,and study center.Conclusion:Muscular tissue desaturation,defined as a baseline SmtO_(2)<80%in the forearm,may be associated with an increased risk of POP.Trial registration:No.ChiCTR-ROC-17012627.

运用Focus-PDCA降低重症监护室患者呼吸机相关性肺炎发生率

目的探讨Focus-PDCA管理程序降低重症监护室患者呼吸机相关肺炎的发生率的效果。方法通过发现重症监护室2016年—2018年呼吸机相关肺炎的发生率逐年递增问题,2019年及时组建专项管理小组,利用Focus-PDCA管理工具进行改进。结果规范重症监护室呼吸机相关性肺炎的预防措施,呼吸机相关肺炎发生率从4.68‰下降至2.28‰。结论重症医学科实施Focus-PDCA管理能有效降低患者呼吸机相关性肺炎的发生率。

高敏C-反应蛋白与白蛋白比值对呼吸机相关性肺炎病人短期内撤机的预测价值

目的探究高敏C-反应蛋白(hs-CRP)与白蛋白(Alb)比值对呼吸机相关性肺炎(VAP)病人短期内撤机的预测价值。方法回顾性分析2018年3月至2020年9月河北省人民医院收治的200例VAP病人的临床资料,根据VAP发生时间的早晚分为早发组(100例,机械通气时间≤4 d)和晚发组(100例,机械通气时间>4 d)。采用酶联免疫吸附法(ELISA)检测血清白细胞介素-8(IL-8)、肿瘤坏死因子-α(TNF-α)、hs-CRP、Alb水平,并计算hs-CRP/Alb比值;利用受试者操作特征曲线(ROC曲线)分析hs-CRP、Alb、hs-CRP/Alb比值对VAP病人短期内撤机的预测价值;采用Kaplan-Meier法绘制以hs-CRP/Alb比值截断值分组的VAP病人短期内撤机率。结果早发组机械通气时间[(5.22±1.68)d]和ICU入住时间[(7.19±1.82)d]高于晚发组[(3.60±1.10)d、(5.31±1.37)d](P<0.05)。与晚发组[(18.13±4.56)μg/L、(55.04±13.57)μg/L、(25.54±4.57)mg/L、(33.31±4.38)g/L]比较,早发组IL-8[(20.82±5.51)μg/L]、TNF-α[(61.41±14.04)μg/L]、hs-CRP[(28.41±5.04)mg/L]显著升高,Alb水平[(30.37±3.35)g/L]显著降低(P<0.05);早发组hs-CRP/Alb比值(0.93±0.25)高于晚发组(0.76±0.12)(P<0.05)。ROC曲线显示,hs-CRP、Alb、hs-CRP/Alb比值预测VAP病人短期内撤机的AUC 95%CI分别为0.72(0.62,0.82)、0.79(0.70,0.88)、0.91(0.85,0.97),灵敏度分别为78.05%、68.38%、80.38%,特异度分别为50.00%、74.00%、96.00%。低hs-CRP/Alb比值组病人短期内撤机率82.03%明显高于高hs-CRP/Alb比值组58.33%(P<0.05)。结论hs-CRP/Alb比值对VAP病人短期内撤机的预测价值较高,可作为参考指标。