Not Using Instillation Saline Before Suctioning 呼吸器相關肺炎的定義 tracheostomy endotracheal intubation Horan, Andrus, & Dudeck, 2008 文獻查證 VAP ㈠ VAP V

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1 無滴入生理食鹽水之抽痰術降低呼吸器相關肺炎之研究 1 2 3* 背景 : 呼吸器相關性肺炎 (ventilator associated pneumonia, VAP) 會延長呼吸器使用天數 增加醫療費用, 滴入生理食鹽水抽痰術常引起病人反嘔等不適, 卻廣地被應用於呼吸器使用的病人 目的 : 探討無滴入生理食鹽水之氣管內管抽痰術對 VAP 發生率的影響 方法 : 以立意取樣方式於中部某醫學中心之加護病房, 先收集 6 個月執行滴入生理食鹽水對照組 (n = 81), 再收集 6 個月無滴入生理食鹽水實驗組 (n = 116), 比較兩組 VAP 發生率的統計差異 結果 : ㈠比較 VAP 發生時間, 在實驗組為使用呼吸器後第 28.0 天 對照組則為第 10.8 天 ㈡兩組於呼吸器相關肺炎的發生率, 實驗組 VAP 發生率為 1.31 低於對照組 9.19, 以 t-test 統計有顯著差異 (p <.05) 結論 : 研究發現無滴入生理食鹽水之抽痰術似乎可降低 VAP 的發生率 關鍵詞 : 生理食鹽水 抽痰術 呼吸器相關肺炎 前言 ventilator-associated pneumonia, VAP 48 VAP VAP Safdar, Dezfulian, Collard, & Saint, 2005 VAP Augustyn, 2007 VAP 70% 40% VAP cshp066@csh.org.tw 2009 Fleming, Steger, & Craven, 2000 VAP VAP VAP VAP VAP VAP VAP doi: /jnhr 護理暨健康照護研究

2 Not Using Instillation Saline Before Suctioning 呼吸器相關肺炎的定義 tracheostomy endotracheal intubation Horan, Andrus, & Dudeck, 2008 文獻查證 VAP ㈠ VAP VAP VAP 1.27 VAP VAP 1% VAP H2 VAP VAP Driks et al., 1987; Rello & Diaz, 2003 ㈡ % 18.7% 3. Ackerman Mick 1998 randomized control trial, RCT Celik Kanan 2006 RCT Overend RCT 5. Pedersen Rosendahl-Nielsen Hjermind Egerod meta-analysis 52 Caruso Denari Ruiz Demarzo Deheinzelin Journal of Nursing and Healthcare Research December 2012 Vol. 8, No. 4

3 VAP 方法 一 研究對象及收案標準 VAP 2009 > 38.4 < 36 < 4,000 mm 3 12,000 mm 3 二 資料收集過程及研究設計 95% power n = 81 1, n = 116 1,264 Apach II TQIP Taiwan quality indicator project VAP VAP VAP VAP 三 倫理考量 四 資料處理及統計分析 SPSS for Windows 16.0 Apach II 15 VAP independent t-test χ 2 結果 一 研究對象基本屬性之差異 independent t-test % 34 42% % 62% Apach II % % 44 38% Apach II % 89 58% 二 抽痰前有無滴入生理食鹽水之 VAP 發生率的差異 independent t-test p < / /81 83% 95% confidence interval NNT number needed to treat 12 1 VAP 95% confidence interval, 7-78 VAP 28.0 VAP 10.8 VAP VAP p <.05 護理暨健康照護研究

4 Not Using Instillation Saline Before Suctioning 表一研究對象基本屬性之比較 對照組 (n = 81) 實驗組 (n = 116) 變項 % M ± SD % M ± SD χ 2 / t p 年齡 ( 歲 ) 70.3 ± ± 12.3 t = 性別 χ 2 = 加護病房天數 9.8 ± ± 10.8 t = 呼吸器使用天數 9.2 ± ± 10.0 t = 有抗生素使用 χ 2 = 有制酸劑之使用 χ 2 = APACH II 15 分率 χ 2 = independent t-test; χ 2 表二滴入生理食鹽水後行氣管內管抽吸術對呼吸器相關肺炎發生率之比較 月份 對照組 (n = 81) 實驗組 (n = 116) 感染數呼吸器人日發生率 ( ) 月份感染數呼吸器人日發生率 ( ) * independent t-test t p 表三比較有無滴入生理食鹽水呼吸器相關肺炎發生率之 NNT 計算 項目無滴入 (n = 116) 有滴入 (n = 81) 2 8 % 1.7 EER 9.9 CER ARR % % CI [1.3,15.1] RRR % 83 95% CI [13,100] NNT 12 95% CI [7,78] EER: experimental event rate; CER: control event rate; ARR (absolute risk reduction) = CER-EER; RRR (relative risk reduction) = ARR/CER; NNT: number needed to treat 討論 VAP Caruso 2009 VAP 328 Journal of Nursing and Healthcare Research December 2012 Vol. 8, No. 4

