中心静脉插管相关感染杜斌课件

中心静脉插管相关感染 北京协和医院杜斌 导管相关性感染 流行病学 美国ICU每年16 000例CRBSI病死率18 0 35 每年死亡500 4 000例每例CRBSI医疗费用 28 690 56 000每年费用 60 000 000 460 000 000 CDC MMWR2002 HeiselmanJAMA1994 DimickArchSurg2001 中心静脉插管相关性感染发病率 患者数n 1 098中心静脉插管n 1 263导管留置天n 6 075细菌定植n 333 26 3 CRBSIn 35 2 7 5 9 1 000导管留置天 SafdarN MakiDG Inflammationattheinsertionsiteisnotpredictiveofcatheter relatedbloodstreaminfectionwithshort term noncuffedcentralvenouscatheters CritCareMed2002 30 2632 2635 中心静脉插管相关性感染 定义 明确的导管相关性血行性感染 导管培养阳性 半定量或定量 拔除导管前外周血培养阳性上述培养中分离出相同微生物可能的导管相关性血行性感染 菌血症 插管部位脓性分泌物 或导管接头培养阳性 或导管血培养分离出相当于外周血培养5倍的微生物或培养阳性差异时间2小时 CohenJ Brun BuissonC TorresA JorgensenJ Diagnosisofinfectioninsepsis Anevidence basedreview CritCareMed2004 32 Suppl S466 S494 中心静脉插管相关性感染 定义 非菌血症导管相关性感染导管培养阳性 且为感染来源没有发生菌血症为排除诊断 没有其他能够解释感染的明显病灶 且拔除导管48小时内感染表现缓解 导管局部感染导管培养 半定量或定量 不 伴局部症状 红 痛 没有全身炎症反应 CohenJ Brun BuissonC TorresA JorgensenJ Diagnosisofinfectioninsepsis Anevidence basedreview CritCareMed2004 32 Suppl S466 S494 中心静脉插管相关性感染 定义 中心静脉插管相关性感染 原发性血行性感染 原发病灶不明 中心静脉插管相关感染 Renaud etal AmJRespirCritCareMed2001 163 1584 90 导管定植 单腔vs 多腔 Z rcherM Tram rMR WalderB ColonizationandBloodstreamInfectionwithSingle VersusMulti LumenCentralVenousCatheters AQuantitativeSystematicReview AnesthAnalg2004 99 177 82 CRBSI 单腔vs 多腔 Z rcherM Tram rMR WalderB ColonizationandBloodstreamInfectionwithSingle VersusMulti LumenCentralVenousCatheters AQuantitativeSystematicReview AnesthAnalg2004 99 177 82 CRBSI 单腔vs 多腔 OR 95 CIfixed Single Lumenn N Multi Lumenn N OR 95 CIfixed 13 99 13 1 2 78 2 6 3 88 1 34 11 2 5 61 8 2 5 68 7 4 Clark Christoff Farkas 1 12 0 31 4 07 1 25 4 0 1 25 4 0 Gupta 1 00 0 06 16 5 0 51 0 0 48 0 Johnson n a 4 39 10 3 0 36 0 McCarthy 7 42 1 00 54 9 23 275 8 4 8 255 3 1 Combined 2 58 1 24 5 37 0 1 1 10 Favorsmulti lumen Favorssinglei lumen Z rcherM Tram rMR WalderB ColonizationandBloodstreamInfectionwithSingle VersusMulti LumenCentralVenousCatheters AQuantitativeSystematicReview AnesthAnalg2004 99 177 82 CRBSI 单腔vs 多腔 Z rcherM Tram rMR WalderB ColonizationandBloodstreamInfectionwithSingle VersusMulti LumenCentralVenousCatheters AQuantitativeSystematicReview AnesthAnalg2004 99 177 82 导管定植与感染 单腔vs 多腔 DezfulianC LavelleJ NallamothuBK KaufmanSR SaintS Ratesofinfectionforsingle lumenversusmultilumencentralvenouscatheters Ameta analysis CritCareMed2003 31 2385 2390 导管定植与感染 插管部位的影响 LorenteL VillegasJ MartinMM JimenezA MoraML Catheter relatedinfectionincriticallyillpatients IntensiveCareMed 2004Aug 30 8 1681 4 Epub2004May25 中心静脉插管相关性感染 发病机制 中心静脉插管相关性感染 发病机制 SafdarN MakiDG