Crit Care:地塞米松对机械通气的COVID-19患者呼吸机相关性肺炎发病率的影响

2022-06-18 MedSci原创 MedSci原创

COVID-19危重患者发生VAP的风险较高,多由多重耐药菌引起,皮质类固醇治疗会增加其风险。

急性呼吸窘迫综合征(ARDS)是COVID-19常见的并发症,经常需要延长有创机械通气时间。由于一些随机对照试验表明,低剂量皮质类固醇治疗可降低死亡率,早期类固醇治疗已成为COVID-19重症患者的标准治疗方法。据报道,在COVID-19危重患者中继发性感染,特别是呼吸机相关肺炎(VAP)的发病率很高。尽管如此,皮质类固醇在感染并发症风险中的作用仍不确定。

近日,危重病医学领域权威杂志Critical Care上发表了一篇研究文章,该研究旨在评估类固醇治疗对接受机械通气的COVID-19患者呼吸机相关性肺炎(VAP)发生率和结局的影响。

研究人员于2020年2月24日至12月31日期间在意大利伦巴第的4个COVID-19重症监护室(ICU)进行了倾向匹配的回顾性队列研究。接受机械通气的成年COVID-19患者分为两组:(1)给予小剂量皮质类固醇(地塞米松6mg/d静脉注射,连续10天)(DEXA+);(2)未使用皮质类固醇(DEXA−)治疗。研究人员采用倾向评分匹配程序(1:1比例),根据年龄、体重、呼气末正压水平、PaO2/FiO2比值、非呼吸顺序器官衰竭评估(SOFA)评分、Charlson共病指数(CCI)、入院时C反应蛋白血浆浓度、性别和入院医院(精确匹配)来确定患者的队列。该研究的干预因素为6mg/天静脉注射地塞米松,治疗10天。

739名患者被纳入研究,通过倾向评分匹配确定了两组,每组158名受试者。89例(56%)DEXA+患者 vs 55例(34%)DEXA−患者发生VAP(RR为1.61(1.26-2.098),p=0.0001),但从住院、入住ICU和插管的时间相似。DEXA+患者VAP粗略发生率(49.58(49.26~49.91) vs. 31.65(31.38~31.91)VAP*1000/pd)(IRR为1.57(1.55~1.58),p<0.0001)以及VAP风险(HR1.81(1.31~2.50),p=0.0003)要高,ICU住院时间和有创机械通气时间也较长,但死亡率相似(RR为1.17(0.85~1.63),p=0.3332)。由G+细菌(主要是金黄色葡萄球菌)和G-细菌(主要是肠杆菌)引起的VAPs相似。41例(28%)VAPs患者是多药耐药菌所致。VAP与ICU和医院LOS及有创机械通气几乎翻倍相关,并死亡率增加(RR为1.64[1.02-2.65],p=0.040),但患者组间无差异。

由此可见,COVID-19危重患者发生VAP的风险较高,多由多重耐药菌引起,皮质类固醇治疗会增加其风险。

原始出处:

Vittorio Scaravilli,et al.Impact of dexamethasone on the incidence of ventilator-associated pneumonia in mechanically ventilated COVID-19 patients: a propensity-matched cohort study.Critical Care.2022.https://ccforum.biomedcentral.com/articles/10.1186/s13054-022-04049-2

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