En réanimation respiratoire il est important de repérer les patients à risque de ventilation mécanique prolongée (VMP) afin de discuter précocement l’indication d’une trachéotomie.
63
Une trachéotomie est pratiquée depuis 1500 ans avant J.-C. Aujourd'hui, une trachéotomie est pratiquée chez près de 25% des patients admis en réanimation. Elle est généralement indiquée pour la ventilation mécanique prolongée [108,109] car elle est associée à une réduction des ulcères buccaux et de la partie inférieure du larynx, une réduction de la résistance du ventilateur et de l'espace mort, une amélioration du confort et de la gestion des sécrétions, une réduction du besoin de sédatif, une facilité de communication et une alimentation par voie orale [110].
À l'heure actuelle, certaines études ont montré que la trachéotomie précoce (moins de 7 jours d'intubation) présentait des avantages significatifs chez les patients intubés. En 1989, l'American College of Chest Physicians a publié un document de consensus recommandant une trachéotomie précoce chez les patients présentant une durée d'intubation estimée supérieure à 21 jours[75]. Par la suite, dans une étude prospective menée auprès de 90 patients, Brook et collaborateurs (2000) [111]ont découvert que les patients ayant subi une trachéotomie précoce avaient des coûts hospitaliers inférieurs. Hsu et collaborateurs (2005) [108] ont montré que les patients ayant subi une trachéotomie après trois semaines de ventilation mécanique présentaient une fréquence plus élevée de réintubation et une mortalité accrue. Une méta-analyse de patients trachéotomisés menée en 2005 a révélé une durée de séjour en USI réduite (15,3 jours (IC 95%: 6,1-24,6)) et une réduction du temps passé en ventilation mécanique (8,5 jours (IC 95%: 1,7-15,3)) [112].
Par conséquent, les patients présentant une intubation prolongée prévue bénéficieraient d'une trachéotomie pratiquée au cours de la première semaine d'intubation.
64
65
Les progrès et le développement des technologies appliquées en médecine en général et en réanimation en particulier ont permis d’améliorer le taux de survie des patients sédatés.
Parmi les techniques couramment utilisées en service de réanimation figure le VM, Le nombre de patients nécessitant une ventilation mécanique (VM) a ainsi considérablement augmenté.
Toutefois l’augmentation de la durée de ventilation mécanique (VMP) prédispose les patients à de nombreuses complications et s’accompagne d’une augmentation de la morbi-mortalité post-sevrage. Ainsi une évaluation précise de la situation du patient candidat à une VMP est indispensable.
Cette présente étude, réalisée sur 219 dossiers de patients ayant séjournés au service de réanimation chirurgicale de l’Hôpital Militaire d’Instruction Mohammed V de Rabat, a eu pour objectif d’identifier les facteurs prédictifsde la nécessité d’une mise sous VMP. Ainsi, dans un premier temps, l’incidence de la VMP a été évaluée et l’impact des différents facteurs de risque été étudié.
Lesfacteursqui ont fourni une excellentevaleur prédictive (P<0,05) de la durée de ventilation mécanique (VM) ont été : Motif d’hospitalisation, Indication à la VM, Score APACHE II. Ces résultats
En parcourant les différentes études faites dans ce sens, nous avons constaté une similarité des résultats pour plusieurs facteurs. La divergence des résultats pour certaines variables peut être expliqué par l’hétérogénéité des populations étudiées.
66
67
RÉSUMÉ
Titre: Les facteurs prédictifs de la ventilation mécanique prolongée.
Auteur : EL OUARIACHI YOUSRA
Mots-clés : Ventilation mécanique prolongée ; facteurs prédictifs ; réanimation.
Introduction: La Ventilation mécanique prolongée (VMP) prédispose les patients à de
nombreuses complications et s’accompagne d’une augmentation de la morbi-mortalité. L’objectif de notre étude est de tenter de prédire les patients candidats à une ventilation mécanique prolongée.
.Matériel et méthodes : Il s’agit d’une étude rétrospective de type analytique, avec revue de littérature, menée sur une période de 18 mois incluant tous les patients admis en réanimation chirurgicale de l’HMIMV-Rabat ayant eu une ventilation de plus de 48 heures, entre Janvier 2016 et Mai 2017. Les patients ont été répartis en 2 groupes ceux qui ont dépassé 7 jours de ventilation mécanique et ceux qui n’ont pas dépassé 7 jours de ventilation mécanique.
Résultats : Durant cette période, 219 malades répondaient aux critères d’inclusions, soit une
incidence globale de 70 %. Près de 29% des patients ont nécessité une ventilation mécanique supérieure à 7 jours. Les variables fortement associées à la ventilation mécanique prolongée étaient les suivantes : le motif d’hospitalisation dominé par la pathologie traumatique ; l’indication de la ventilation mécanique ;score APACHE II. L’âge et le sexe étaient des facteurs indépendants à la VMP.
