经皮中心静脉置管感染预防指南.ppt

经皮中心静脉置管感染预防指南,梁大伟天坛医院神经内科2005.8.20,导管相关感染的诊断定义,局部感染定义：（1）局部自发或经触压后有脓性渗出，无需细菌学证据。（2）穿刺部位的红肿、发热、硬结（三者中任两者），及血清样物质自发或触压后渗出，穿刺部位细菌培养阳性。,导管相关感染的诊断定义,菌血症感染的定义：（1）外周血培养结果阳性，且为一种微生物，导管片段（近端或远端）经定量或半定量方法分离出同一种微生物（种类及耐药谱），无其它感染源。（2）导管内回抽血定量培养出10倍于同时外周血培养的菌株。（3）导管穿刺部位渗出的脓液、血清、血浆样物质或导管皮下部分、皮下埋植部分培养与外周血培养出同一种细菌（种类及耐药谱）。,导管相关感染的诊断定义,可能感染的定义包括：（1）两次或两次以上血培养（无论是外周血还是中心静脉回抽血）出同一种细菌（种类及耐药谱），且临床及实验室证实无其它感染源。（2）一次阳性血培养结果为或念球菌（无论是外周血还是中心静脉回抽血），且临床及实验室证实无其它感染源。（3）免疫抑制或粒细胞减少（粒细胞2%使用涂有抗菌素的导管减少导管相关的血流感染，当导管相关血流感染2%时减少花费。,Insertcathetersatthesubclavianvenoussite,Theriskofcatheter-relatedinfectionislowerwithsubclaviancatheterizationthanwithinternaljugularorfemoralcatheterization锁骨下静脉置管的导管相关感染风险小于颈内静脉或股静脉置管,Usemaximalsterile-barrierprecautionsduringcatheterinsertion,Useofamask,cap,sterilegown,sterilegloves,andlargesteriledrapereducestherateofinfectionsandreducescosts戴口罩、帽子、无菌手套，穿无菌衣，覆盖无菌大单等能减少感染发生率，降低花费。,Avoidtheuseofantibioticointments,Theapplicationofantibioticointmentsincreasestherateofcolonizationbyfungi,promotesthedevelopmentofantibiotic-resistantbacteria,andhasnotbeenshowntoaffecttheriskofcatheterrelatedbloodstreaminfections使用抗生素软膏增加真菌定殖率，增加耐药菌的产生，并不能降低导管相关血流感染的发生率,Disinfectcatheterhubs,Catheterhubsarecommonsitesofcathetercontaminatio导管活栓是导管污染的常见部位,Donotscheduleroutinecatheterchanges,Scheduled,routinereplacementofcentralvenouscathetersatanewsitedoesnotreducetheriskofcatheter-relatedbloodstreaminfection;scheduled,routineexchangeofcathetersoveraguidewireisassociatedwithatrendtowardincreasedcatheterrelatedinfections有计划的、常规的CVC更换到新位置并不能降低导管相关血流感染的发生率；有计划的、常规的导丝引导下的导管更换有可能增加导管相关感染。,Removecatheterswhentheyarenolongerneeded,Theprobabilityofcolonizationandcatheter-relatedbloodstreaminfectionincreasesovertime随着时间推移，细菌定殖和导管相关血流感染的可能性增大。,TypesofCatheter-AssociatedInfections,Cathetercolonization导管细菌定殖Growthoforganismsfromacathetersegmentbyeithersemiquantitativeorquantitativeculture通过半定量或定量培养，使导管片段的微生物生长Catheter-relatedbloodstreaminfection导管相关的血流感染Isolationofthesameorganismfromabloodcultureandfromasemiquantitativeorquantitativecultureofacathetersegment,accompaniedbyclinicalsymptomsofbloodstreaminfectionwithoutanyotherapparentsourceofinfection血培养分理出的细菌与导管片段半定量或定量培养得到的细菌相同，并伴有血流感染的临床症状，而没有其它明显的感染源。Exit-siteinfection出口感染Erythema,tenderness,induration,orpurulencewithin2cmoftheexitsiteofthecatheter在导管出口2cm范围内出现红肿、触痛、硬结或化脓,ManagementofSuspectedCatheter-RelatedBloodstreamInfection,Sepsisisdefinedasasystemicresponsetoinfection,manifestedbytwoormoreofthefollowingconditions:temperatureabove38.5Corbelow36.0C;heartrateabove90beatsperminute;respiratoryrateabove20breathsperminuteorpartialpressureofarterialcarbondioxidebelow32mmHg;andwhite-cellcountgreaterthan12,000percubicmillimeterorlessthan4000percubicmillimeterorwith10percentimmature(band)forms.脓毒症是指感染的全身反应，具有下列两条或两条以上的表现：体温高于38.5度或低于36度；心率高于90次/分；呼吸频率高于20次/分或动脉二氧化碳分压低于32mmHg；白细胞计数超过12000/mm3或低于4000/mm3或幼稚细胞达到10。,ManagementofSuspectedCatheter-RelatedBloodstreamInfection,Septicshockisdefinedassepsis-inducedhypotensionorarequirementforvasopressorsorinotropicagentstomaintainbloodpressuredespiteadequatefluidresuscitation,alongwiththepresenceofperfusionabnormalitiesthatmayinclude(butarenotlimitedto)lacticacidosis,oliguria,oracutealterationinmentalstatus.脓毒症性休克是指脓毒症诱发的低血压或在充分液体复苏下仍需要血管升压药或血管收缩药维持血压，伴有灌注异常，包括（但不限于）乳酸酸中毒、少尿、急性精神状态改变,ManagementofSuspectedCatheter-RelatedBloodstreamInfection,Whenbloodculturesareobtained,samplesfromperipheralsitesarepreferred.Cathetertipculturesshouldbeperformedbythesemiquantitativeorquantitativetechnique.如果做血培养，最好是取周围位点的样本。导管尖培养应当采用定量或半定量方法。,ManagementofSuspectedCatheter-RelatedBloodstreamInfection,Empiricalantibiotictherapyforsuspectedcatheter-relatedbloodstreaminfectionshouldincludevancomycin.Antibioticsthatareeffectiveagainstgram-negativeorganismsshouldbeadded,especiallyifthepatientisimmunocompromisedorhasneutropenia,isinfectedwithgram-negativeorganisms,orhasotherriskfactorsforinfectionwithgram-negativeorganisms.Inpatientswithacatheter-relatedbloodstreaminfection,treatmentformorethan14daysisindicatedinpatientswithendocarditis(durationoftreatment,4to6weeks)orStaphylococcusaureusbacteremia(2to3weeks).怀疑导管相关血流感染时，进行经验性抗生素治疗要包括万古霉素。还要包括能有效对抗革兰氏阴性菌的抗生素，特别是当患者有免疫受损或中性粒细胞减少症时。有的患者至少治疗14天，有心内膜炎时治疗期为4-6周，金黄色葡萄球菌菌血症治疗2-3周。,临床路径,GuidelinesforthePreventionofIntravascularCatheterRelatedInfections,ClinicalInfectiousDiseases2002;35:1281-1307,MMWR2002;51(No.RR-10):1-29,Eliminatingcatheter-relatedbloodstreaminfectionsintheintensivecareunit.,CritCareMed2004;32(10):2014-2020,这是一篇由JohnHopkinsHospital的ICU团队.利用一些实际的intervention将practiceguidelines转换为ICU里面的实际作为.包括每日执行checklist,评估病患需要CVC的indications,建立标准CVCcathet