培训课件-呼吸机相关性肺炎诊断与预防策略探讨黎毅敏.pptVIP

经验性抗生素治疗原则 取决于 什么病房 (环境) 什么病人 是否免疫抑制 是否有感染性休克 是否前面用过抗生素 肾功能情况 经济情况 单药治疗或联合治疗 确诊呼吸道感染 P. aeruginosa, Acinetobacter, Enterobacter, Klebsiella : 联合治疗 ?-lactamine + aminoside E. coli, SAOS, H. influenzae : 单药治疗 如无感染性休克 ? -lactamine 晚期VAP = 联合治疗 = B-lactamine + aminoside 猛击策略 = 快, 狠, 短 一次注射, 高峰浓度, 3-5 天 喹喏酮 喹喏酮耐药 与 B-lactamines交叉耐药 盲取标本 ± BAL “阳性 BAL- 血抗原测定 – 血病毒测定 治疗 “阴性 活检 激素治疗? 不改变 “阴性 ARDS 每周两次检测: AT 2002年 策略 Prevention of VAP Semi-recumbent (45°) position Sucralfate vs H2 blockers Aspiration of subglottic secretions Kinetic bed Frequency of ventilator circuit changes Decreased VAP Mixed Mixed Mixed; only + in surgery patients No effect Use in all patients Either in pts at moderate risk for stress GI bleed Consider in prolonged MV Consider in surgery patients Change as needed Intervention Results Recommendations Collard HR et al. Ann Intern Med 2003 Keenan SP et al. Crit Care Clin 2002 Positioning and VAP: Summary The supine position is an independent risk factor for VAP Multivariate analysis, data not shown The semirecumbent position (45°) reduces the frequency and risk of VAP Especially in patients receiving enteral nutrition Must be for the majority of the day Strategy for Management of Suspected VAP(1) Antoni Torres, NEJM 350;5 Jan 29, 2004 Clinical Condition Strategy Rationale Step1: initial evaluation Clinical suspicion of VAP Retrieval of secretions Risk of delayed or (based on classic for quantitative culture; inappropriate Criteria or CPIS6) immediate initiation of antibiotics antibiotics outweighs risks associated with antibiotics overuse Strategy for Management of Suspected VAP(2) Antoni Torres, NEJM 350;5 Jan 29, 2004 Clinical Condition Strategy Rationale Step2: reevaluation at 48-72hr Clinical suspicion of VAP Continuation of Therapeutic Confirmed (clinically, antibiotics (adjust benefit in terms Microbiologically, or both) according to of outc