ObjectiveTo analyze the influencing factors of ventilator-associated pneumonia (VAP) in comprehensive intensive care units (ICUs) in a certain district of Shanghai, and to provide evidence for developing targeted measures to prevent and reduce the occurrence of VAP.MethodsThe target surveillance data of 1 567 inpatients with mechanical ventilation over 48 hours in comprehensive ICUs of 5 hospitals in the district from January 2015 to December 2017 were retrospectively analyzed to determine whether VAP occurred. The data were analyzed with SPSS 21.0 software to describe the occurrence of VAP in patients and to screen the influencing factors of VAP.ResultsThere were 133 cases of VAP in the 1 567 patients, with the incidence of 8.49% and the daily incidence of 6.01‰; the incidence of VAP decreased year by year from 2015 to 2017 (χ2trend=11.111, P=0.001). The mortality rate was 12.78% in VAP patients while was 7.25% in non-VAP patients; the difference was significant (χ2=5.223, P=0.022). A total of 203 pathogenic bacteria were detected in patients with VAP, mainly Gram-negative bacteria (153 strains, accounting for 75.37%). The most common pathogen was Pseudomonas aeruginosa. The single factor analysis showed that gender, age, Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score, the length of ICU stay, and the length of mechanical ventilation were the influencing factors of VAP (χ2=9.572, 5.237, 34.759, 48.558, 44.960, P<0.05). Multiple logistic regression analysis found that women [odds ratio (OR)=1.608, 95% confidence interval (CI) (1.104, 2.340), P=0.013], APACHE Ⅱ score >15 [OR=4.704, 95%CI (2.655, 8.335), P<0.001], the length of ICU stay >14 days [OR=2.012, 95%CI (1.188, 3.407), P=0.009], and the length of mechanical ventilation >7 days [OR=2.646, 95%CI (1.439, 4.863), P=0.002] were independent risk factors of VAP.ConclusionsNosocomial infection caused by mechanical ventilation in this area has a downward trend, and the mortality rate of patients with VAP is higher. For the patients treated with mechanical ventilation in ICU, we should actively treat the primary disease, shorten the length of ICU stay and the length of mechanical ventilation, and strictly control the indication of withdrawal, thereby reduce the occurrence of VAP.
ObjectiveTo systematically review the risk factors associated with sleep disorders in ICU patients.MethodsWe searched The Cochrane Library, PubMed, EMbase, Web of Science, CNKI, Wanfang Data, VIP and CBM databases to collect cohort studies, case-control studies and cross-sectional studies on the risk factors associated with sleep disorders in ICU patients from inception to October, 2018. Two reviewers independently screened literature, extracted data and evaluated the bias risk of included studies. Then, meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 9 articles were included, with a total of 1 068 patients, including 12 risk factors. The results of meta-analysis showed that the combined effect of equipment noise (OR=0.42, 95%CI 0.26 to 0.68, P=0.000 4), patients’ talk (OR=0.53, 95%CI 0.42 to 0.66, P<0.000 01), patients’ noise (OR=0.39, 95%CI 0.21 to 0.74, P=0.004), light (OR=0.29, 95%CI 0.18 to 0.45, P<0.000 01), night treatment (OR=0.36, 95%CI 0.26 to 0.50, P<0.000 01), diseases and drug effects (OR=0.17,95%CI 0.08 to 0.36, P<0.000 01), pain (OR=0.37, 95%CI 0.17 to 0.82, P=0.01), comfort changes (OR=0.34,95%CI 0.17 to 0.67,P=0.002), anxiety (OR=0.31,95%CI 0.12 to 0.78, P=0.01), visit time (OR=0.72, 95%CI 0.53 to 0.98, P=0.04), economic burden (OR=0.63, 95%CI 0.48 to 0.82, P=0.000 5) were statistically significant risk factors for sleep disorders in ICU patients.ConclusionCurrent evidence shows that the risk factors for sleep disorders in ICU patients are environmental factors (talking voices of nurses, patient noise, and light), treatment factors (night treatment), disease factors (disease itself and drug effects, pain,) and psychological factors (visiting time, economic burden). Due to the limited quality and quantity of included studies, more high quality studies are needed to verify the above conclusions.
Objective To analyze the species distribution and resistance of the pathogens isolated fromblood cultures of the patients in intensive care unit ( ICU) , and provide a basis for prevention and control of bloodstream infections in critically ill patients. Methods The data of blood cultures of the patients in ICUduring January 2009 to December 2011 was investigated retrospectively.Results In the last 3 years, positive rate of blood cultures of ICU patients was 15. 4% , 15. 7% , and 17. 6% respectively. Among the isolates, Gram-positive bacteria were predominant ( 52. 3% ) , followed in order by gram-negative bacteria ( 33. 1% ) and fungi ( 14. 7% ) . Aerobe and facultative anaerobe were the predominant bacterial isolates ( 99. 7% ) . Enterococcus faeciumand Staphylococcus spp. were the most common gram-positive bacteria, and 4. 5% of E. faecium isolates were resistant to vancomycin. Rate of methicillin-resistance for S. aureus and S. epidermidis was 73. 5% and 93. 7% respectively. In terms of gram-negative bacteria, Acinetobacter calcoaceticus- A. baumannii complex were the leading species, 96. 9% of the isolates had multi-drug resistance and 14. 1% of the isolates had extra-drug resistance. Klebsiella pneumonia and Escherichia coli isolates were less frequently isolated and those producing extended spectrum beta-lactamases accou ted for 70. 3% and 80. 0% of the isolates respectively. Candida spp. was the most common fungi isolates ( 96. 7% )with an annual change of species distribution and declining susceptibility to azoles.Conclusions Gram-positive bacteria should be the major target for prevention and control of bloodstream infections in critically ill patients. Whereas, more attention should be paid to the infection caused by candida spp. and multidrug resistant gram-negative bacteria.
