如何判讀重癥患者新發(fā)發(fā)熱？ppt課件

1、How to evaluation of new fever in ICU, Infection or not?Shuhua Wu MD&PH.DICU 2nd affiliated hospital of Soochow University OGrady NP, Crit Care Med. 2021 Apr;36(4):1330-49.Nosocomial infection(醫(yī)院感染) 國外：Hospital associated infection，Hospital acquired infection，Hospital infection，Nosocomial infect

2、ion等。目前常用的是后三者； 國內(nèi)，曾先用過“醫(yī)學(xué)性感染，“醫(yī)院獲得性感染，“醫(yī)院內(nèi)感染等，近年來逐漸一致稱為“醫(yī)院感染。2022-2-183Anywhere- when do you touch? Anywhere- when do you touch? 2022-2-184普通共識：1醫(yī)院感染應(yīng)以住院病人作為主要分析判別的對象。在實(shí)踐中，以在醫(yī)院感染發(fā)生率進(jìn)展統(tǒng)計(jì)。只需明確根聽闡明系在住院期間感染而出院后才出現(xiàn)病癥的，才干將其列入。2醫(yī)院感染的統(tǒng)計(jì)，不包括病人在入院前已開場或入院時(shí)已處于埋伏期的感染。假設(shè)病人這次住院前和入院后的感染是在前次住院期間所得，亦列為醫(yī)院感染。由于埋伏期幅度多有

3、變化值，尤其是埋伏期不明者而難于確定時(shí)，在統(tǒng)計(jì)時(shí)，以入院后48小時(shí)內(nèi)發(fā)生的，列為醫(yī)院感染。3確以為醫(yī)院感染者，應(yīng)有診斷的根據(jù)，并按一致的規(guī)范作出診斷。Whats Nosocomial infection？2022-2-185衛(wèi)生部部長令衛(wèi)生部部長令配套的技術(shù)性規(guī)范文件配套的技術(shù)性規(guī)范文件 衛(wèi)生部衛(wèi)生部 組織、管理 教育與培訓(xùn) 監(jiān)測、報(bào)告與反響 突發(fā)醫(yī)院感染事件的報(bào)告與處置 醫(yī)院感染流行迸發(fā)的報(bào)告與處置 醫(yī)院的消毒與隔離 醫(yī)院一次性用品的管理 抗菌藥物合理運(yùn)用的管理Fever Evaluation Measuring Body Temperature and Defining Fever as

4、Thresholds for Diagnostic Effort. Recommendations for Measuring Temperature1. Choose the most accurate and reliable method to measure temperature based on the clinical circumstances of the patient. Temperature is most accurately measured by an intravascular, esophageal, or bladder thermistor, follow

5、ed by rectal, oral, and tympanic membrane measurements, in that order (Table 2). Axillary measurements, temporal artery estimates, and chemical dot thermometers should not be used in the ICU (level 2). Rectal thermometers should be avoided in neutropenic patients (level 2).Recommendations for Measur

6、ing Temperature-1Recommendations for Measuring Temperature-22. Any device used to measure temperature must be maintained and calibrated appropriately, using the manufacturers guidelines as a r eference(level 2).3. Any device used to measure temperature must be used in a manner that does not facilita

7、te spread of pathogens by the i nstrument or the operator(level 2).4. The site of temperature measurement should be recorded with the temperature in the chart (level 1).5. A new onset of temperature of 38.3C is a reasonable trigger for a clinical assessment but not necessarily a laboratory or radiol

8、ogic evaluation for infection (level 3).6. A new onset of temperature of 36.0C in the absence of a known cause of hypothermia (e.g., hypothyroidism, cooling blanket, etc.) is a reasonable trigger for a clinical assessment but not necessarily a laboratory or radiologic evaluation for infection(level

9、3).7. Critical care units could reduce the cost of fever evaluations by eliminating automatic laboratory and radiologic tests for patients with new temperature elevation (level 2). Instead, these tests should be ordered based onclinical assessment. A clinical and labo-ratory evaluation for infection

10、, con-versely, may be appropriate in euther-mic or hypothermic patients, depending on clinical presentation.Recommendations for Measuring Temperature-3Blood Cultures Blood culture system Recommendations for Obtaining Blood CulturesBlood culture systemRecommendations for Obtaining Blood Cultures-11.