Thepathogenesisofcatheter relatedbloodstreaminfectionwithnoncuffedshort termcentralvenouscatheters IntensiveCareMed 2004Jan 30 1 62 7 Epub2003Nov26 对照组 治疗组 1 洗必太 75 酒精 含洗必太的敷料 中心静脉插管相关性感染 致病菌 SafdarN MakiDG Inflammationattheinsertionsiteisnotpredictiveofcatheter relatedbloodstreaminfectionwithshort term noncuffedcentralvenouscatheters CritCareMed2002 30 2632 2635 能否依靠临床表现鉴别菌血症 PeduzziP etal PredictorsofbacteremiaandGram negativebacteremiainpatientswithsepsis ArchInternMed1992 152 529 535 能否依靠临床表现鉴别菌血症 PeduzziP etal PredictorsofbacteremiaandGram negativebacteremiainpatientswithsepsis ArchInternMed1992 152 529 535 能否依靠临床表现鉴别CRBSI SafdarN MakiDG Inflammationattheinsertionsiteisnotpredictiveofcatheter relatedbloodstreaminfectionwithshort term noncuffedcentralvenouscatheters CritCareMed2002 30 2632 2635 能否依靠临床表现鉴别CRBSI SafdarN MakiDG Inflammationattheinsertionsiteisnotpredictiveofcatheter relatedbloodstreaminfectionwithshort term noncuffedcentralvenouscatheters CritCareMed2002 30 2632 2635 能否依靠临床表现鉴别CRBSI SafdarN MakiDG Inflammationattheinsertionsiteisnotpredictiveofcatheter relatedbloodstreaminfectionwithshort term noncuffedcentralvenouscatheters CritCareMed2002 30 2632 2635 能否依靠临床表现鉴别导管相关感染 插管部位炎症表现不敏感 多数导管感染并无相应表现 不特异 出现相应表现亦无需拔除导管 提示导管感染的症状和体征插管部位脓性分泌物插管部位蜂窝织炎超过4mm 血培养的临床价值 导管血 BeutzM ShermanG MayfieldJ FraserVJ KollefMH Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients Chest2003 123 854 861 血培养的临床价值 外周血 BeutzM ShermanG MayfieldJ FraserVJ KollefMH Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients Chest2003 123 854 861 血培养的临床价值 导管血vs 外周血 BeutzM ShermanG MayfieldJ FraserVJ KollefMH Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients Chest2003 123 854 861 三腔CVC应当从哪个腔取血 DobbinsBM CattonJA KiteP McMahonMJ WilcoxMH Eachlumenisapotentialsourceofcentralvenouscatheter relatedbloodstreaminfection CritCareMed2003 31 1688 1690 三腔CVC应当从哪个腔取血 在CRBSI的病例 40 的CVC仅一个导管腔有细菌的明显定植随机从一个导管腔留取血培养 阴性结果的可能性为66 2 3 总体而言 对于CRBSI病例 随机从一个导管腔留取血培养 阴性结果可能性为40 60 的机会发现细菌定植 DobbinsBM CattonJA KiteP McMahonMJ WilcoxMH Eachlumenisapotentialsourceofcentralvenouscatheter relatedbloodstreaminfection CritCareMed2003 31 1688 1690 DTD对于诊断CRBSI的意义 目的 证实同时从外周静脉和中心静脉采取的血培养阳性时间差 DTD 对于鉴别CRBSI和非CRBSI的作用设计 前瞻性临床试验研究对象 15个月内总共9例CRBSI和24例非CRBSI GaurAH FlynnPM GianniniMA etal Differenceintimetodetection asimplemethodtodifferentiatecatheter relatedfromnon catheter relatedbloodstreaminfectioninimmunocompromisedpediatricpatients ClinInfectDis 2003Aug15 37 4 469 75 DTD对于诊断CRBSI的意义 结果与非CRBSI相比 CRBSI的DTD显著增加 457vs 4min P 001 采用DTD 120min作为诊断CRBSI的临界值敏感性 88 9 