呼吸機(jī)捆綁式治療的探討課件

呼吸機(jī)捆綁式治療的探討

AReviewoftheVentilatorBundle來自美國(guó)的報(bào)道

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

Agroupofinterventionsrelatedtoadiseaseprocess,that,whenexecutedtogether,resultinbetteroutcomesthanwhenimplementedindividually.關(guān)于呼吸機(jī)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(píng)價(jià)拔管指征DailyAssessmentofReadinesstoExtubate4.預(yù)防消化道潰瘍PepticUlcerProphylaxis5.預(yù)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(jī)相關(guān)肺炎

GOAL:ReduceVentilator-AssociatedPneumonia(VAP)根據(jù)隨機(jī)實(shí)驗(yàn):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(jīng)常調(diào)換姿勢(shì)MayRequireFrequentRepositioning其他?....Others?....2.每日間歇停止使用鎮(zhèn)靜劑DailySedationVacations

2.每日間隔應(yīng)用鎮(zhèn)靜藥物

DailySedationVacations

目的:減少通氣時(shí)間及ICU入住時(shí)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(píng)價(jià)拔管指征DailyAssessmentofReadinesstoExtubate

3.每日評(píng)價(jià)拔管指征

DailyAssessmentofReadinesstoExtubate

目的:減少通氣時(shí)間及ICU入住時(shí)間

GOALS:DecreaseDurationofVentilationandLengthofICUStay基于以下隨機(jī)實(shí)驗(yàn)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(píng)價(jià)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(yù)防消化道潰瘍

PepticUlcerProphylaxis

4.潰瘍預(yù)防PepticUlcerProphylaxis

矛盾與問題:-機(jī)械通氣患者PUD的發(fā)病率?-相互矛盾的研究結(jié)果-Meta-分析推薦使用-PUD可增加VAP風(fēng)險(xiǎn)-誰是最佳?ControversiesandQuestions:-IncidenceofPUDinventilatedpatients?-Conflictingstudies-Meta-analyseshavebeenusedforrecommendations-PUDmayincreasetheriskofVAP-Whichmedicationsarebest?4.潰瘍預(yù)防PepticUlcerProphylaxis

ASHP診治規(guī)范1.患者接受機(jī)械通氣>48小時(shí)

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

Patientswithcoagulopathy3.入院前一年內(nèi)曾有過消化道出血

Patientswithh/oGIbleedingw/in1yearofadmission4.有至少兩項(xiàng)以下危險(xiǎn)因素

Patientswithatleasttwoofthefollowingriskfactors -敗血癥

Sepsis -ICU時(shí)間超過1周

ICUstayofmorethan1week -出血6天或以上

Occultbleedinglasting6daysormore -應(yīng)用大劑量皮質(zhì)激素

Useofhigh-dosecorticosteroids**Medicationchoiceinstitution-specificIHI-對(duì)此干預(yù)未給出指征Doesnotspecifypatientselectionforthisintervention-未特別強(qiáng)調(diào)某項(xiàng)治療Doesnotspecifymedication4.潰瘍預(yù)防

PepticUlcerProphylaxis

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

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

DVTProphylaxis

目的:預(yù)防靜脈血栓形成

GOAL:PreventionofThromboembolicEvents基于以下隨機(jī)實(shí)驗(yàn)BasedonRandomizedStudies:Summary:ACCP.CHEST.2004;126:338S-400S.5.預(yù)防深靜脈血栓DVTProphylaxis

ACCP診治規(guī)范

最嚴(yán)重的患者處于中至高度風(fēng)險(xiǎn)中1. 有出血危險(xiǎn)者:低分子或小劑量肝素2. 有出血危險(xiǎn)者:機(jī)械壓迫裝置避免使用阿斯匹林MostCriticallyILLPatientsareatModeratetoHighRisk1. Withoutriskofbleeding:eitherlow-molecularorlowdoseunfractionatedheparin2. Withriskofbleeding:mechanicalcompressiondevicesalone3. AspirinshouldbeavoidedIHI

呼吸機(jī)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(yīng)用以取得治療的成功…eachelementin…everypatient….每個(gè)病人,每項(xiàng)措施均要落實(shí)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(jī)捆綁降低VAP的報(bào)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(jī)捆綁VentilatorBundle捆綁的證據(jù)及應(yīng)用-院內(nèi)應(yīng)用捆綁治療可降低VAP-非隨機(jī)實(shí)驗(yàn);無其他觀察指標(biāo)-IHI現(xiàn)在強(qiáng)調(diào)VAP;VAP捆綁或呼吸機(jī)捆綁?-DVT和PUD預(yù)防治療對(duì)VAP并無特異性預(yù)防作用BUNDLEEVIDENCEandAPPLICATION-HospitalsusingbundleshavereportedgreatreductionsinVAP-non-randomized;nootheroutcomes-IHInowemphasizesVAP;VAPBUNDLEorVentilatorBundle?-DVTandPUDProphylaxisarenotspecifictopreventionofVAPIHI

呼吸機(jī)捆綁的解釋VentilatorBundle

Interpretation

Pros積極的-較好的總結(jié)Goodsummary-好的開端Goodstaringpoint-所有措施均在至少一次隨機(jī)臨床實(shí)驗(yàn)的基礎(chǔ)上AllinterventionsbasedonatleastonerandomizedtrialCons負(fù)面的-有些方面相互矛盾Someareascontroversial-缺乏技術(shù)細(xì)節(jié)Detailslacking(whichpatients,when,otherspe