11、Obtain three to four blood cultures within the first 24 hrs of the onset of fever. Every effort must be made to draw the first cultures before the initiation of antimicrobial therapy. They can be drawn consecutively or simultaneously, unless there is suspicion of an endovascular infection, in which

12、case separate venipunctures by timed intervals can be drawn to demonstrate continuous bacteremia(level 2).2. Additional blood cultures should be drawn thereafter only when there is clinical suspicion of continuing or recurrent bacteremia or fungemia or for test of cure, 48 96 hrs after initiation of

13、 appropriate therapy for bacteremia/fungemia. Additional cultures should not be drawn as a single specimen but should always be paired (level 2). Recommendations for Obtaining Blood Cultures-23. For patients without an indwelling vascular catheter, obtain at least two blood cultures using strict ase

14、ptictechnique from peripheral sites by separate venipunctures after appropriate disinfection of the skin (level 2).4. For cutaneous disinfection, 2% chlorhexidine gluconate in 70% isopropyl alcohol is the preferred skin antiseptic, but tincture of iodine is equally effective. Both require 30 secs of

15、 drying time before proceeding with the culture procedure. Povidone iodine is an acceptable alternative, but it must be allowed to dry for 2 mins (level 1).Recommendations for Obtaining Blood Cultures-35. The injection port of the blood culture bottles should be wiped with 70 90% alcohol before inje

16、cting the blood sample into the bottle to reduce the risk of introduced contamination (level 3).6. If the patient has an intravascular catheter, one blood culture should be drawn by venipuncture and at leastone culture should be drawn through an intravascular catheter. Obtaining blood cultures exclu

17、sively throughintravascular catheters yields slightly less precise information than information obtained when at least oneculture is drawn by venipuncture (level 2).Recommendations for Obtaining Blood Cultures-47. Label the blood culture with the ex-act time, date, and anatomic site from which it wa

18、s taken (level 2).8. Draw 20 30 mL of blood per culture (level 2).9. Paired blood cultures provide more useful information than single blood cultures. Single blood cultures are not recommended, except in neonates (level 2). 10. Once blood cultures have been obtained after the onset of new fever, add

19、itional blood cultures should beordered based on clinical suspicion of continuous or recurrent bacteremia or fungemia (level 2).Intravascular Devices and Fever Recommendations for Management of Intravascular CathetersRecommendations for Management of Intravascular Catheters-11. Examine the patient a

20、t least daily for inflammation or purulence at the exit site or along the tunnel, and assess the patient for signs of venous thrombosis or evidence of embolic phenomena (level 2).2. Any expressed purulence from the insertion site should be Gram stained and cultured (level 2).3. If there is evidence

21、of a tunnel infection, embolic phenomenon, vascular compromise, or septic shock, thecatheter should be removed and cultured and a new catheter inserted at a different site (level 2).4. With short-term temporary cathetersperipheral venous catheters,noncuffed central venous catheters, or arterial cath

22、etersif catheter-related sepsis (i.e., source of the infection is a colonized catheter) is considered likely, the suspect catheter or catheters should be removed and a catheter segment cultured. Blood cultures should be obtained as well. With all short-term catheters, a 5- to 7-cm intracutaneous seg

23、ment should be cultured to document the source of bacteremia; with short peripheral venousor arterial catheters, the tip should be cultured; with longer central venous catheters, the intracutaneous segmentand tip should be cultured; and with pulmonary artery catheters, the introducer and the pulmona

24、ry artery catheter should be cultured (level 1).Recommendations for Management of Intravascular Catheters-25. At least two blood cultures should be obtained. At least one blood culture should be obtained peripherally by venipuncture. One specimen should be obtained from the suspected catheter (level

25、 1). If a quantitative culture system is available, it should be used to diagnose the catheter as the source of bacteremia/fungemia. Alternatively,differential time to positivity can be used if both blood cultures are positive for the same organism. The distal port is the logical port from which to

26、draw cultures. When short-term, uncuffed central venous catheters are suspected of infection, it is usually more efficient to remove the existing catheter and replace it than to draw quantitative cultures (level 2).Recommendations for Management of Intravascular Catheters-26. Do not routinely cultur

27、e all catheters removed from ICU patients. Culture only those catheters suspected of being the source of infection (level 2).7. It is not necessary to routinely cultureinfusate specimens as part of the evaluation for catheter-related infections, unless there is clinical suspicion for infected infusa

