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1、呼吸机捆绑式治疗的探讨A Review of the Ventilator Bundle,来自美国的报道,Question,什么是捆绑?What is a Bundle?,ANSWER,BUNDLE:同时综合运用一组有效的治疗手段优于运用单一治疗手段.A group of interventions related to a disease process,that,when executed together,result in better outcomes than when implemented individually.,呼吸机捆绑Ventilator Bundle,运用一组干预手
2、段综合提高机械通气患者的治疗效果A group of interventions.that result in better outcomes in patients receiving mechanical ventilation,关于呼吸机捆绑,1.升高床头30-45度Elevating Head of Bed to 30-45 degrees2.每日间歇停止使用镇静药物Daily Sedation Vacations3.每日评价拔管指征 Daily Assessment of Readiness to Extubate4.预防消化道溃疡 Peptic Ulcer Prophylaxis5
3、.预防深静脉血栓 DVT Prophylaxis,1.升高床头 30-45 度,1.升高床头 30-45 度目的:减少呼吸机相关肺炎 GOAL:Reduce Ventilator-Associated Pneumonia(VAP),根据随机实验:Drakulovic et al.Lancet.1999:354:1851-58,Drakulovic et alLancet.1999;354:1851-8.,临床可疑VAP Clinically Suspected VAP Head Elevated Supine头部抬高 仰卧3/39(8%)16/47(34%)*仰卧位为一独立的与死亡相关的危险因
4、子Supine position also independent risk factor for mortality,升高床头30-45度潜在并发症 Potential Complications,休克病人低血压 Hypotension in Shock可压迫股部血管装置 May Compromise Femoral Devices须经常调换姿势 May Require Frequent Repositioning其他?.Others?.,2.每日间歇停止使用镇静剂 Daily Sedation Vacations,2.每日间隔应用镇静药物 Daily Sedation Vacations
5、目的:减少通气时间及ICU入住时间 GOALS:Decrease Duration of Ventilation and Length of ICU Stay,Based on Randomized Study:Kress et al.NEJM.2000:342:1471-7,Kress et alNEJM.2000;342:1471-7.,Vacation No Vacation有间隔无间隔通气天数 4.9 days*7.3 dayDuration Ventilation ICU 天数6.4 days*9.9 daysICU Stay*P 0.05,2.每日间歇使用镇静剂Daily Seda
6、tion Vacations潜在并发症 Potential Complications,中心静脉管,气管插管或其他装置意外脱出 Accidental removal of endotracheal tubes,central lines,other equipment,3.每日评价拔管指征 Daily Assessment of Readiness to Extubate,3.每日评价拔管指征Daily Assessment of Readiness to Extubate 目的:减少通气时间及ICU入住时间 GOALS:Decrease Duration of Ventilation and
7、 Length of ICU Stay,基于以下随机实验Based on Randomized Studies:Ely et al.NEJM.1996:335:1864-9.Esteban et al.NEJM.1995;332:345-50.,3.每日评价拔管指征Daily Assessment of Readiness to Extubate,自主呼吸实验:Spontaneous Breathing Trial:允许病人通过T管或应用小于等于 5cm 水柱压力的CPAP下自主呼吸Allowing the patient to breathe spontaneously through ei
8、ther a T-tube circuit or with 5cm CPAP,Ely et alNEJM.1996;335:1864-9.Esteban et alNEJM.1995;332:345-60,Ely Daily SB No Daily SB每日自主呼吸 无每日自主呼吸4.5 days*6.0 daysEsteban multiple SB once daily SBIMVPS 多次 每日一次5 days4 days3 days*3 days*P 0.05,3.每日评价拔管指征Daily Assessment of Readiness to Extubate潜在并发症Potenti
9、al Complications,-中心静脉管,气管插管或其他装置意外脱出 Accidental removal of endotracheal tubes,central lines,other equipment,4.预防消化道溃疡 Peptic Ulcer Prophylaxis,4.溃疡预防(抗酸,硫糖铝,H2-受体拮抗剂,etc.)Peptic Ulcer Prophylaxis(antacids,sucralfate,H2-receptor antagonists,etc.)目的:预防应急性溃疡Goal:Prevention of Stress Ulcers,Based on Ra
10、ndomized Studies:Summary:Am J Health-Syst Pharm.1999;56:341-79.,4.溃疡预防 Peptic Ulcer Prophylaxis,矛盾与问题:-机械通气患者PUD的发病率?-相互矛盾的研究结果-Meta-分析推荐使用-PUD 可增加VAP风险-谁是最佳?Controversies and Questions:-Incidence of PUD in ventilated patients?-Conflicting studies-Meta-analyses have been used for recommendations-PUD
