经皮中心静脉置管感染预防指南(课件）

经皮中心静脉置管感染预防指南,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。,Insert catheters at the subclavian venous site,The risk of catheter-related infection is lower with subclavian catheterization than with internal jugular or femoral catheterization 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,Use maximal sterile-barrier precautions during catheter insertion,Use of a mask, cap, sterile gown, sterile gloves, and large sterile drape reduces the rate of infections and reduces costs 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。,Avoid the use of antibiotic ointments,The application of antibiotic ointments increases the rate of colonization by fungi, promotes the development of antibiotic-resistant bacteria, and has not been shown to affect the risk of catheterrelated bloodstream infections 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,Disinfect catheter hubs,Catheter hubs are common sites of catheter contaminatio 导管活栓是导管污染的常见部位,Do not schedule routine catheter changes,Scheduled, routine replacement of central venous catheters at a new site does not reduce the risk of catheter-related bloodstream infection; scheduled, routine exchange of catheters over a guide wire is associated with a trend toward increased catheterrelated infections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。,Remove catheters when they are no longer needed,The probability of colonization and catheter-related bloodstream infection increases over time 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。,Types of Catheter-Associated Infections,Catheter colonization导管细菌定殖 Growth of organisms from a catheter segment by either semiquantitative or quantitative culture 通过半定量或定量培养，使导管片段的微生物生长Catheter-related bloodstream infection导管相关的血流感染 Isolation of the same organism from a blood culture and from a semiquantitative or quantitative culture of a catheter segment, accompanied by clinical symptoms of bloodstream infection without any other apparent source of infection 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-site infection出口感染 Erythema, tenderness, induration, or purulence within 2 cm of the exit site of the catheter 在导管出口2cm范围内出现红肿、触痛、硬结或化脓,Management of Suspected Catheter-Related Bloodstream Infection,Sepsis is defined as a systemic response to infection, manifested by two or more of the following conditions: temperature above 38.5C or below 36.0C; heart rate above 90 beats per minute; respiratory rate above 20 breaths per minute or partial pressure of arterial carbon dioxide below 32 mm Hg; and white-cell count greater than 12,000 per cubic millimeter or less than 4000 per cubic millimeter or with 10 percent immature (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。,Management of Suspected Catheter-Related Bloodstream Infection,Septic shock is defined as sepsis-induced hypotension or a requirement for vasopressors or inotropic agents to maintain blood pressure despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include (but are not limited to) lactic acidosis, oliguria, or acute alteration in mental status. 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,Management of Suspected Catheter-Related Bloodstream Infection,When blood cultures are obtained, samples from peripheral sites are preferred. Cathetertip cultures should be performed by the semiquantitative or quantitative technique. 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。,Management of Suspected Catheter-Related Bloodstream Infection,Empirical antibiotic therapy for suspected catheter-related bloodstream infection should include vancomycin. Antibiotics that are effective against gram-negative organisms should be added, especially if the patient is immunocompromised or has neutropenia, is infected with gram-negative organisms, or has other risk factors for infection with gram-negative organisms. In patients with a catheter-related bloodstream infection, treatment for more than 14 days is indicated in patients with endocarditis (duration of treatment, 4 to 6 weeks) or Staphylococcus aureus bacteremia (2 to 3 weeks).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,Guidelines for the Prevention of Intravascular Catheter Related Infections,Clinical Infectious Diseases2002;35:1281-1307,MMWR 2002;51(No.RR-10):1-29,Eliminating catheter-related bloodstream infections in the intensive care unit.,Crit Care Med 2004; 32(10): 2014-2020,这是一篇由John Hopkins Hospital的ICU团队.利用一些实际的intervention将practice guidelines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CVC cathe