呼吸机bundle疗效观察PPT培训课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,呼吸机bundle疗效观察,BUNDLE,的概述,VAP BUNDLE,的内容和实施,VAP BUNDLE,疗效新发现,VAP BUNDLE,的展望,定义,集束化（,BUNDLE,）策略,定义：集束化治疗策略是指为了提高护理指南的可行性和依从性，为针对某种问题而制定的一系列（一般为,3-5,个）有循证支持的联合护理措施。,呼吸机相关性肺炎集束,中心静脉导管相关性感染集束,感染性休克集束,集束化的实施,当患者在难以避免的风险下治疗时，由医护人员提供的一系列安全有效的医疗护理干预的集合。,集束化,治疗,循证医学,医疗护,理措施,综合方案,BUNDLE,的概述,VAP BUNDLE,疗效新发现,VAP BUNDLE,的内容和实施,VAP BUNDLE,的展望,VAP,的简介,定义,呼吸机相关性肺炎,(ventilator-associated pneumonia,VAP),：,指患者在,建立人工气道,(,气管插管或切开,),并机械通气,48 h,以后或撤机拔管后,48 h,以内,所发生的医院获得性肺炎。是一种严重的院内感染和并发症，也是,ICU,内最常见的感染之一。,VAP,的发病情况,国外有文献报导接受机械通气的患者,VAP,发病率达,46%,，病死率高达,50-69%,而,79.2%,的,VAP,发生在开始机械通气的,4d,内。,国内调查表明,VAP,的发病率为,18.53%,，病死率为,32.5%,。,ICU,住院时间延长,4.3-6.1,天，住院时间延长了,4-9,天。,国外数据：每个病人平均多花了约,40000,美元。,VAP BUNDLE,的内容,抬高床头,30-45,氯已定口腔清洁,中断镇静药的输注,自主呼吸试验,预防消化道溃疡,预防深静脉血栓,VAP BUNDLE,的实施,管理,流程,B,E,C,D,A,组建呼吸机质量控制小组,制订质量管理目标,和相关规定,明确目标责任,集束化管理策略应用效果分析,集束化管理措施,从,VAP BUNDLE,得到益处,降低,VAP,的发生率、降低入住,ICU,天数、降低病死,亡率；实现医护队伍的沟通、协助，促进医疗质量的持,续改进，实现教育、审计、反馈和流程的重建等,1-9,1.Klompas M.Ventilator-associated pneumonia:is zero possible?,Clin Infect Dis,.2010;51(10):1123-1126.,2.Youngquist P,Carroll M,Farber M,et al.Implementing a ventilator bundle in a community hospital.,Jt Comm J Qual Patient Saf,.2007;33(4):,219-225.,3.Resar R,Pronovost P,Haraden C,Simmonds T,Rainey T,Nolan T.Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.,Jt Comm J Qual Patient Saf,.2005;31(5):243-248.,4.Talbot TR,Carr D,Parmley CL,et al.,Sustained reduction of ventilator-associated pneumonia rates using real-time course correction with a ventilator bundle compliance dashboard.,Infect Control Hosp Epidemiol,.2015;36(11):1261-1267.,5.Berenholtz SM,Pham JC,Thompson DA,et al.Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.,Infect Control Hosp Epidemiol,.2011;32(4):305-314.,6.Bouadma L,Deslandes E,Lolom I,et al.Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit.,Clin Infect Dis,.2010;51(10):1115-1122.,7.Marra AR,Cal RG,Silva CV,et al.,Successful prevention of ventilator-associated pneumonia in an intensive care setting.,Am J Infect Control,.2009;37(8):619-625.,8.Burger CD,Resar RK.“Ventilator bundle”approach to prevention of ventilator-associated pneumonia.,Mayo Clin Proc,.2006;81(6):849-850.,9.Bird D,Zambuto A,ODonnell C,et al.,Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit.,Arch Surg,.2010;145(5):465-470.,问 题,10.,Drakulovic MB,Torres A,Bauer TT,Nicolas JM,Nogue S,FerrerM.Supine body position as a risk factor for nosocomial pneumonia in mechanicall,ventilated patients:a randomised trial.,Lancet,.1999;354(9193):1851-1858.,11,.,van Nieuwenhoven CA,Vandenbroucke-Grauls C,van Tiel FH,et al.,Feasibility and effects of the semirecumbent position to prevent,ventilator-associated pneumonia:a randomized study.,Crit Care Med,.2006;34(2):396-402.,12,.,Keeley L.Reducing the risk of ventilator-acquired