Conclusion : A l’issue de notre travail et des autres études faites dans ce sens, isolement les
données de séjour ne peuvent prédire la durée de ventilation mais ensemble ils peuvent définir les groupes à risque d’une VMP.
68
ABSTRACT
Title: Predictive factors of prolonged mechanical ventilation. Author: EL OUARIACHI YOUSRA
Keywords: Prolonged mechanical ventilation; predictive factors; resuscitation.
Introduction: Prolonged Mechanical Ventilation (PMV) predisposes patients to many
complications and is accompanied by an increase in morbidity and mortality. The aim of our study is to try to predict patients who are candidates for prolonged mechanical ventilation.
Material and methods: This is a retrospective study of the analytical type, with review of the literature, conducted over a period of 18 months, including all patients admitted to
HMIMV-Rabat surgical ICU who were under ventilation for more than 48 hours, between January 2016
and May 2017. Patients were divided into 2 groups: those who exceeded 7 days of mechanical ventilation and those who did not exceed 7 days of mechanical ventilation.
Results: During this period, 219 patients met the inclusion criteria, an overall incidence of
70%. Almost 29% of patients required mechanical ventilation more than 7 days. The variables strongly associated with prolonged mechanical ventilation were as follows: the pattern of hospitalization dominated by traumatic pathology; indication of mechanical ventilation; APACHE II. Age and sex were independent factors of PMV.
Conclusion: From our study and other studies done in this direction, isolation of the residence data cannot predict the duration of ventilation but together they can define the risk groups of a VMP.
69
صخلم
ناونعلا : ةيؤبنتلا لماوعلا ددمملا يعانطصلاا سفنتلا
فلؤملا
:
ىرسي
يشايرولا
ةيساسلأا تاملكلا
:
يعانطصلاا سفنتلا
ددمملا
,
ةيؤبنتلا لماوعلا
;
شاعنإ
.
ةمدقم
:
وط يعانطصلاا سفنتلا
دملأا لي
ضرعي
اھقفاريو تافعاضملا نم ديدعلل ىضرملا
ملأاب ةباصلإا تلادعم يف ةدايز
تايفولاو ضار
.
ؤبنتلا ةلواحم وھ انتسارد نم فدھلا
نيحشرملا ىضرملاب
ددمملا يعانطصلاا سفنتلا
.
قرطلاو داوملا
:
ىرخأ ثاحبأو تاسارد ضارعتسا عم ةيليلحت ةيداعتسإ ةساردب رملأا قلعتي
ةرتف للاخ تيرجأ
18
يحارجلا شاعنلإا ةحلصم اوجلو نيذلا ىضرملا عيمجل ، اًرًھش
ىفشتسملاب
رياني نيب ام ةدتمملا ةرتفلا يف طابرلاب سماخلا دمحم يساردلا يركسعلا
2016
رايأو
2017
سفنتلا نم اودافتسا نيذلاو
يعانطصلاا
نم رثكلأ
48
، ةعاس
ميسقت مت
اوزواجت نيذلا كئلوأ نيتعومجم ىلإ ىضرملا
7
نم مايأ
سفنتلا
يعانطصلاا
نيذلا كئلوأو
زواجتت مل
7
نم مايأ
سفنتلا
لاا
يعانطص
.
جئاتنلا
: :
اقبط
ا
تانريياعمل
لوبقم
للاخ ،
هذھ
ةرتفلا
،
219
ًاضيرم
يأ
ةبسنب
70
مھنم ٪
ام
نم برقي
%29
نوجاتحي
ىلإ
سفنت
يعانطصا
ٍةدمل
نم رثكأ
7
مايأ
.
تاريغتملا تناك
ةوقب ةطبترملا
ددمملا يعانطصلاا سفنتلاب
يلاتلا وحنلا ىلع
:
ببس
ھيلع نميھي ءافشتسلاا
ا
ىضرم
ثداوحلا
,
ةراشإ
يعانطصلاا سفنتلا
,
APACHE II
.
نلاماع سنجلاو رمعلا
نع نلاقتسم
ددمملا يعانطصلاا سفنتلا
ةصلاخلا
:
انجتنتسا
نم
هاجتلاا اذھ يف تيرجأ يتلا ىرخلأا تاساردلاو انلمع
,
نأ
لك
لماع
ىلع
ادح
نكميلا
نأ
أبنتي
ةدمب
ًاعم نكل يعانطصلاا سفنتلا
مھنكمي
ديدحت
لا
تاعومجم
ةضرعملا
ديدمتل
يعانطصلاا سفنتلا
70
ANNEXE 1
Fiche d’exploitation
Nom………..…prénom………… Service d’origine Date d’admission à l’hôpital : ………
Le motif d'hospitalisation :... Date d’admission en réa :……… Date de sortie de réa Age………....….sexe………
TERRAIN Les antécédents et comorbidités Le service d'origine : le motif d'hospitalisationle score de gravité APACHE II Indication de la VM Trachéotomie :
Durée de ventilation mécanique
EVOLUTION
Durée de séjour : ………. Si décès :date ... cause………
71
72
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73
74
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