經(jīng)皮中心靜脈置管感染預(yù)防指南課件

1、經(jīng)皮中心靜脈置管感染預(yù)防指南梁大偉天壇醫(yī)院神經(jīng)內(nèi)科導(dǎo)管相關(guān)感染的診斷定義 局部感染定義：（ 1 ）局部自發(fā)或經(jīng)觸壓后有膿性滲出，無需細菌學(xué)證據(jù)。（ 2 ）穿刺部位的紅腫、發(fā)熱、硬結(jié)（三者中任兩者），及血清樣物質(zhì)自發(fā)或觸壓后滲出，穿刺部位細菌培養(yǎng)陽性。 導(dǎo)管相關(guān)感染的診斷定義菌血癥感染的定義：（ 1 ）外周血培養(yǎng)結(jié)果陽性，且為一種微生物，導(dǎo)管片段（近端或遠端）經(jīng)定量或半定量方法分離出同一種微生物（種類及耐藥譜），無其它感染源。（ 2 ）導(dǎo)管內(nèi)回抽血定量培養(yǎng)出 10 倍于同時外周血培養(yǎng)的菌株。（ 3 ）導(dǎo)管穿刺部位滲出的膿液、血清、血漿樣物質(zhì)或?qū)Ч芷は虏糠?、皮下埋植部分培養(yǎng)與外周血培養(yǎng)出同一種細菌

2、（種類及耐藥譜）。 導(dǎo)管相關(guān)感染的診斷定義可能感染的定義包括：（ 1 ）兩次或兩次以上血培養(yǎng)（無論是外周血還是中心靜脈回抽血）出同一種細菌（種類及耐藥譜），且臨床及實驗室證實無其它感染源。（ 2 ）一次陽性血培養(yǎng)結(jié)果為 或念球菌（無論是外周血還是中心靜脈回抽血），且臨床及實驗室證實無其它感染源。（ 3 ）免疫抑制或粒細胞減少（粒細胞 2% 使用涂有抗菌素的導(dǎo)管減少導(dǎo)管相關(guān)的血流感染，當(dāng)導(dǎo)管相關(guān)血流感染2%時減少花費。Use maximal sterile-barrier precautions during catheter insertionUse of a mask, cap, steri

3、le gown, sterile gloves, and large sterile drape reduces the rate of infections and reduces costs 戴口罩、帽子、無菌手套，穿無菌衣，覆蓋無菌大單等能減少感染發(fā)生率，降低花費。Avoid the use of antibiotic ointmentsThe application of antibiotic ointments increases the rate of colonization by fungi, promotes the development of antibiotic-res

4、istant bacteria, and has not been shown to affect the risk of catheterrelated bloodstream infections 使用抗生素軟膏增加真菌定殖率，增加耐藥菌的產(chǎn)生，并不能降低導(dǎo)管相關(guān)血流感染的發(fā)生率Disinfect catheter hubsCatheter hubs are common sites of catheter contaminatio 導(dǎo)管活栓是導(dǎo)管污染的常見部位Do not schedule routine catheter changesScheduled, routine replac

5、ement 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有計劃的、常規(guī)的CVC更換到新位置并不能降低導(dǎo)管相關(guān)血流感染的發(fā)生率；有計劃的、常規(guī)的導(dǎo)絲引導(dǎo)下的導(dǎo)管更換有可

6、能增加導(dǎo)管相關(guān)感染。Remove catheters when they are no longer neededThe probability of colonization and catheter-related bloodstream infection increases over time 隨著時間推移，細菌定殖和導(dǎo)管相關(guān)血流感染的可能性增大。Types of Catheter-Associated InfectionsCatheter colonization導(dǎo)管細菌定殖 Growth of organisms from a catheter segment by either

7、semiquantitative or quantitative culture 通過半定量或定量培養(yǎng)，使導(dǎo)管片段的微生物生長Catheter-related bloodstream infection導(dǎo)管相關(guān)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 with

8、out any other apparent source of infection 血培養(yǎng)分理出的細菌與導(dǎo)管片段半定量或定量培養(yǎng)得到的細菌相同，并伴有血流感染的臨床癥狀，而沒有其它明顯的感染源。Exit-site infection出口感染 Erythema, tenderness, induration, or purulence within 2 cm of the exit site of the catheter 在導(dǎo)管出口2cm范圍內(nèi)出現(xiàn)紅腫、觸痛、硬結(jié)或化膿Management of Suspected Catheter-Related Bloodstream Infection

9、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

10、white-cell count greater than 12,000 per cubic millimeter or less than 4000 per cubic millimeter or with 10 percent immature (band) forms. 膿毒癥是指感染的全身反應(yīng)，具有下列兩條或兩條以上的表現(xiàn)：體溫高于38.5度或低于36度；心率高于90次/分；呼吸頻率高于20次/分或動脈二氧化碳分壓低于32mmHg；白細胞計數(shù)超過12000/mm3或低于4000/mm3或幼稚細胞達到10。Management of Suspected Catheter-Related

11、Bloodstream InfectionSeptic 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 acidos

12、is, oliguria, or acute alteration in mental status. 膿毒癥性休克是指膿毒癥誘發(fā)的低血壓或在充分液體復(fù)蘇下仍需要血管升壓藥或血管收縮藥維持血壓，伴有灌注異常，包括（但不限于）乳酸酸中毒、少尿、急性精神狀態(tài)改變Management of Suspected Catheter-Related Bloodstream InfectionWhen blood cultures are obtained, samples from peripheral sites are preferred. Cathetertip cultures should be

13、 performed by the semiquantitative or quantitative technique. 如果做血培養(yǎng)，最好是取周圍位點的樣本。導(dǎo)管尖培養(yǎng)應(yīng)當(dāng)采用定量或半定量方法。Management of Suspected Catheter-Related Bloodstream InfectionEmpirical antibiotic therapy for suspected catheter-related bloodstream infection should include vancomycin. Antibiotics that are effective

14、 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 fo

15、r 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).懷疑導(dǎo)管相關(guān)血流感染時，進行經(jīng)驗性抗生素治療要包括萬古霉素。還要包括能有效對抗革蘭氏陰性菌的抗生素，特別是當(dāng)患者有免疫受損或中性粒細胞減少癥時。有的患者至少治療14天，有心內(nèi)膜炎時治療期為4-6周，金黃色葡萄球菌菌血癥治療2-3周。臨床路徑Guidelines for the Preventio

16、n of Intravascular Catheter Related Infections Clinical Infectious Diseases2002;35:1281-1307MMWR 2002;51(No.RR-10):1-29Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004; 32(10): 2014-2020這是一篇由John Hopkins Hospital的ICU團隊.利用一些實際的intervention將practice guidelines轉(zhuǎn)換為ICU里面的實際作為.包括每日執(zhí)行checklist,評估病患需要CVC的indications,建立標(biāo)準(zhǔn)CVC catheterizatio