Inflammation and the host reponse to injury, a large-scale collaborative project: Patient-oriented research core- Standard operating procedures for clinical care - II. Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma patient
Inflammation and the host reponse to injury, a large-scale collaborative project: Patient-oriented research core- Standard operating procedures for clinical care - II. Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma patient
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DOI：
10.1097/01.ta.0000220424.34835.f1
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发表时间：
2006-05-01
影响因子：
--
通讯作者：
Maier, Ronald V.
中科院分区：
文献类型：
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作者：
Minei, Joseph P.;Nathens, Avery B.;Maier, Ronald V.
呼吸机相关性肺炎（VAP*）是ICU环境中最常见的医院感染。受伤的患者特别容易发生VAP，部分原因是诸如直接胸部创伤伴肺挫伤和无法控制与创伤性脑损伤相关的口咽分泌物等损伤。创伤后免疫抑制是公认的严重创伤的并发因素。此外，用于护理受伤患者的常见疗法，如输血，全胃肠外营养和反复前往手术室增加了这种免疫功能低下的状态。疾病控制中心（CDC）通过国家医院感染监测系统（NNIS）报告，创伤ICU患者每1000个呼吸机日的VAP中位发生率（11.4）高于任何其他单独类型的外科ICU（普通外科、心脏外科、神经外科等）。这一比率是内科（3.7）或冠心病护理（4.0）ICU的两倍多。1 VAP的发病率和死亡率难以确定。在一项针对混合人群的匹配队列研究中，肺炎导致死亡的相对风险为32%。2这种增加仅在内科ICU患者中显著，其中归因于肺炎的相对死亡风险为65%，这表明VAP的发作提示了医学上虚弱的平衡。很可能，手术患者由于通过存活的手术干预（或其损伤）而被选择，具有足够的储备，使得VAP发作不太可能是致命的。然而，额外的住院时间（4-6天）和相关费用，加上抗菌药物使用对ICU生态的不利影响，需要积极的预防策略和实用的循证方法来管理危重创伤患者的VAP。
Ventilator-associated pneumonia (VAP*) is the most common nosocomial infection encountered in the ICU setting. Injured patients are particularly prone to VAP due in part to injuries such as direct chest trauma with pulmonary contusion and inability to control oropharyngeal secretions associated with traumatic brain injury. Post-injury immunosuppression is a recognized complicating factor of severe injury. Furthermore, common therapies used in caring for injured patients, such as blood transfusion, total parenteral nutrition and repeated trips to the operating room add to this immunocompromised state. The Centers for Disease Control (CDC), through the National Nosocomial Infections Surveillance System (NNIS), report that the median rate of VAP per 1000 ventilator days for patients in trauma ICU's (11.4) was higher than any other individual type of surgical ICU (general surgery, cardiac surgery, neurosurgical, etc.). This rate was more than double that seen in medical (3.7) or coronary care (4.0) ICU's. 1The mortality and morbidity attributable to VAP is difficult to ascertain. In a matched cohort study looking at a mixed population, the relative risk of death attributable to pneumonia was 32%. 2 This increase was only significant in medical ICU patients where the relative risk of death attributable to pneumonia was 65%, suggesting an episode of VAP tips the balance for the medically frail. It is likely that surgical patients, by virtue of either being selected by surviving operative intervention (or their injuries) have adequate reserve such that an episode of VAP is less likely to be fatal. However, the additional length of stay (4–6 days) and associated costs, 3 coupled with the detrimental effects of antimicrobial use on ICU ecology, calls for aggressive prevention strategies and a practical, evidence-based approach to managing VAP in critically ill trauma patients.