Objective To analyze morbility，risk factors，etiology，treatment and outcome of nosocomial pulmonary fungal infections in respiratory intensive care unit（RICU）.Methods Forty-seven respiratory RICU patients with nosocomial pulmonary fungal infections between July 2000 and June 2005 were retrospectively analyzed.Results All of the 47 cases were clinically diagnosed as probable nosocomial pulmonary fungal infections，with the morbidity of 10.8% significantly higher than general wards（1.8%，Plt;0.005）.COPD and bacterial pneumonia were the major underlying diseases of respiratory system with a percent of 38.30% and 36.17%，respectively.Forty-one patients (87.2%) had risk factors for fungal infections.Compared with general wards，the proportion of Aspergillosis was higher in RICU without significant difference (Pgt;0.1)；the proportions of Candida glabrata and Candida tropicalis were higher too，but that of Candida krusei was relatively low.The effective rate of antifungal treatment was 79.1% and fluconazol was the most common used antifungal agents.The mortality of fungal infection in RICU was higher than that of general wards but without significant difference（Pgt;0.1）.Conclusion The morbidity of nosocomial pulmonary fungal infection in respiratory RICU is higher than that in general wards.The proportions of infection caused by Aspergilli and some Candida resistant to fluconazol is relatively high.Early and effective treatment is needed in these patients considering the poor prognosis.
Objective To formulate an evidence-based nursing scheme of eye care for an unconscious patient undergoing mechanical ventilation with eye complication. Methods Under the principle of PICO, the issue was put forward aiming directly at patient’s clinical manifestations, and the following databases as The Cochrane Library (Issue 12, 2011), PubMed (January 1980 to November 2011), EMbase (1974 to 2011) and CBM (1978 to 2011) were searched. Results A total of 3 guidelines, 2 systematic reviews and 9 randomized controlled trials (RCTs) were included. The evidence showed that eye cleaning was the very important part of eye care, and the commonly-used cleaning or rinsing solutions were saline and sterile water. Both moist cover and lubricating eye drops / ointment were used to prevent dryness in the eyes. For instance, polyethylene moisture covers could effectively prevent corneal abrasion, and lubricating eye drops / ointment were beneficial to eye observation, so these two methods needed to be properly selected in combination with patient’s conditions. Nurses had to assess the ability of the patient to close eyelids daily and helped the patient to close eyes, but the passive eyelids closure was inferior to the artificial tear ointment in the effect on preventing corneal abrasions; the integrated intervention of maintaining eyelids closure and forming eyeballs moisture chamber was more effective to prevent eye complications. According to the available evidence mentioned herein and the patient’s conditions, the following nursing scheme of eye care was formulated: cleaning the eyelids and peripheral skin using 0.9% saline gauze, covering the eyes with sterile polyethylene films which were fixed by anti-allergic adhesive tapes, changing the dressing every 12 hours, and observing closure of the eyelids every day. Seven days later, eye symptoms got obviously improved, with decreasing secretion, without congestion and chemosis, and negative results of fluorescein staining test. Conclusion Eye cleaning removes secretion and bacteria from the eyes. Polyethylene film prevents tear from evaporation and fully promotes the immune function of tears which can reduce the risk of infection. Eyelids closure and local moisture environment benefit the corneal epithelial repair.
Objective To analyze the etiology, risk factors, and prognosis of late-onset hospitalacquired pneumonia ( L-HAP) in respiratory ICU. Methods In this retrospective case control study, 30 L-HAP patients and 30 patients without HAP in respiratory ICU were enrolled to investigate the features and risk factors of L-HAP. Stratification was made according to the onset time of L-HAP. The etiology and pathogen distribution at each stage were described and analyzed. Results Univariate analysis revealed thatunconsciousness, aspiration, mechanical ventilation, hypoalbuminemia, and long-term use of proton pump inhibitor were significantly associated with L-HAP. Logistic regression analysis revealed that mechanical ventilation( OR = 8. 7) and hypoalbuminemia ( OR = 20. 4) were independent risk factors for L-HAP. The L-HAP patients had longer stay in hospital, long-termantibiotic use, and higher mortality compared with the patients without HAP. For the patients whose L-HAP onset time within 6-14 days, the dominated pathogens were Acinetobacter baumannii and Klebsiella pneumonia. For those within 15-28 days, the dominated pathogens were Pseudomonas aeruginosa, Acinetobacter baumanni, and Staphylococcus aureus. For those beyond 29 days, the dominated pathogens were Pseudomonas aeruginosa and Stenotrophomonas maltophilia. Conclusions Mechanical ventilation and hypoalbuminemia are independent risk factors for L-HAP. The pathogen features of L-HAP are quite different at different inhospital stage.
