1、蛛网膜下腔出血后感染并发症的危险因素 Infectious complications of aneurysmal SAH,王 宁 首都医科大学宣武医院神经外科ICU 2009-06-21,目录,动脉瘤破裂造成的临床级联反应 感染性并发症的危险因素及对预后的影响 肺炎在肺部并发症的状况？ 肺部并发症的预防与控制,动脉瘤破裂造成的临床级联反应,A higher mortality and morbidity disease,The mortality rate for SAH in the 1966 Cooperative Study on Intracranial Aneurysms was
2、50% at 29 days33% in a recent analysis of in-hospital deaths among SAH patients admitted through an emergency department,Nature history,In the prospective Cooperative Aneurysm Study, rebleeding was maximal (4%) on the first day after SAH and then constant at a rate of 1% per day to 2% per day over t
3、he subsequent 4 weeks. Several prospective follow-up cohorts have demonstrated that the risk of rebleeding with conservative therapy is between 20% and 30% for the first month after hemorrhage and then stabilizes at a rate of 3% per year.,并发症是影响预后的重要因素,The factors that strongly influence outcome aft
4、er SAH,Patient factors: the severity of initial hemorrhage, age, sex, time to treatment, and medical co-morbidities such as untreated and treated hypertension, atrial fibrillation, congestive heart failure, coronary artery disease, and renal disease. Aneurysm factors: size, location in the posterior
5、 circulation, and possibly morphology. Institutional factors include the availability of endovascular services, the volume of SAH patients treated, and the type of facility in which the patient is first evaluated.Cross DT. Mortality rates after subarachnoid hemorrhage: variations according to hospit
6、al case volume in 18 states. J Neurosurg.2003;99:810817.,Vasospasm,Angiographic vasospasm is seen in 30% to 70% of patients In contemporary series, 15% to 20% of such patients suffer stroke or die of vasospasm despite maximal therapy Looked at another way, vasospasm appears to account for nearly 50%
7、 of the deaths in patients surviving to treatment after SAHLongstreth WT. Clinical course of spontaneous subarachnoid hemorrhage: a population-based study in King County, Washington. Neurology. 1993;43:712718.,Hydrocephalus,Acute hydrocephalus (ventricular enlargement within 72 hours) is reported to
8、 occur in 20% to 30% of patients.Chronic ventriculomegaly requiring permanent shunting procedures is reported at rates of 18% to 26% of surviving patients.,Seizures,More recent retrospective reviews report a low frequency of seizures ranging from 6% to18%.Delayed seizures occurred in 7% of patients
9、in another series.,Balance of water and electrolytes,The reported incidence of hyponatremia after SAH ranges from 10% to 30%.,感染性并发症的危险因素及对预后的影响,两种手术方式治疗动脉瘤并发症分布,Wartenberg, Katja E. IMPACT OF NOSOCOMIAL INFECTIOUS COMPLICATIONS AFTER SUBARACHNOID HEMORRHAGE . Neurosurgery. 2008 62(1), 8087,Wartenbe
10、rg, Katja E. IMPACT OF NOSOCOMIAL INFECTIOUS COMPLICATIONS AFTER SUBARACHNOID HEMORRHAGE . Neurosurgery. 2008 62(1), 8087,神经原性肺水肿 （Neurogenic pulmonary edema ）,The incidence of NPE was 8% (39 of 477 patients). Most patients with NPE were severely impaired and all of them presented with radiologicall
11、y severe hemorrhagePatients with NPE showed poor neurologic outcome (Glasgow outcome scale 1 to 3 in 25% vs.77% of patients) Muroi C. Neurogenic pulmonary edema in patients with subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2008 Jul;20(3):188-92,亚低温治疗增加感染,Gasser S, et al. Long-term hypothermia i
12、n patients with severe brain edema after poor-grade subarachnoid hemorrhage: feasibility and intensive care complications. J Neurosurg Anesthesiol. 2003;15(3):240-8,Clinical data of Hypothermia,NICU患者发生SAP的危险因素,Ruediger Hilker.MD,et al. Stroke,2003;34:975-981,SAP的临床危险因素,R Dziewas,et al. J Neurol Neu
13、rosurg Psychiatry 2004;75:852856.,如何有效控制肺感染并发症?,临床经验性治疗与细菌病原学治疗关系,经验性抗菌素与对病原菌敏感抗菌素治疗的结合和统一,Tracheostomy,Early tracheostomy after intubation has also been shown： To reduce rates of pneumonia, To decrease mortality, To shorten both the length of ICU stay and the duration of mechanical ventilation in a
14、 population of medical ICU patientsRumbak MJ: A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 32:16891694, 2004,抗菌素应用之外的抗感染措施,Elevating the head of the
15、bed Upright positioning during feedingLimiting the duration of mechanical ventilation are important factors in reducing the incidence of ventilator-associated pneumonia. Daily sedation interruption and weaning trials have also been shown to limit the duration of mechanical ventilation. Restricted bl
16、ood transfusions, Tight glucose control are recommended measures to prevent ventilator-associated pneumoniaAmerican Thoracic Society, Infectious Diseases Society of America: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am
17、 J Respir Crit Care Med 171:388416, 2005,Neuroscience-specific intensive care units that are staffed by specialized neurointensivists and neurosurgeons will reduce mortality and improve functional outcome,小结,对所有急性动脉瘤性 SAH的病人都要把并发症的预防作为重要的临床决策 动脉瘤破裂后多种因素会造成感染并发症，而肺炎是发生率最高的感染 抗菌素的应用只是治疗肺感染的措施之一；早期气管切开，积极的肺部护理，全身液体平衡管理综合运用才能有效控制肺炎,THANKS,