pneumonia through head of bed elevation.,Nurs Crit Care,.2007;12(6):287-294.,13,.,Herzig SJ,Howell MD,Ngo LH,Marcantonio ER.Acid-suppressive medication use and the risk for hospital-acquired pneumonia.,JAMA,.2009;301(20):2120-2128.,14,.,Miano TA,Reichert MG,Houle TT,MacGregor DA,Kincaid EH,Bowton DL.Nosocomial pneumonia risk and stress ulcer prophylaxis:a comparison of pantoprazole vs ranitidine in cardiothoracic surgery patients.,Chest,.2009;136(2):440-447.,15,.,Sasabuchi Y,Matsui H,Lefor AK,Fushimi K,Yasunaga H.Risks and benefits of stress ulcer prophylaxis for patients with severe sepsis.,Crit Care Med,.2016;44(7):e464-e469.,16,.,Price R,MacLennan G,Glen J;SuDDICU Collaboration.Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care:systematic review and network meta-analysis.,BMJ,.2014;348:g2197.,Klompas M,Speck K,Howell MD,Greene LR,Berenholtz SM.Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation:systematic review and meta-analysis.,JAMA Intern Med,.2014;174(5):751-761.,18,Kress JP,Pohlman AS,OConnor MF,Hall JB.,Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation.,N Engl J Med,.2000;342(20):1471-1477.,19,.,Girard TD,Kress JP,Fuchs BD,et al.Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care(Awakening and Breathing controlled trial):a randomised controlled trial.,Lancet,.2008;371(9607):126-134.,20,.,Mehta S,Burry L,Cook D,et al;SLEAP Investigators;Canadian Critical Care Trials Group.Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol:a randomized controlled trial.,JAMA,.2012;308(19):1985-1992.,也有文献报道预防应激性溃疡可能提高,VAP,风险，氯已定口腔清洁与潜在高死亡率有关,10-20,BUNDLE,的概述,VAP BUNDLE,的内容和实施,VAP BUNDLE,的展望,VAP BUNDLE,疗效新发现,JAMA Internal Medicine,Published online July 18,2016,IMPORTANCE,背景,JAMA Internal Medicine,Published online July 18,2016,呼吸机集束化治疗包括床头抬高，中断镇静药输注，自主呼吸试验，深静脉血栓预防，消化道溃疡预防以及氯已定口腔护理均得到普遍实施，但是各项措施的绝对与相对作用尚不清楚。,OBJECTIVE,目的,评价呼吸机集束化治疗措施及联合使用与呼吸机相关事件（,VAEs,）、拔管时间、机械通气期间病死率、出院时间及住院死亡之间的相关性。,JAMA Internal Medicine,Published online July 18,2016,设计、场景和对象,这项回顾性队列研究包括了布里格姆及妇女医院,2009,年,1,月,1,日至,2013,年,12,月,31,日连续收治的接受至少,3,天机械通气的所有,5539,名患者。,JAMA Internal Medicine,Published online July 18,2016,MAIN OUTCOMES AND MEASURES,主要预后和指标,呼吸机相关事件、拔管存活时间与机械通气期间病死率，以及出院时间与住院死亡的风险比（,HR,）。效应模型采用,Cox,比例风险回归以及,Fine-Gray,竞争风险模型，并对患者人口统计学特征、合并症、病房类型、疾病严重程度、近期操作、过程指标禁忌症，每日临床状态指标以及年份进行校正。,JAMA Internal Medicine,Published online July 18,2016,结 果,表,1,患者特征,患者数,(%)(N=5539),a,年龄，平,均（,SD,）,y,61.2,（,16.1,）,性别,男性,3208,（,57.9,）,女,2331,（,42.1,）,种族,白人,4342,（,78.4,）,黑人,474,（,8.6,）,拉丁裔,201,（,3.6,）,亚裔,148,（,2.7,）,其它,374,（,6.8,）,重症监护,室的类型,内科,ICU,1746,（,31.5,）,外科,ICU,1205,（,21.8,）,神经科,727,（,13.1,）,心脏外科,668,（,12.1,）,心内科,627,（,11.3,）,胸外科,566,（,10.2,）,合并症,冠状动脉疾病,1203,（,21.7,）,充血性心脏衰竭,1217,（,22.0,）,周围血管疾病,391,（,7.1,）,慢性肺部疾病,643,（,11.6,）,糖尿病,672,（,12.1,）,慢性肾脏病,607,（,11.0,）,慢性肝病,171,（,3.1,）,淋巴瘤,187,（,3.4,）,固体恶性肿瘤,872,（,15.7,）,酗酒,237,（,4.3,）,察尔森合并症评,分，平均（,SD,）,b,3.6,（,2.7,）,呼吸机相关事件（,VAEs,）,c,770,（,13.9,）,IVACd,313,（,5.7,）,呼吸机相关性肺炎,（,VAP,）可能性,197,（,3.6,）,机械通气天数,累计通气天数,48,865,平均（,SD,）,8.8,（,8.7,）,中间值（,IQR,）,6,（,4-10,）,住院天数,d,平均（,SD,）,25,（,22,）,中间值（,IQR,）,20,（,12-32,）,院内死亡率,1512,（,27.3,）,缩写：,IQR,，四分位数间距,;,IVAC,，感染相关的呼吸机相关并发症,;,VAP,，呼吸机相关性肺炎,a:,一个百分比已四舍五入，不得总计,100,。