為預防應激性潰瘍和消化道出血, 質子泵抑制劑( PPI) 、組胺H2 受體拮抗劑( H2 RA) 以及硫糖鋁在ICU中的應用非常普遍。既往的研究認為以PPI 或H2RA 為代表的抑酸劑( ASD) 可致胃液pH 值增高, 為細菌在胃腔內定植創造了條件, 并進而增加醫院獲得性肺炎( HAP) , 尤其是呼吸機相關性肺炎( VAP) 發生的風險。我們通過文獻復習發現,ASD 與VAP 的關聯性迄今仍無明確的證據, 已有的臨床研究結論互為矛盾; 另一方面, 既往研究多集中于硫糖鋁與H2RA 的比較, 有關PPI 和H2RA 導致VAP 的風險比較研究仍然缺乏, PPI 是否比H2 RA 更易發生VAP 也缺乏研究可資證明。為此我們將有關內容綜述如下, 以供同道參考。
“拯救膿毒癥運動（Surviving Sepsis Campaign，SSC）”是國際危重病醫學界為提高膿毒癥診治水平、降低病死率而于2002年發起的全球性運動。隨后，由多個國際學術組織暨國際專家組發起與組編的《嚴重膿毒癥與膿毒癥休克治療指南》[1]及其修訂版[2]（以下統稱為“SSC指南”）分別于2004年和2008年頒布。指南以循證醫學為依據，總結了早期目標指導治療（EGDT）、強化血糖控制（TGC）、小劑量激素替代治療、活性蛋白C（APC）治療等治療方案，其核心就是將各自獨立的療法整合為整體化的“集束化治療策略（Bundle Strategy）”，以期最大限度地發揮綜合治療效應[3]。按照SSC的建議，集束化治療策略包括膿毒癥復蘇集束化策略（Sepsis Resuscitation Bundle）和膿毒癥治療集束化策略（Sepsis Management Bundle）。前者要求在診斷嚴重膿毒癥后的6 h內完成血乳酸測定、血培養、早期廣譜抗菌藥物應用和EGDT等6項治療策略；后者則要求在24 h內完成由小劑量激素、APC、TGC和限制氣道平臺壓構成的4項治療策略[4]。顯然，上述策略借鑒了創傷救治的“黃金6小時”和“白銀24小時”的理念。 目前已有越來越多的研究證據支持集束化治療策略在急診和ICU的早期實施，并顯示出病死率降低的趨勢。但實際的情況是臨床上對該策略的實施與執行嚴重不足，集束化治療策略所代表的強化、優先、積極的治療理念并未獲得普遍的貫徹，進而影響到獲得病死率顯著降低的收益。另一方面，集束化治療策略的各治療要素也非完美，其所依據的相關臨床試驗存在著諸多不足甚至可疑之處，而單純的療法疊加是否真能發揮事半功倍的效果也值得考量。為此，本文就當前國際上的相關研究進展進行反思，以供同道參考。
呼吸機相關性肺炎( VAP) 是指患者接受機械通氣治療48 h 后至停用機械通氣、拔除人工氣道后48 h 內發生的肺實質的感染性炎癥。為接受機械通氣患者最常見的院內感染。VAP的發生率和病死率由于診斷手段不同, 報道不一。國外報道, VAP 發生率為9% ～70% [ 1] , 病死率高達20% ～71% [ 2, 3] ; 國內醫院調查, VAP發生率為48. 5% , 病死率為37. 5% [ 4] 。患者一旦發生VAP, 易造成撤機困難, 并可導致患者在ICU的停留時間及住院時間延長, 增加相關的醫療費用, 嚴重者可導致患者死亡。因此, VAP的早期預防、早期診斷和治療就顯得非常重要, 本文就近年來VAP 的診治現狀做一概述, 以供同道參考。
Objective To analyze the prognostic factors in the postoperative patients with prolonged mechanical ventilation after extracorporeal circulation.Methods From Oct 2004 to Oct 2007，35 cases of postoperative patients after extracorporeal circulation required mechanical ventilation for ≥24 hours in ICU were enrolled.The patients were divided into death group and survival group.Preoperative variables including blood glucose，serum albumin，creatinine and ejection fraction（EF），intra-operative variables such as cardiopulmonary bypass（CPB） duration，aortic cross clamp（ACC） time，blood transfusion，and postoperative variables such as vital sign arrival at ICU，renal function，drainage in first 24 hours，APACHEⅡ score，ventilation duration were analyzed retrospectively.Results There were significant differences in blood glucose，serum albumin，EF，CPB，ACC，fresh frozen plasma transfusion，APACHEⅡ，creatinine，APTT and oxygenation index between the death group（12 cases，34.29%） and the survival group（23 cases，65.71%）.Stepwise logistic regression analysis indicated that EF（OR=0.7973，95%CI 0.6417-0.9906） and APACHEⅡ（OR=1.8588，95%CI 1.1071-3.1210） were predictors of prognosis.Conclusions High mortality is found in postoperative patients after extracorporeal circulation with prolonged mechanical ventilation.The main predictors of prognosis were EF and APACHEⅡ.It’s important to assess preoperative condition for cardiac surgical patients completely and provide more intensive perioperative care.
