ApostolokasVVAPProject课件.pptVIP

Ventilator-Associated Pneumonia Prevention Michael J. Apostolakos, MD Associate Professor of Medicine Director, Adult Critical Care University of Rochester VAP: Why is it Important? VAP occurs in 10-25% of patients undergoing mechanical ventilation (4-16 cases/1000 ventilator days Patients stay in ICU on average 4-9 more days Attributable mortality 20-50% High morbidity and mortality IT IS PREVENTABLE VAP Definition Clinically defined pneumonia Is associated with a ventilator Pneumonia occurs 48 hours or more after being placed on ventilator Pneumonia occurs within 48 hours after extubation Number of VAP/number of ventilator days x 1000 Diagnostic Strategies: Clinical vs. Bacteriologic Clinical Dx as subsequent slide Sensitivity vs specificity altered based on number of criteria used Etiology defined by semi-quantitative cultures Emphasizes prompt abx Abx choice based on risk factors Therapy modified by response and cultures Over sensitive, less specific Bacteriologic Uses quantitative cultures of lower resp secretions (BAL or PSB) to define pna and org Decision on initial abx still clinically based Consistently finds less org than qualitative cultures Less abx used Findings not always consistent or reproducible False neg may lead to under treatment Clinically Defined Pneumonia: Diagnosis Two or more serial CXRs with at least one of the following New or progressive and persistent infiltrate Consolidation Cavitation At least one of the following: Fever (38 C with no other recognized cause Leukopenia (4,000 WBC/mm3) or leukocytosis ( 12,000 WBC/mm3) For adults 70 years old, altered mental status with no other recognized cause And at least two of the following: New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements New onset or worsening cough, or dyspnea, or tachypnea Rales or bronchial breath sounds Worsening gas exchange, increased oxygen requirements, or increased ventilator demand