,b,：分数范围从,0,到,37,，评分越高表明更大的合并症。,c:,包括,IVAC,和可能的,VAP,。,d:,包括可能的,VAP,。,JAMA Internal Medicine,Published online July 18,2016,a:,包括对没有接受连续注射镇静剂患者的记录。,表,2.,每年实施护理措施对通气天数的比率,7057(74.9),8075(82.2),9377(88.7),10 276(87.1),5894(81.3),预防血栓,8711(92.5),8880(90.4),9490(89.7),10 387(88.0),6323(87.2),预防应激,性溃疡,3069(32.6),2845(29.0),3031(28.7),3026(25.6),1779(24.5),自主呼吸试验,7470(79.3),6838(69.6),7710(72.9),9268(78.5),5274(72.7),中断镇静,药物输注,a,8508,（,90.3,）,8740,（,89.0,）,8984,（,85.0,）,9825,（,83.2,）,5620,（,77.5,）,氯已定,口腔护理,8088,（,85.9,）,8322,（,84.8,）,8717,（,82.4,）,9460,（,80.2,）,5185,（,71.5,）,抬高床头,（,N=9417,）,（,N=9819,）,（,N=10575,）,（,N=11802,）,（,N=7252,）,2013,2012,2011,2010,2009,年度，通气天数（,%,）,护理措施,JAMA Internal Medicine,Published online July 18,2016,表,3.,护理措施与呼吸机相关事件（,VAEs,）之间的关联,a,.11,0.55(0.27-1.14),.05,0.60(0.36-1.00),.42,0.87(0.61-1.23),氯已定口腔护理,.02,7.69(1.44-41.10),.20,1.62(0.78-3.35),.19,1.34(0.87-2.07),应激性溃疡,.90,1.13(0.16-7.78),.96,0.96(0.26-3.56),.51,0.78(0.38-1.62),血栓,预防,.52,0.79(0.39-1.60),.05,0.60(0.37-1.00),.001,0.55(0.40-0.76),自主呼吸,试验,.63,0.82(0.37-1.82),.88,1.04(0.61-1.78),.76,0.95(0.67-1.35),中断镇静药,物输注,.41,1.60(0.53-4.88),.66,1.16(0.59-2.28),.23,1.33(0.84-2.11),抬高床头,P,值,呼吸机相关肺炎（,VAP,）的可能性,P,值,感染相关的呼吸机相关的并发症（,IVACs,）,P,值,呼吸机相关事件（,VAEs,）,HR(95%CI),护理措施,缩写：,HR,，风险比,;IVACs,，感染相关的呼吸机相关的并发症,;VAEs,，,呼吸机相关事件,;VAP,，呼吸机相关肺炎。,a,：包括,IVACs,和可能的,VAP,。,JAMA Internal Medicine,Published online July 18,2016,表,4.,护理措施与患者预后之间的关联,.44,1.01(0.98-1.05),.26,0.99(0.98-1.01),.006,1.63(1.15-2.31),.18,0.92(0.80-1.04),氯已定,口腔护理,.90,1.00(0.96-1.04),.89,1.00(0.98-1.03),.62,0.91(0.64-1.31),.17,1.12(0.95-1.32),应激性,溃疡,.26,0.97(0.92-1.02),.41,1.02(0.97-1.07),.23,1.39(0.82-2.37),.001,2.57(1.80-3.66),血栓,预防,.46,0.99(0.96-1.02),.92,1.00(0.98-1.02),.001,0.28(0.20-0.38),.001,2.48(2.23-2.76),自主呼吸试验,.001,0.92(0.88-0.96),.001,1.09(1.05-1.14),.001,0.51(0.38-0.68),.001,1.81(1.54-2.12),中断镇静,药物输注,.36,0.98(0.93-1.03),.80,1.01(0.96-1.05),.42,0.86(0.59-1.25),.001,1.38(1.14-1.68),抬高床头,P,值,院内,死亡,a,P,值,出院为止生存,P,值,呼吸机通气死亡,P,值,缩拔管为止生存,结果，,HR(95%CI),护理措施,缩写：,HR,，风险比,a,：此分析仅限于接受机械通气患者。,JAMA Internal Medicine,Published online July 18,2016,CONCLUSIONS AND RELEVANCE,结论与意义,标准的呼吸机集束化措施与患者为中心的临床预后之间的相关性各异。床头抬高、中断镇静药输注、自主呼吸试验及血栓预防似乎有益，而每日氯已定口腔护理及应激性溃疡预防对某些患者可能有害。,JAMA Internal Medicine,Published online July 18,2016,BUNDLE,的概述,VAP BUNDLE,的内容和实施,VAP BUNDLE,疗效新发现,VAP BUNDLE,的展望,呼吸机,BUNDLE,的展望,抬高床头,30-45,自主呼吸试验,中断镇静药输注,预防深静脉血栓,预防消化道溃疡,氯已定口腔清洁,？,？,*,*,传统,bundle,的有效组分,有循证医学证据证明有效的护理治疗措施,未来的,BUNDLE,模式,未来,VAP BUNDLE,的模式,？,“,航母,style,”,