特异性 100 PPV 100 NPV89 96 试验前CRBSI概率28 54 结论 在应用持续读数血培养系统的医院中 DTD是诊断CRBSI的一种简单可靠的方法 GaurAH FlynnPM GianniniMA etal Differenceintimetodetection asimplemethodtodifferentiatecatheter relatedfromnon catheter relatedbloodstreaminfectioninimmunocompromisedpediatricpatients ClinInfectDis 2003Aug15 37 4 469 75 中心静脉插管相关感染 治疗 立即拔除导管选择新的部位插管在原部位经导丝重新置入导管拔除导管进行培养培养阳性时拔除新置入导管应用抗生素 拔除导管实际感染的比例 MerrerJ DeJongheB GolliotF etal 2001 Complicationsoffemoralandsubclavianvenouscatheterizationincriticallyillpatients arandomizedcontrolledtrial JAMA286 700 707 LeonC Alvarez LermaF Ruiz SantanaS etal 2003 Antisepticchamber containinghubreducescentralvenouscatheter relatedinfection aprospective randomizedstudy CritCareMed31 1318 1324 RanucciM IsgroG GiomarelliPP etal 2003 Impactofoligoncentralvenouscathetersoncathetercolonizationandcatheter relatedbloodstreaminfection CritCareMed31 52 59 DobbinsBM CattonJA KiteP etal 2003 Eachlumenisapotentialsourceofcentralvenouscatheter relatedbloodstreaminfection CritCareMed31 1688 1690 DarouicheRO RaadII HeardSO etal 1999 Acomparisonoftwoantimicrobial impregnatedcentralvenouscatheters CatheterStudyGroup NEnglJMed340 1 8 患者发热时能否保留中心静脉导管 RijndersBJ PeetermansWE VerwaestC WilmerA VanWijngaerdenE WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter relatedinfection arandomizedtrial IntensiveCareMed 2004 30 1073 1080 DOI10 1007 s00134 004 2212 x 医生怀疑CRI 计划拔除CVC 研究组 标准治疗组 留取血培养x2 拔除CVC CVC继续留置5天 血培养阳性或血流动力学不稳定 拔除CVC 感染好转 感染持续 保留CVC 血流动力学不稳定 收缩压 90mmHg或较基础值降低40mmHg以上 且无导致低血压的其他原因 平均动脉压 60mmHg需要应用多巴胺或多巴酚丁胺维持血压 或在过去12小时内上述药物剂量增加超过5 g kg min开始应用去甲肾上腺素维持血压 或在过去12小时内上述药物剂量增加超过0 25 g kg min RijndersBJ PeetermansWE VerwaestC WilmerA VanWijngaerdenE WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter relatedinfection arandomizedtrial IntensiveCareMed 2004 30 1073 1080 DOI10 1007 s00134 004 2212 x 患者发热时能否保留中心静脉导管 RijndersBJ PeetermansWE VerwaestC WilmerA VanWijngaerdenE WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter relatedinfection arandomizedtrial IntensiveCareMed 2004 30 1073 1080 DOI10 1007 s00134 004 2212 x 中心静脉插管相关性感染 预防 GuidelinesforthePreventionofIntravascularCatheter RelatedInfections August2002 www cdc govMermelLA PreventionofIntravascularCatheter relatedInfections AnnInternMed2000 132 391 402 中心静脉插管相关性感染 治疗 不符合IDSA治疗指南的比例第一阶段34 24 71 普通病房 23 52 44 明显高于ICU 1 19 5 p 01 第二阶段44 23 52 15 7 46 p 004 RijndersBJA VandecasteeleSJ VanWijngaerdenE DeMunterP PeetermansWE UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter RelatedInfection ABefore AfterStudy ClinicalInfectiousDiseases2003 37 