28、te or blood products (level 2).Recommendations for Management of Intravascular Catheters-3Pulmonary Infections and ICU-Acquired PneumoniaRecommendations for Evaluation of Pulmonary Infections. -If a febrile patient is suspected of having a lower respiratory tract infection by clinical or radiographi

29、c assessment:Recommendations for Evaluation of Pulmonary Infections-1 1 . A chest imaging study should be obtained. In most cases, an upright portable anteroposterior chest radiograph is the most feasible study to obtain. Posterior-anterior chest radiographs with lateral view or CT scan offer more i

30、nfor-mation and should be obtained when clinically indicated, especially to rule out opportunistic infections in immu-nocompromised patients (level 1).2. Obtain one sample of lower respira-tory tract secretions for direct exami-nation and culture before initiation of or change in antibiotics. Expect

31、orated sputum, induced sputum, tracheal se-cretions, or bronchoscopic or nonbron-choscopic alveolar lavage material can be used effectively. Recommendations for Evaluation of Pulmonary Infections-2 If pneumonia is documented by physical examinationand radiographic evaluation, a deci-sion to employ b

32、ronchoscopy or other invasive diagnostic approaches should be considered based on an individualbasis and the availability of local ex-pertise (level 2).3. Respiratory secretions obtained for microbiological evaluation should be transported to the laboratory and pro-cessed in 2 hrs (level 2).4. Respi

33、ratory secretions that are judged to be appropriate samples by the laboratory should be evaluated by Gram-negative stain and cultured for routine aerobic and facultative bacteria. Recommendations for Evaluation of Pulmonary Infections-3 Additional stains, rapid tests, cultures, and other tests shoul

34、d be performed as epidemiologically appropriate (level 2).5. Quantitative cultures can provide useful information in certain patient populations laboratories; however, quantitative cultures have not yet been sufficientlystandardized nor have they been shown to alter outcome for this technique to be

35、considered part of routine evaluation (level 2).6. Pleural fluid should be obtained with ultrasound guidance for Gram-negative stain and routine culture (withother studies as clinically indicated) if there is an adjacent infiltrate or another reason to suspect infection and the fluidcan be safely as

36、pirated (level 2).Stool Evaluation in the FebrilePatient in the ICURecommendations for Evaluation of the Gastrointestinal Tract. -If more than two stools per day conform to the con-tainer in which they are placed in a patient at risk for C. difficileand if clinical evaluation indicates that a labora

37、tory evaluation is necessary:Recommendations for Evaluation of the Gastrointestinal Tract-1Send one stool sample for C. difficile common antigen, EIA for toxin A and B, or tissue culture assay (level 2).2. If the first specimen for C. difficile is negative and testing is performed by an EIA method,

38、send an additional sample for C. difficile EIA evaluation. A second specimen is not necessary if the common antigen test was negative (level 2).3. If severe illness is present and rapid tests for C. difficile are negative or unavailable, consider flexible sigmoidoscopy (level 3).4. If severe illness

39、 is present, consider empirical therapy with vancomycin while awaiting diagnostic studies. Empirical therapy is not generally recommended if two stool evaluations are negative using a reliable assay. Although it may be more cost-effective than making the diagnosis, the empirical use of antibiotics,

40、especially vancomycin, is discouraged because of the risk of producing resistant pathogens (level 2).5. Stool cultures for other enteric pathogens are rarely indicated in a patient who did not present to the hospitalwith diarrhea or in patients who are not HIV infected. Recommendations for Evaluatio

41、n of the Gastrointestinal Tract-2Send stool cultures for other enteric pathogens and examine for ova and parasites only if epidemiologically appropriate or evaluating an immunocompromised host (level 2).6. Test stool for norovirus if the clinical and epidemiologic setting is appropriate. Testing for

42、 norovirus is usually only available in state laboratories and is usually performed in outbreak settings. Obtain consultation with infection control and public health authorities (level 3).Recommendations for Evaluation of the Gastrointestinal Tract-3Urinary Tract InfectionRecommendations for Evalua

43、tion of the Urinary TractRecommendations for Evaluation of the Urinary Tract-11. For patients at high risk for urinary tract infection (kidney transplant patients, granulocytopenic patients, or patients with recent urologic surgery or obstruction), if clinical evaluation suggests a patient may have

44、symptomatic urinary tract infection, a laboratory evaluation is necessary. Obtain urine for microscopic exam, Gram-negative stain, and culture (level 2).2. Patients who have urinary catheters in place should have urine collected from the sampling port of the catheter and not from the drainage bag (l

