中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

儿童法洛四联症术后呼吸机相关性肺炎的临床研究

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目的 探讨法洛四联症(Tetralogy of Fallot, TOF)术后呼吸机相关性肺炎(Ventilator-associated pneumonia, VAP)的发生率、病原菌特点、危险因素及预后情况,为 TOF 术后 VAP 防治提供可靠临床依据。 方法 将 2013 年 1 月至 2017 年 12 月在广东省人民医院心外科行 TOF 术后机械通气超过 48 小时的 181 例患儿,男 121 例,女 60 例,平均年龄(11.2±10.4)月,分为 VAP 组(n=44)和非 VAP 组(n=137),用 t 检验、χ2 检验及 logistic 回归分析方法,筛选 VAP 发病的可能危险因素。 结果 共纳入 181 例,其中 VAP 44 例,非 VAP 137 例,VAP 发生率为 24.3%。 VAP 常见病原菌为革兰阴性菌占 69.7%。单因素分析发现两组在术前缺氧发作、术前肺炎、术前使用呼吸机、体外循环(CPB)时间、气管插管重插管、肺不张、低心排、腹腔引流、输注新鲜冰冻血浆等方面比较,差异有统计学意义(P<0.05);多因素 logistic 回归分析显示:体外循环时间(OR 值 1.011)、气管插管重插管(OR 值 14.548)、肺不张(OR 值 6.139)、低心排(OR 值 3.054)为法洛四联症术后 VAP 发生的独立危险因素(P<0.05)。与非 VAP 组相比,VAP 患儿机械通气时间长、ICU 停留时间长,总住院时间长。 结论 TOF 术后 VAP 发生率较高,致使病人机械通气时间及住院时间延长,应根据 VAP 的危险因素采取综合防治措施,以期降低其发生率。

Objectives This study aimed to investigate the incidence, pathogens, risk factors and clinical outcomes for ventilator- associated pneumonia (VAP) in children after tetralogy of Fallot (TOF) surgical correction, in order to offer reliable data for the prevention of VAP. Methods This was a retrospective study performed at Guangdong General Hospital and 181 children (male 121, female 60, mean age 11.2±10.4 months) undergoing surgical correction for TOF were included. ALL the children who received mechanical ventilation for 48 hours or longer between January 2013 and December 2017 were classified into VAP group (n=44) and non-VAP group (n=137). T test, χ2 test and multiple logistic regression analysis were used to identify the possible risk factors for VAP. Results This study enrolled 181 patients , of which 44 were diagnosed as having VAP, and the incidence of VAP was 24.3%. The most frequent isolated pathogen was Gram-Negative bacteria (69.7%). Single factor analysis showed that the variables significantly associated with a risk factor of VAP were: hypoxic spells, preoperative pneumonia, preoperative mechanical ventilation support, cardiopulmonary bypass time (CPB), reintubation, pulmonary atelectasis, low cardiac output syndrome (LCOS), intra-abdominal drainage and transfusion of fresh frozen plasma. The multiple logistic regression showed CPB time (OR=1.011), reintubation (OR=14.548), pulmonary atelectasis (OR=6.139) and LCOS (OR=3.054) were independent risk factors for VAP in children after TOF surgical correction. Patients with VAP had prolonged duration of mechanical ventilation, a longer ICU stay and longer hospitalization time. Conclusions The VAP rate in this population is higher than that reported abroad, which leads to prolonged duration of mechanical ventilation and a longer hospital stay. The effective measures for prevention of VAP should be taken according to the related risk factors for VAP to decrease the incidence of VAP in children after TOF surgical correction.

