YOĞUN BAKIM DIŞI KOŞULLARDA TAKİP EDİLEN ENTÜBE HASTALARDAKİ VENTİLATÖR İLİŞKİLİ PNÖMONİLERİN DEĞERLENDİRİLMESİ

Year 2010, Volume: 24 Issue: 2, 79 - 85, 01.10.2010

Ebru Çakir Edis Osman Nuri Hatipoğlu İlker Yılmam Alper Eker Özlem Tansel Necdet Süt

Abstract

Aralık 2006 tarihine kadar hastanemizde sadece 7 yatak kapasiteli, genellikle postoperatif hastaların izlendiği yoğun bakım ünitesi (YBÜ) mevcuttu. Yatak kapasitesi yetersiz olduğundan dolayı invaziv mekanik ventilasyon ihtiyacı olan hastalar servislerin içinde ideal olmayan koşullarda takip edilmekteydi. Biz bu çalışmada YBÜ dışında, ideal olmayan koşullarda servislerde takip edilmek zorunda kalan ventilatör ilişkili pnömonilerde (VIP) izole edilen etkenleri, tedavi başarısını ve sağkalım oranlarını saptamayı amaçladık. Biz bu çalışmada; YBÜ dışında servislerde invaziv mekanik ventilasyon uygulanan hastalarda geli- şen VIP'li ardışık 43 erişkin hastayı prospektif olarak değerlendirdik. Tüm hastalar tedavi başar ısı açısından Göğüs Hastalıkları, İnfeksiyon Hastalıkları ve hastadan sorumlu klinisyenden oluşan bir ekip tarafından izlendi. Hastaların yaşam sürelerinin analizinde Kaplan Meier yöntemi uygulandı. Bu hastalarda en sık izole edilen etken Acinetobacter spp. (n= 17) olarak saptandı. Tedavi sonu klinik başarı (kür+iyileşme) oranı %20.9 iken bu oran takip sonunda (altı hafta) %16.3'e geriledi. Kaplan Meier sürvi analizine göre 3,14, 42 ve 365. gün sürvi oranları sırasıyla %72, 34, 16, 11 olarak bulundu. VIP ide al yoğun bakım koşullarında yönetilse dahi mortalitesi yaklaşık %50'dir. Gerçek yoğun bakım koşulları dışında ise mortalite %80'lere yükselmektedir. İnvaziv mekanik ventilasyon gereksinimi olan hastalar mutlaka ideal yoğun bakım koşullarında yönetilmelidir.

Keywords

Ventilatör ilişkili pnömoni, mortalite, yoğun bakım

THE ASSESSMENT OF VENTILATOR ASSOCIATED PNEUMONIA AT INTUBATED PATIENTS WHO HAS FOLLOWED UP NON-INTENSIVE CARE CONDITIONS?

Abstract

In our h ospital, there was only one intensive Care Units (ICU) with seven beds capacity, following up postoperative patients, until 2006. Due to the insufficient number of beds, some patients requiring mechanical ventilation followed-up in the general wards under the unsuitable conditions. The aim of this study is to determine the isolated pathogens, the success rate of the treatment and survival rates of patients with ventilator- associated pneumonia (VAP) who had monitorized in poorly conditions in the outside of ICU. Forty three adult patients with VAP who had followed-up outside of the ICU were assessed prospectively. All patients were monitored by a team of Pulmonary and Infectious Disease specialists, and the clinician in charge of the patient. Kaplan-Meier methods were used for survival analysis. In t hese patients, the most common isolated pathogen was Acinetobacter spp. (n=17). The clinical success (cure+convalescent) rate was 20.9% at the end of the treatment, whereas it was 16.3% at the end of the follow-up period (six week). According to the Kplan-Meier method, survival rates were 72%, 34%, 16% and 11% for 3, 14, 42 and 365 days, respectively. In spite of management under ideal ICU conditions, the mortality rate of VAP is approximately 50%, and this rate increases up to 80% outside of the ICU conditions. Patients requiring invasive mechanical ventilation should be managed under ideal ICU conditions.