45、evel 2).Recommendations for Evaluation of the Urinary Tract-23. Urine should be transported to the laboratory and processed within 1 hr to avoid bacterial multiplication. Iftransport to the laboratory will be delayed for 1 hr, the specimen should be refrigerated. Alternatively, a preservative could

46、be used but is less preferable to refrigeration (level 2).4. Cultures from catheterized patients showing 103 cfu/mL represent true bacteriuria or candiduria, but neither higher counts nor the presence of pyuria alone are of much value in determining if the catheter-associated bacteriuria or candidur

47、ia is the cause of a patients fever; in most cases, it is not the cause of fever (level 1).Recommendations for Evaluation of the Urinary Tract-35. Gram stains of centrifuged urine will reliably show the infecting organisms and can aid in the selection of anti-infective therapy if catheter-associated

48、 urosepsis is suspected (level 1).6. Rapid dipstick tests are not recommended for patients with urinary catheters in the analysis of possible catheter-associated infection (level 1).Sinusitis Recommendations for Evaluation of the SinusesRecommendations for Evaluation of the Sinuses1. If clinical eva

49、luation suggests that sinusitis may be a cause of fever, a CT scan of the facial sinuses should be obtained (level 2).2. If the patient has not responded to empirical therapy, puncture and aspiration of the involved sinuses underantiseptic conditions should be performed (level 2).3. Aspirated fluid

50、should be sent for Gram-negative stain and culture for aerobic and anaerobic bacteria and fungi to determine the causative pathogen and its antimicrobial susceptibility (level 1).Postoperative Fever Recommendations for Evaluation of Fever Within 72 Hours of SurgeryRecommendations for Evaluation of F

51、ever Within 72 Hours of Surgery-11. A chest radiograph is not mandatory during the initial 72 hrs postoperatively if fever is the only indication (level 3).2. A urinalysis and culture are not mandatory during the initial 72 hrs post-operatively if fever is the only indication. Urinalysis and culture

52、 should be performed for those febrile patients having indwelling bladder catheters for 72 hrs (level 3).3. Surgical wounds should be examined daily for infection. They should not be cultured if there is no symptom orsign suggesting infection (see below) (level 2).4. A high level of suspicion should

53、 be maintained for deep venous thrombosis, superficial thrombophlebitis, andpulmonary embolism, especially in patients who are sedentary, have lower limb immobility, have a malignantneoplasm, or are taking an oral contraceptive (level 2).Recommendations for Evaluation of Fever Within 72 Hours of Sur

54、gery-2Surgical Site Infections Recommendations for Evaluation of Surgical Site InfectionRecommendations for Evaluation of Surgical Site Infection-11. Examine the surgical incision at least once daily for erythema, purulence, or tenderness as part of the fever evaluation (level 2).2. If there is susp

55、icion of infection, the incision should be opened and cultured (level 2).3. Gram-negative stain and cultures should be obtained from any expressed purulence obtained from levels withinthe incision consistent with a deep incisional or organ/space surgical site infection. Tissue biopsies or aspirates

56、are preferable to swabs (level 3).4. Drainage from superficial surgical site infections may not require Gram-negative stain and culture because incision, drainage, and local care may be sufficient treatment and antibiotic therapy may not be required. Superficial swab cultures are likely to be contam

57、inated with commensal skin flora and are not recommended (level 2).5. Standard guidelines should be used to define burn wound infection (level 3).Recommendations for Evaluation of Surgical Site Infection-2Central Nervous System Infection Recommendations for Evaluation of Central Nervous System Infec

58、tionsRecommendations for Evaluation of Central Nervous System Infections-11. If altered consciousness or focal neurologic signs are unexplained, lumbar puncture should be considered in anypatient with a new fever, unless there is a contraindication to lumbar puncture (level 3).2. For a patient with

59、a new fever and new focal neurologic findings suggesting disease above the foramen magnum,an imaging study is usually required before lumbar puncture. If a mass is present, neurology/neurosurgery consultation is required to determine the optimal diagnostic approach (level 2).3. In febrile patients w

60、ith an intracranial device, CSF should be obtained for analysis from the CSF reservoir. IfCSF flow to the subarachnoid space is obstructed, it may be prudent to also obtain CSF from the lumbar space(level 3).4. In patients with ventriculostomies who develop stupor or signs of meningitis, the catheter sh