【原】心血管衰竭与呼吸机相关性下呼吸道感染治疗的关系

罂粟花anesthGH 2021-07-21

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The association of cardiovascular failure with treatment for ventilator-associated lower respiratory tract infection

背景与目的

呼吸机相关性下呼吸道感染(VA-LRTIs)、呼吸机相关性肺炎(VAP)或气管支气管炎(VAT)是重症监护病房(ICU)中最常见的院内感染。本研究旨在探讨对VA-LRTI患者进行适当的抗生素治疗是否能有效降低心血管衰竭患者的死亡率。

方法

这是一项预先设计好的大型前瞻性队列研究，对来自两大洲8个国家的机械通气患者进行至少48小时的亚组分析。经改良的序贯性器官衰竭评估（mSOFA）心血管评分为4分（在VA-LRTI诊断时，需要至少12小时）的患者被视为患有心血管衰竭。

结果

在2960例患者中，有689例(23.2%)发生VA-LRTI, 174例(25.3%)发生心血管衰竭。心血管衰竭患者ICU内死亡率明显高于非心血管衰竭患者(58% vs. 26.8%; p<0.001; OR 3.7; 95% CI 2.6–5.4)。倾向评分分析发现，抗生素治疗不当是非心血管衰竭患者ICU内死亡的独立危险因素，但在患有心血管衰竭的患者中则不是。当对VA-LRTI患者进行倾向评分分析时，使用适当的抗生素治疗可使仅患有VAP的非心血管衰竭患者生存获益。

结论

在VA-LRTI伴有心血管衰竭的患者中，使用适当的抗生素治疗与ICU内更高的生存率无相关性。此外，我们发现在无心血管衰竭的患者中，使用适当的抗生素治疗可使仅患有VAP的患者生存获益。

原始文献摘要

Martin-Loeches I, Torres A, Povoa P, et al.The association of cardiovascular failure with treatment for ventilator-associated lower respiratory tract infection[J]. Intensive Care Med,2019,45(12):1753-1762.

Purpose: Ventilator associated-lower respiratory tract infections (VA-LRTIs), either ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), accounts for most nosocomial infections in intensive care units (ICU) including. Our aim was to determine if appropriate antibiotic treatment in patients with VA-LRTI will efectively reduce mortality in patients who had cardiovascular failure.

Methods: This was a pre-planned subanalysis of a large prospective cohort of mechanically ventilated patients for at least 48 h in eight countries in two continents. Patients with a modifed Sequential Organ Failure Assessment (mSOFA) cardiovascular score of 4 (at the time of VA-LRTI diagnosis and needed be present for at least 12 h) were defined as having cardiovascular failure.

Results: VA-LRTI occurred in 689 (23.2%) out of 2960 patients and 174 (25.3%) developed cardiovascular failure. Patients with cardiovascular failure had signifcantly higher ICU mortality than those without (58% vs. 26.8%; p<0.001; OR 3.7; 95% CI 2.6–5.4). A propensity score analysis found that the presence of inappropriate antibiotic treatment was an independent risk factor for ICU mortality in patients without cardiovascular failure, but not in those with cardiovascular failure. When the propensity score analysis was conducted in patients with VA-LRTI, the use of appropriate antibiotic treatment conferred a survival benefit for patients without cardiovascular failure who had only VAP.

Conclusions: Patients with VA-LRTI and cardiovascular failure did not show an association to a higher ICU survival with appropriate antibiotic treatment. Additionally, we found that in patients without cardiovascular failure, appropriate antibiotic treatment conferred a survival beneft for patients only with VAP.

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