Reappraisal of Routine Oral Care With Chlorhexidine Gluconate for Patients Receiving Mechanical Ventilation Systematic Review and Meta-Analysis
Reappraisal of Routine Oral Care With Chlorhexidine Gluconate for Patients Receiving Mechanical Ventilation Systematic Review and Meta-Analysis
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DOI：
10.1001/jamainternmed.2014.359
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发表时间：
2014-05-01
影响因子：
39
通讯作者：
Berenholtz, Sean M.
中科院分区：
文献类型：
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作者：
Klompas, Michael;Speck, Kathleen;Berenholtz, Sean M.
重要性：在大多数医院，常规口腔护理是接受机械通气的患者的标准护理。这项政策是建立在荟萃分析的基础上的，这些荟萃分析表明呼吸机相关性肺炎的风险降低，但这些荟萃分析可能具有误导性，因为心脏手术和非心脏手术研究之间缺乏区分，开放标签研究和双盲研究混为一谈，并且没有充分重视以患者为中心的结果，如机械通气时间、住院时间和死亡率。目的评估常规口腔护理和洗必泰对接受机械通气的患者以患者为中心的结果的影响。数据来源PubMed，Embase，CINAHL，和科学网，从最初到2013年7月，没有日期或语言的限制。STUDY SELECT随机临床试验比较了洗必泰和安慰剂在接受机械通气的成年人中的作用。在171篇独特的引文中，16项研究，包括3630名患者，符合纳入标准。数据提取和合成合格试验被独立识别，评估偏倚风险，并由2名研究人员提取。分歧通过协商一致得到解决。我们对心脏手术和非心脏手术以及开放标签和双盲研究进行了分层研究。结果随机服用洗必泰的心脏手术患者下呼吸道感染较少(相对风险为0.56[95%CI，0.41~0.77])，而非心脏手术患者呼吸机相关肺炎的风险无显著差异(RR，0.88[95%CI，0.66~1.16])。在心脏外科研究中，洗必泰和安慰剂的死亡率没有显著差异(RR，0.88[95%CI，0.25-2.14])，在非心脏外科研究中，死亡率没有显著增加(RR，1.13[95%CI，0.99-1.29])。两组患者的平均机械通气时间和重症监护住院时间无显著差异。住院时间和抗生素处方的数据有限。结论洗必泰的常规口腔护理预防了心脏手术患者的医院内肺炎，但并不能降低非心脏手术患者呼吸机相关性肺炎的风险。在这两个人群中，洗必泰的使用都不影响以患者为中心的结果。鼓励非心脏手术患者使用洗必泰进行常规口腔护理的政策值得重新评估。
IMPORTANCE Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses-may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality.OBJECTIVE To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation.DATA SOURCES PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language.STUDY SELECTION Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria.DATA EXTRACTION AND SYNTHESIS Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non-cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis.MAIN OUTCOMES AND MEASURES Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing.RESULTS There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non-cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited.CONCLUSIONS AND RELEVANCE Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.