980 3 如何改进依从性 发现CRBSI后 向主治医生发送有关标准化治疗的电子邮件 作为电子病历的一部分 将打印文件放在病房医生的桌上不进行面对面的讨论对于非白色念珠菌引发的CRBSI 建议主治医生找感染科医生会诊以确定个体化治疗方案 RijndersBJA VandecasteeleSJ VanWijngaerdenE DeMunterP PeetermansWE UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter RelatedInfection ABefore AfterStudy ClinicalInfectiousDiseases2003 37 980 3 如何改进依从性 RijndersBJA VandecasteeleSJ VanWijngaerdenE DeMunterP PeetermansWE UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter RelatedInfection ABefore AfterStudy ClinicalInfectiousDiseases2003 37 980 3 中心静脉插管相关感染 宣教 LoboRD LevinAS GomesLMP CursinoR ParkM FigueiredoVB TaniguchiL PolidoCG CostaSF ImpactofaneducationalprogramandpolicychangesondecreasingcatheterassociatedbloodstreaminfectionsinamedicalintensivecareunitinBrazil AmJInfectControl2005 33 83 7 继续教育项目 操作规程标准化 预防策略 5Key BestPractice Issues 拔除不必要的中心静脉插管手部清洁采取最严格的消毒隔离措施应用洗必太进行皮肤消毒避免应用股静脉插管 MMWR 2002 51 RR 10 手部清洁 1977以来 共有7项前瞻性研究显示 改进手部清洁能够显著减少各种感染并发症 Larsen ClinInfectDis1999 29 1287 94Lancet2000 356 1307 1312 最严格的隔离措施 maximalbarrierprecautions 对于医生而言手部清洁非无菌帽子和口罩帽子应覆盖所有头发口罩应当罩紧口鼻无菌手套和隔离衣对于患者而言使用大的无菌铺巾覆盖患者头部和身体 最严格的隔离措施 maximalbarrierprecautions 最严格的隔离措施 MBP 文献回顾 AmJMed1991 91 3B 197S 205SInfectControlHospEpidemiol1994 15 231 8 皮肤消毒 洗必太 AnnInternMed 2002 136 792 801 皮肤消毒 洗必太 AnnInternMed 2002 136 792 801 选择哪个部位进行插管 ICU股静脉和锁骨下静脉插管的RCT145名患者股静脉插管 144名患者锁骨下静脉插管预后股静脉插管组感染并发症更高 19 8 vs4 5 p 001 股静脉插管组血栓并发症更多 21 5 vs 1 9 p 001 完全性血栓栓塞6 vs 0 机械并发症发生率相似 17 3 vs18 8 p NS JAMA2001 286 700 7 ICU医生的依从性 为期2周的观察期对医生设盲26根导管8 31 根新置入中心静脉插管18 69 根通过导丝更换的导管没有紧急插管 BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 ICU医生的依从性 BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 消除CRBSI 医务人员的宣教VAD政策以及网络教育项目www hopkins heic org prevention vad html避免烦琐的准备过程 插管车反复检查每日询问导管是否可以拔除清单观察到医生违反操作规程时 护士有权终止其操作 BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 CRBSI清单 操作前 医生是否 洗手消毒操作部位在无菌情况下铺巾覆盖患者全身操作过程中 医生是否 使用无菌手套 口罩和无菌隔离衣保持无菌区域所有操作辅助人员是否均遵从上述要求 BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 CRBSI BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 CSICUCRBSI 2002 干预措施 NNIS均值 BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 CSICUCRBSI 2002 每年预防43例CRBSI每年减少8例 0 15 患者死亡节约医疗费用 1 945 922 1 483 844 2 408 000 BerenholtzSM PronovostPJ LipsettPA HobsonD EarsingK FarleyJE MilanovichS Garrett MayerE WintersBD RubinHR DormanT PerlTM Eliminatingcatheter relatedbloodstreaminfectionsintheintensivecareunit CritCareMed 2004Oct 32 10 2014 20 CentralLineBundle 手部清洁插管时最严格的隔离措施洗必太皮肤消毒选择适当的插管部位普通中心静脉插管选择锁骨下静脉每日评估留置导管的必要性立即拔除不必要的导管 CentralLineBundle 授权护士强调使用中心静脉清单 以确保与