关键词: 法洛四联症; 呼吸机相关性肺炎; 发生率; 病原菌; 危险因素; 预后

Key words: Tetralogy of Fallot; Ventilator-associated pneumonia; Incidence; Pathogen; Risk factor; Outcome

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1. 中华医学会重症医学分会. 呼吸机相关性肺炎诊断、预防和治疗指南. 中华内科杂志, 2013, 52(6): 524-543.
2. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. American Journal of Infection Control, 2008, 36(5): 309-332.
3. 高海红, 谈林华, 张彩云, 等. 婴幼儿心内直视术后呼吸机相关性肺炎高危因素分析. 中华肺部疾病杂志电子版, 2012, 5(3): 210-215.
4. 孙悦霖, 符跃强, 马宏图, 等. 先天性心脏病术后呼吸机相关性肺炎病原菌变化及危险因素分析. 中国当代儿科杂志, 2015, (11): 1204-1209.
5. Bigham MT, Amato R, Bondurrant P, et al. Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and Implementing a Sustainable Solution. The Journal of Pediatrics, 2009, 154(4): 582-587.
6. Tang CW, Liu PY, Huang YE, et al. Ventilator-associated pneumonia after pediatric cardiac surgery in southern Taiwan. J Microbiol, 2009, 42(5): 413-419.
7. Li SL, Zhang YJ, Li SJ, et al. Risk Factors Associated with Prolonged Mechanical Ventilation after Corrective Surgery for Tetralogy of Fallot. Congenital Heart Disease, 2015, 10(3): 254-262.
8. 史晨, 张燕搏, 程军, 等. 先天性心脏病术后呼吸机相关性肺炎致病菌及其耐药性分析. 中华实用诊断与治疗杂志, 2015, (10): 1009-1011.
9. 谈林华, 朱雄凯, 俞建根, 等. 婴儿先天性心脏病术后呼吸机相关性肺炎致病菌及耐药性分析. 中华急诊医学杂志, 2005, 14(03): 225-228.
10. Roeleveld PP, Guijt D, Kuijper EJ, et al. Ventilator-associated pneumonia in children after cardiac surgery in The Netherlands. Intensive Care Medicine, 2011, 37(10): 1656-1663.
11. Hortal J, Giannella M, Pérez M J, et al. Incidence and risk factors for ventilator-associated pneumonia after major heart surgery. Intensive Care Medicine, 2009, 35(9): 1518-1525.
12. Vijay G, Mandal A, Sankar J, et al. Ventilator Associated Pneumonia in Pediatric Intensive Care Unit: Incidence, Risk Factors and Etiological Agents. The Indian Journal of Pediatrics, 2018, 85(10): 861-866.
13. 朱晓东, 张宝仁, 主编. 心脏外科学. 第一版. 北京: 人民卫生出版社, 2007: 564-580.
14. Shaath GA, Jijeh A, Faruqui F, et al. Ventilator-Associated Pneumonia in Children After Cardiac Surgery. Pediatric Cardiology, 2014, 35(4): 627-631.
15. Mercer Rosa L, Elci OU, Decost G, et al. Predictors of Length of Hospital Stay After Complete Repair for Tetralogy of Fallot: A Prospective Cohort Study. Journal of the American Heart Association, 2018, 7(11): e008719.
16. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Critical Care Medicine, 2003, 31(5): 1312-1317.
17. Marelich GP, Murin S, Battistella F, et al. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest, 2000, 118(2): 459-467.
18. Wang T, Wang X, Liu J, et al. Substitution of artificial colloids for fresh frozen plasma in pediatric cardiopulmonary bypass surgery. Pediatric Anesthesia, 2018, 28(10): 914-923.
19. Banupriya B, Biswal N, Srinivasaraghavan R, et al. Probiotic prophylaxis to prevent ventilator associated pneumonia (VAP) in children on mechanical ventilation: an open-label randomized controlled trial. Intensive Care Medicine, 2015, 41(4): 677-685.
20. Yolanda PeñaLópez, Pujol M, Campins M, et al. Implementing a Care bundle approach reduces Ventilator-associated pneumonia and delays Ventilator-associated tracheobronchitis in children: Differences according to endotracheal or tracheostomy devices. International Journal of Infectious Diseases, 2016(http://dx.doi.org/10.1016/j.ijid.2016.09.021).
21. Yilmaz G, Aydin H, Aydin M, et al. Staff education aimed at reducing ventilator-associated pneumonia. Journal of Medical Microbiology, 2016, 65(12): 1378-1384.
22. Tamayo E, Francisco Javier álvarez, Beatriz Martínez-Rafael, et al. Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery. Journal of Critical Care, 2012, 27(1): 18-25.