脱机后意外拔管及重新插管对重症监护病房医院获得性肺炎风险的影响：一项前瞻性多中心研究

Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit: a prospective multicenter study.

作者信息

de Lassence Arnaud, Alberti Corinne, Azoulay Elie, Le Miere Eric, Cheval Christine, Vincent François, Cohen Yves, Garrouste-Orgeas Maïté, Adrie Christophe, Troche Gilles, Timsit Jean-François

机构信息

Medical ICU, Avicenne Hospital, Bobigny, France.

出版信息

Anesthesiology. 2002 Jul;97(1):148-56. doi: 10.1097/00000542-200207000-00021.

DOI:10.1097/00000542-200207000-00021

PMID:12131116

Abstract

BACKGROUND

The authors prospectively evaluated the occurrence and outcomes of unplanned extubations (self-extubation and accidental extubation) and reintubation after weaning, and examined the hypothesis that these events may differ regarding their influence on the risk of nosocomial pneumonia.

METHODS

Data were taken from a prospective, 2-yr database including 750 mechanically ventilated patients from six intensive care units.

RESULTS

One hundred five patients (14%) experienced at least one episode of these 3 events; 51 self-extubations occurred in 38 patients, 24 accidental extubations in 22 patients, and 56 reintubations after weaning in 45 patients. The incidence density of these 3 events was 16.4 per 1,000 mechanical ventilation days. Reintubation within 48 h was needed consistently after accidental extubation but was unnecessary in 37% of self-extubated patients. Unplanned extubation and reintubation after weaning were associated with longer total mechanical ventilation (17 vs. 6 days; P < 0.0001), intensive care unit stay (22 vs. 9 days; P < 0.0001), and hospital stay (34 vs. 18 days; P < 0.0001) than in control group, but did not influence intensive care unit or hospital mortality. The incidence of nosocomial pneumonia was significantly higher in patients with unplanned extubation or reintubation after weaning (27.6% vs. 13.8%; P = 0.002). In a Cox model adjusting on severity at admission, unplanned extubation and reintubation after weaning increased the risk of nosocomial pneumonia (relative risk, 1.80; 95% confidence interval, 1.15-2.80; P = 0.009). This risk increase was entirely ascribable to accidental extubation (relative risk, 5.3; 95% confidence interval, 2.8-9.9; P < 0.001).

CONCLUSION

Accidental extubation but not self-extubation or reintubation after weaning increased the risk of nosocomial pneumonia. These 3 events may deserve evaluation as an indicator for quality-of-care studies.

摘要

背景

作者前瞻性评估了计划外拔管（自行拔管和意外拔管）及撤机后再次插管的发生情况和结局，并检验了这些事件对医院获得性肺炎风险的影响可能存在差异这一假设。

方法

数据取自一个前瞻性的、为期2年的数据库，该数据库包含来自6个重症监护病房的750例机械通气患者。

结果

105例患者（14%）经历了这3种事件中的至少1次；38例患者发生了51次自行拔管，22例患者发生了24次意外拔管，45例患者撤机后进行了56次再次插管。这3种事件的发病密度为每1000个机械通气日16.4次。意外拔管后始终需要在48小时内再次插管，但37%的自行拔管患者无需再次插管。计划外拔管和撤机后再次插管与总机械通气时间延长（17天对6天；P<0.0001）、重症监护病房住院时间延长（22天对9天；P<0.0001）和住院时间延长（34天对18天；P<0.0001）相关，但不影响重症监护病房或医院死亡率。计划外拔管或撤机后再次插管的患者医院获得性肺炎的发生率显著更高（27.6%对13.8%；P=0.002）。在根据入院时严重程度进行调整的Cox模型中，计划外拔管和撤机后再次插管增加了医院获得性肺炎的风险（相对风险，1.80；95%置信区间，1.15 - 2.80；P=0.009）。这种风险增加完全归因于意外拔管（相对风险，5.3；95%置信区间，2.8 - 9.9；P<0.001）。