11、 may increase the risk of VAP-Which medications are best?,4.溃疡预防 Peptic Ulcer Prophylaxis,ASHP 诊治规范1.患者接受机械通气 48 小时 Patients receiving mechanical ventilation for 48 hours2.患者存在凝血异常 Patients with coagulopathy3.入院前一年内曾有过消化道出血 Patients with h/o GI bleeding w/in 1 year of admission4.有至少两项以下危险因素 Patients
12、 with at least two of the following risk factors-败血症 Sepsis-ICU 时间超过1周 ICU stay of more than 1 week-出血6天或以上 Occult bleeding lasting 6 days or more-应用大剂量皮质激素 Use of high-dose corticosteroids*Medication choice institution-specific IHI-对此干预未给出指征Does not specify patient selection for this intervention-未
13、特别强调某项治疗Does not specify medication,4.溃疡预防 Peptic Ulcer Prophylaxis潜在并发症 Potential Complications,-增加VAP 和其他感染的风险 Increase risk of VAP and other infections(MH Kollef.Crit Care Med.2004;32:1395-1405.),5.预防深静脉血栓 DVT Prophylaxis,5.预防深静脉血栓 DVT Prophylaxis目的:预防静脉血栓形成 GOAL:Prevention of Thromboembolic Even
14、ts,基于以下随机实验Based on Randomized Studies:Summary:ACCP.CHEST.2004;126:338S-400S.,5.预防深静脉血栓DVT ProphylaxisACCP 诊治规范,最严重的患者处于中至高度风险中1.有出血危险者:低分子或小剂量肝素2.有出血危险者:机械压迫装置避免使用阿斯匹林Most Critically ILL Patients are at Moderate to High Risk1.Without risk of bleeding:either low-molecular or low dose unfractionated
15、heparin2.With risk of bleeding:mechanical compression devices alone3.Aspirin should be avoided,5.预防深静脉血栓DVT Prophylaxis潜在并发症 Potential Complications,-应用肝素可导致出血Bleeding if heparin used,IHIVentilator Bundle 呼吸机捆绑,1.升高床头30-45度Elevating Head of Bed to 30-45 degrees2.每日间歇停止使用镇静药物Daily Sedation Vacations3
16、.每日评价拔管指征 Daily Assessment of Readiness to Extubate4.预防消化道溃疡 Peptic Ulcer Prophylaxis5.预防深静脉血栓 DVT Prophylaxis,IHI 呼吸机捆绑 Ventilator Bundle,a bundle is a cohesive unit.The steps must all be completed to succeed;the“all or none”feature is the source of the bundles power捆绑是 有”或 无”的策略,要麽不用,要麽全部应用以取得治疗的成
17、功each element inevery patient.每个病人,每项措施均要落实,Our Lady of Lourdes Hospital,Binghampton,New York,USA290 Days With a VAP Rate of Zero(March 2004 to January 2005)290天未发生VAP,University of Rochester/Strong Health Rochester,New York,USA300 Days With a VAP Rate of Zero 大于300天未出现VAP,呼吸机捆绑降低VAP的报道,Dominican Ho
18、spital97 daysSanta Cruz,CASt.Vincents Hospital255 daysBirmingham,ALVirginia Mason Medical Center180 daysSeattle,WAUniversity of Texas MD Anderson 50%reductionHouston,TXNaval Medical Center150 daysSan Diego,CAOur Lady of Lourdes290 daysBinghampton,NYUniversity of Rochester/Strong300 daysRochester,NY,
19、IHI 呼吸机捆绑Ventilator Bundle,捆绑的证据及应用-院内应用捆绑治疗可降低 VAP-非随机实验;无其他观察指标-IHI 现在强调VAP;VAP 捆绑或呼吸机捆绑?-DVT 和 PUD预防治疗对VAP并无特异性预防作用BUNDLE EVIDENCE and APPLICATION-Hospitals using bundles have reported great reductions in VAP-non-randomized;no other outcomes-IHI now emphasizes VAP;VAP BUNDLE or Ventilator Bundle?
20、-DVT and PUD Prophylaxis are not specific to prevention of VAP,IHI 呼吸机捆绑的解释Ventilator BundleInterpretation,Pros 积极的-较好的总结 Good summary-好的开端 Good staring point-所有措施均在至少一次随机临床实验的基础上 All interventions based on at least one randomized trialCons 负面的-有些方面相互矛盾 Some areas controversial-缺乏技术细节 Details lacking(which patients,when,other specifics)-捆绑之概念尚须更多验证 Benefit of BUNDLE concept?,IHI关于呼吸机捆绑的解释,1.升高床头30-45度Elevating Head of Bed to 30-45 degrees2.每日间歇停止使用镇静药物Daily Sedation Vacations3.每日评价拔管指征 Daily Assessment of Readiness to Extubate4.预防消化道溃疡 Peptic Ulcer Prophylaxis5.预防深静脉血栓 DVT Prophylaxis,