Objective To investigate the drug resistance and homogeneous analysis of Acinetobacter baumanii in emergency intensive care unit ( EICU) . Methods Four multidrug-resistant Acinetobacter baumannii ( MDR-Ab) strains isolated fromnosocomial inpatients fromJuly 25 to September 7 in 2009 were collected and tested for drug sensitivity and MIC determination as well. The A. baumannii isolates were typed with pulsed-field gel electrophoresis ( PFGE) to determine whether they derived fromthe same clone.Results Four isolates from nosocomial inpatients were resistant to multiple antibiotics including carbapenem. The PFGE types identified from four isolates were A and B. The A. baumannii isolates did not derived from the same clone. Conclusion The prevalence of nosocomial infection is not due to transmission of the same strains among different individuals in EICU.
Objective To evaluate the clinical features and complications of bedside tracheal intubation in intensive care unit ( ICU) , and explore the suitable strategy of intubation. Methods In this retrospective study,42 patients who underwent bedside tracheal intubation in ICU during September 2008 and March 2009 were divided into a schedule group ( n =24) and an emergency group ( n =18) . The time to successful intubation, number of intubation attempts, and complications were recorded. The schedule group was defined as those with indications for intubation and fully prepared, while the emergency group was defined as those undergoing emergency intubations without full preparation due to rapid progression of disease and accidental extubation. Results The success rate for all patients was only 57. 1% on the first attempt ofintubation. The main complications during and after induction were hypotension ( 45. 2% ) and hypoxemia ( 50. 0% ) . Compared with the emergency group, the schedule group had fewer attempts to successful intubation ( 1. 71 ±1. 12 vs. 2. 67 ±1. 75) , higher success rate on the second attempt ( 87. 5% vs.61. 1%) , and lower ypoxemia incidence ( 29. 1% vs. 77. 8%, P lt; 0. 05) . Conclusions The tracheal intubation in ICU is a difficult and high risk procedure with obvious complications. Early recognition ofpatients with indications and well preparation are critical to successful bedside intubation.
Objective To analyze risk factors for prolonged stay in intensive care unit (ICU) after cardiac valvular surgery. Methods Between January 2005 and May 2005, five hundred and seven consecutive patients undergone cardiac valvular surgery were divided into two groups based on if their length of ICU stay more than 5 days (prolonged stay in ICU was defined as 5 days or more). Group Ⅰ: 75 patients required prolonged ICU stay. Group Ⅱ: 432 patients did not require prolonged ICU stay. Univariate and multivariate analysis (logistic regression) were used to identify the risk factors. Results Seventyfive patients required prolonged ICU stay. Univariate risk factors showed that age, the proportion of previous heart surgery, smoking history and repeat cardiopulmonary bypass (CPB) support, cardiothoracicratio, the CPB time and aortic crossclamping time of group Ⅰ were higher or longer than those of group Ⅱ. The heart function, left ventricular ejection fraction (LVEF), pulmonary function of group Ⅰwere worse than those of group Ⅱ(Plt;0.05, 0.01). Logistic regression identified that preoperative age≥65 years (OR=4.399), LVEF≤0.50(OR=2.788),cardiothoracic ratio≥0.68(OR=2.411), maximal voluntary ventilation observed value/predicted value %lt;71%(OR=4.872), previous heart surgery (OR=3.241) and repeat CPB support during surgery (OR=18.656) were final risk factors for prolonged ICU stay. Conclusion Prolonged ICU stay after cardiac valvular surgery can be predicted through age, LVEF, cardiothoracic ratio, maximal voluntary ventilation, previous heart surgery and repeat CPB support during surgery. The patients with these risk factors need more preoperative care and postoperative care to reduce mortality, morbidity and avoid prolonged ICU stay after cardiac valvular surgery.
Objective To evaluate systematically the effectiveness and safety of procalcitonin ( PCT) -guided therapy in comparison with standard therapy in patients with suspected or confirmed severe bacterial infections in intensive care unit ( ICU) . Methods Five randomized controlled trials ( 927 patients) were included for statistical analysis by the cochrane collaboration′s RevMan5. 0 software. Results PCT-guided therapy was associated with a significant reduction in duration of antibiotic therapy [ MD =- 2. 01, 95% CI ( - 2. 37, - 1. 64) , P lt;0. 00001] , but the mortality [ OR =1. 11, 95% CI ( 0. 83, 1. 49) ,P =0. 47] and length of ICU stay[ MD = 0. 49, 95% CI( - 1. 44, 2. 42) , P = 0. 62] were not significantly different. Conclusions An algorithmbased on serial PCT measurements would allow a more judicious use of antibiotics than currently traditional treatment of patients with severe infections in ICU. It can reduce the use of antibiotics and appears to be safe.