5 結論與建議 VAP 1.63 Cochrane RCT Raymond 1995 誌謝 97 CSH-97-A-16 參考文獻 [Wang, C. H., & Maa, S. H. (2009). Risk factors and preventive strategies of ventilator-associated pneumonia. Chang Gung Nursing, 20(1), ] [Wu, S. C., & Chen, C. C. (2004). Study on factors for ventilator-associated pneumonia in intensive care unit. Taiwan Journal of Public Health, 23(6), ] 1994 CQI [Li, T. Y., Ke, Y. H., Yeh, H. Y., Shih, G. H., & Lien, G. S. (1994). Applying the CQI theory to improve the technique of suction. The Journal of Nursing, 41(2), ] [Lee, C. H., Chang, H. T., Chen, Y. C., & Wu, H. D. (2009). Evidence-based strategy of VAP prevention. Infection Control Journal, 19(3), ] =1887&mp=1 [Centers for Disease Control, Taiwan, ROC. (2009). Definitions of healthcare-associated infections (2nd ed.). Retrieved from em=15825&ctnode=1887&mp=1] [Juang, I. F. (1995). Is it necessary to instill normal saline solution into an endotracheal tube before suctioning? The Journal of Nursing, 42(2), ] [Huang, Y. C., Wang, W. H., Hsieh, H. H., Chung, H. C., & Wang, L. S. (2004). Ventilator associated pneumonia and its risk factors in a surgical intensive care unit- A study at a teaching hospital in eastern Taiwan. Tzu Chi Nursing Journal, 3(3), ] Ackerman, M. H., & Mick, D. J. (1998). Instillation of normal saline before suctioning in patients with pulmonary infections: A prospective randomized controlled trial. American Journal of Critical Care, 7(4), Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27(4), Caruso, P., Denari, S., Ruiz, S. A., Demarzo, S. E., & Deheinzelin, D. (2009). Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Critical Care Medicine, 37(1), doi: / CCM.0b013e Celik, S. A., & Kanan, N. (2006). A current conflict: Use of isotonic sodium chloride solution on endotracheal suctioning in critically ill patients. Dimensions of Critical Care Nursing, 25(1), 護理暨健康照護研究

6 Not Using Instillation Saline Before Suctioning Driks, M. R., Craven, D. E., Celli, B. R., Manning, M., Burke, R. A., Garvin, G. M.,... McCabe, W. R. (1987). Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The New England Journal of Medicine, 317(22), doi: /nejm Fleming, C. A., Steger, K. A., & Craven, D. E. (2000). Host- and device-associated risk factors for nosocomial pneumonia: Cost-effective strategies for prevention. In W. R. Jarvis (Ed.), Nosocomial pneumonia (pp ). New York, NY: Marcel Dekker. Horan, T. C., Andrus, M., & Dudeck, M. A. (2008). CDC/NHSN surveillance definition of health care-associated infection and criteria for specific type of infections in the acute care setting. American Journal of Infection Control, 36(5), doi: /j.ajic Overend, T. J., Anderson, C. M., Brooks, D., Cicutto, L., Keim, M., McAuslan, D., & Nonoyama, M. (2009). Updating the evidence-base for suctioning adult patients: A systematic review. Canadian Respiratory Journal, 16(3), Pedersen, C. M., Rosendahl-Nielsen, M., Hjermind, J., & Egerod, I. (2009). Endotracheal suctioning of the adult intubated patient- What is the evidence? Intensive and Critical Care Nursing, 25(1), doi: /j.iccn Raymond, S. J. (1995). Normal saline instillation before suctioning: Helpful or harmful? A review of the literature. American Journal of Critical Care, 4(4), Rello, J., & Diaz, E. (2003). Pneumonia in the intensive care unit. Critical Care Medicine, 31(10), doi: /01.ccm D2 Safdar, N., Dezfulian, C., Collard, H., & Saint, S. (2005). Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Critical Care Medicine, 33(10), doi: /01.ccm d9 330 Journal of Nursing and Healthcare Research December 2012 Vol. 8, No. 4

7 Reducing Ventilator-Associated Pneumonia (VAP) by not Using Instillation Saline Before Suctioning Mei-Yu Lai 1 Shu-Hua Chang 2 Yi-Hui Sung 3 * 1 MSN, RN, Head Nurse, Department of Nursing, Chung Shan Medical University Hospital; 2 BSN, RN, Department of Nursing, Chung Shan Medical University Hospital; 3 MSN, RN, Supervisor, Department of Nursing, Chung Shan Medical University Hospital and Adjunct Instructor, School of Nursing, Chung Shan Medical University. Background: Ventilator-associated pneumonia (VAP) has been shown to increase total number of ventilatordependent days and increase medical costs. Although using instillation saline prior to endotracheal suctioning induces nausea in some patients, it remains a common practice with ventilator-dependent patients. To improve this situation, we used an evidence-based method to assess the potential relationship between instillation saline and VAP. Purpose: This study compared VAP incidence rates between patients receiving instillation saline and those who did not prior to endotracheal suctioning. Methods: Purposive sampling was conducted in the intensive care unit of a medical center. Data on the instillation saline (control) group (n = 81) were collected for 6 months, followed by 6 months of data collection on the noinstillation saline (experimental) group (n = 116). We compared collected data to indentify differences in VAP incidence between the two. Results: VAP was diagnosed on average at day 28.0 for the experimental group and at day 10.8 for the control group. The VAP incidence rate was 1.31 for the experimental group and 9.19 for the control group. A t-test found both differences to be statistically significant (p <.05). Conclusions: Not using instillation saline before endotracheal suction was found to significantly decrease VAP incidence and reduce medical expenditures. Key Words: saline, suctioning, ventilator-associated pneumonia. Accepted for publication: November 5, 2012 *Address correspondence to: Yi-Hui Sung, No. 110, Chien Kuo N. Rd. Sec. 1, Taichung City 40201, Taiwan, ROC. Tel: +886 (4) ext ; cshp066@csh.org.tw 護理暨健康照護研究