Objective To investigate the species distribution and antibiotic resistance of pathogens fromcatheter-related bloodstream infections ( CRBSI) in intensive care unit( ICU) , to provide evidence for the guidance of clinical rational administration.Methods A retrospective analysis was performed to review the microbiological and susceptibility test data of all CRBSI patients in ICU from January 2009 to December 2011. The patterns of antibiotic resistance among the top seven bacteria were compared. Results 67 cases of CRBSI were detected with 81 strains, including 40 Gram-positive ( G+ ) bacteria( 49.4% ) , 38 Gram-negative( G- ) bacteria ( 46.9% ) , and 3 fungi ( 3.7% ) . The main pathogens causing CRBSI were coagulase negative Staphylococci ( 27 strains, 33.3%) , Acinetobacter baumannii ( 12 strains, 14.8% ) , Klebsiella pneumoniae( 9 strains, 11. 1% ) , Staphylococcus aureus ( 8 strains, 9. 9% ) , Pseudomonas aeruginosa ( 7 strains, 8. 6% ) , Escherichia coli ( 6 strains, 7.4% ) , suggesting that Staphylococcus epidermidis was predominant pathogenic G+ bacteria, and Acinetobacter baumannii was predominant G- bacteria. The antibiotic resistance tests demonstrated that isolated G- bacillus was highly sensitive to carbopenem, while vancomycin-resistant G+ bacteria were not found. Conclusions Within the latest 3 years, the predominant pathogens of CRBSI in ICU are Staphylococcus epidermidis and Acinetobacter baumannii. Acinetobacter baumannii exhibited high drug resistance to all antibiotics.
Objective To investigate the outcome and prognostic factors of hospital mortality in patients with acute cerebrovascular disease requiring mechanical ventilation.Methods Data from 94 patients with acute cerebrovascular disease in central intensive care unit(ICU) were collected and retrospectively analyzed.Prognostic factors of hospital mortality were analyzed by univariate statistics and multivariate logistic regression.Results Hospital mortality was 53.2%(50/94).There was significance diference in parameters such as APACHE II score，blood glucose，lengh of hospital stay，lengh of ICU stay，time of mechanical ventilation，incision of trachea，lung infections，lesion loci and its naturer between the survival and non-survival groups（all Plt;0.05）.Multivariate logistic regression revealed that blood glucose，lung infections，diseased region under tentorium of cerebellum，time of mechanical ventilation were independent prognostic risk factors of hospital mortality(all Plt;0.05).Whereas the lengh of ICU stay was protective factor(Plt;0.05).Conclusion The hospital mortality is considerably high in patients with acute cerebrovascular disease requiring mechanical ventilation. The prognostic factors such as blood glucose and lung infections should be evaluate cautiously and prevented aggressively.