呼吸机bundle疗效观察.pptx

呼吸机治疗BUNDLE效果观察 让临床重新思考 海南医学院附属医院ICU 胡志华 BUNDLE的概述 VAP BUNDLE的内容和实施 VAP BUNDLE 疗效新发现 VAP BUNDLE 的展望 定义定义集束化（集束化（BUNDLEBUNDLE）策略）策略 定义：集束化治疗策略是指为了提高护理指南的可定义：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（行性和依从性，为针对某种问题而制定的一系列（一般为一般为3-5个）有循证支持的联合护理措施。个）有循证支持的联合护理措施。呼吸机相关性肺炎集束呼吸机相关性肺炎集束 中心静脉导管相关性感染集束中心静脉导管相关性感染集束 感染性休克集束感染性休克集束 集束化的实施集束化的实施 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。员提供的一系列安全有效的医疗护理干预的集合。集束化集束化 治疗治疗 循证医学循证医学 医疗护医疗护 理措施理措施 BUNDLE的概述 VAP BUNDLE 疗效新发现 VAP BUNDLEVAP BUNDLE的内容和实施 VAP BUNDLE 的展望 VAPVAP的简介的简介 定义定义 呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)：指患者在建立人工气道建立人工气道(气管插管或切开气管插管或切开)并机械通气并机械通气48 h 48 h 以后或撤机拔管后以后或撤机拔管后48 h 48 h 以内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 VAP 的发病情况的发病情况 国外有文献报导接受机械通气的患者国外有文献报导接受机械通气的患者VAPVAP发病率达发病率达46%46%，病死率高达病死率高达5050-69%,69%,而而79.2%79.2%的的VAP VAP 发生在开始机械通发生在开始机械通气的气的4d4d内。内。国内调查表明国内调查表明VAPVAP的发病率为的发病率为18.53%18.53%，病死率为，病死率为32.5%32.5%。ICUICU住院时间延长住院时间延长4.34.3-6.16.1天，住院时间延长了天，住院时间延长了4 4-9 9天。天。国外数据：每个病人平均多花了约国外数据：每个病人平均多花了约4000040000美元。美元。VAP BUNDLE VAP BUNDLE 的内容的内容 抬高床头抬高床头3030-4545 氯已定口腔清洁氯已定口腔清洁 中断镇静药的输注中断镇静药的输注 自主呼吸试验自主呼吸试验 预防消化道溃疡预防消化道溃疡 预防深静脉血栓预防深静脉血栓 VAP BUNDLE VAP BUNDLE 的实施的实施 管理管理 流程流程 B E C D A 组建呼吸机质组建呼吸机质量控制小组量控制小组 制订质量管理目标制订质量管理目标 和相关规定和相关规定 明确目标责任明确目标责任 集束化管理策略集束化管理策略应用效果分析应用效果分析 集束化管理措施集束化管理措施 从 VAP BUNDLE 得到益处 降低降低VAPVAP的发生率、降低入住的发生率、降低入住ICUICU天数、降低病死天数、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.问问 题题 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:g2197.17.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):751-761.18.18Kress 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 Breat