呼吸机捆绑式治疗的探讨.ppt

呼吸机捆绑式治疗的探讨A Review of the Ventilator Bundle Question ANSWER 呼吸机捆绑Ventilator Bundle 运用一组干预手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 degrees 2. 每日间歇停止使用镇静药物Daily Sedation Vacations 3. 每日评价拔管指征 Daily Assessment of Readiness to Extubate 4. 预防消化道溃疡 Peptic Ulcer Prophylaxis 5. 预防深静脉血栓 DVT Prophylaxis 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. 每日间隔应用镇静药物 Daily Sedation Vacations 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 day Duration Ventilation ICU 天数 6.4 days* 9.9 days ICU Stay *P 0.05 2. 每日间歇使用镇静剂Daily Sedation 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 目的:减少通气时间及ICU入住时间 GOALS: Decrease Duration of Ventilation and 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 th