Keywords

Ventilator- associated pneumonia, mortality, intensive care unit

References

• 1. American Thoracic Society Documents. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated and Healthcare-associated Pneumonia. Am J Respir Crit Care Med 2005; 171: 388-416.
• 2. Kollef MH, Morrow LE, Niederman MS, Leeper KV, Anzueto A, Benz- Scott L, Rodino FJ. Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 2006; 129: 1210-8.
• 3. Garnacho-Montero J, Ortiz-Leyba C, FernandezHinojosa E, Aldabo-Pallas T, Cayuela A, Marquez-Vacaro JA, Garcia-Curiel A, JimenezJimenez FJ. Acinetobacter baumannii ventilatorassociated pneumonia: epidemiological and clinical findings. Intensive Care Med 2005; 31: 649-55.
• 4. www.yogunbakim.org.tr/yogun_bakim_standartlar›
• 5. Türk Toraks Derne¤i eriflkinlerde hastanede geliflen pnömoni tan› ve tedavi uzlafl› raporu. Türk Toraks Dergisi 2010; 10: 3-13.
• 6. Garcia JC, Ferreria Filho OF, Grion CM, Carrilho CM. Impact of the implementation of a therapeutic guidline on the treatment of nosocomial pneumonia acquired in the intensive care unit of a university hospital. J Bras Pneumol 2007; 33: 175-84.
• 7. Dominguez AA, Arango MV, Torres A. Treatment failure in patients with ventilatorassociated pneumonia. Semin Respir Crit Care Med 2006; 27: 104-14.
• 8. Gursel G, Aydogdu M, Ozy›lmaz E, Ozis TN. Risk factors for treatment failure in patients with ventilator- associated pneumonia receiving appropriate antibiotic therapy. J Crit Care 2008; 23: 34-40.
• 9. Zanetti G, Bally F, Greub G, Garbino J, Kinge T, Lew D, Romand JA, Bille J, Aymon D, Stratchounski L, Krawczyk L, Rubinstein E, Schaller MD, Chiolero R, Glauser MP, Cometta A; Cefepime Study Group. Cefepime versus Imipenem-Cilastatin for Treatment of Nosocomial Pneumonia in Intensive Care Unit Patients: a Multicenter, Evaluator- Blind, Prospective, Randomized Study. Antimicrob Agents Chemother 2003; 47: 3442-7.
• 10. Torres A, Bauer TT, Leon-Gil C, Castillo F, Alvarez- Lerma F, Martinez- Pellus A, LealNoval SR, Nadal P, Palomar M, Blanquer J, Ros F. Treatment of severe nosocomial pneumonia: a prospective randomised comparison of intravenous ciprofloxacin with imipenem/cilastatin. Thorax 2000; 55: 1033-9.
• 11. Porzecanski I, Bowton DL. Diagnosis and Treatment of Ventilator- Associated Pneumonia. Chest 2006; 130: 597-604.
• 12. Erbay RH, Yalcin AN, Zincir M, Serin S, Atalay H. Costs and risk factors for ventilator associated pneumonia in a Turkish university hospital’s intensive care unit: a case-control study. BMC Pulm Med 2004; 4: 3.
• 13. Cook D. Ventilator associated pneumonia: perspectives on the burden of illness. Intensive Care Med 2000; 1: 31- 7.
• 14. Cakir Edis E, Caglar T, Otkun M, Gurcan M, Hatipoglu ON, Erkan T. Hastane kökenli pnömonilerde sorumlu etkenler ve antimikrobiyal direnç de¤iflimi. ‹nfeksiyon Dergisi 2006; 20: 107-10.
• 15. Erdem I, Ozgultekin A, Sengoz Inan A, Dincer E, Turan G, Ceran N, Ozturk E, Senbayrak Akcay S, Akgun N, Goktas P. Incidence, etiology and antibotic resistance patterns of gram-negative microorganisms isolated from patients with ventilatorassociated pneumonia in a medical-surgical intensive care unit of a teaching hospital in ‹stanbul, Turkey (2004- 2006). Jpn J Infect Dis 2008; 61: 339-42.
• 16. Weber DJ, Rutala WA, Sickbert-Bennett EE, Samsa GP, Brown V, Niederman MS. Microbiology of ventilator-associated pneumonia compared with that of hospital-acquired pneumonia. Infect Control Hosp Epidemiol 2007; 28: 825-31.