經(jīng)皮中心靜脈置管感染預(yù)防指南

經(jīng)皮中心靜脈置管感染預(yù)防指南整理課件導(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)?！?〕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。整理課件導(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)定量或半定量方法別離出同一種微生物〔種類及耐藥譜〕，無其它感染源?！?〕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?！?〕導(dǎo)管穿刺部位滲出的膿液、血清、血漿樣物質(zhì)或?qū)Ч芷は戮植俊⑵は侣裰簿植颗囵B(yǎng)與外周血培養(yǎng)出同一種細菌〔種類及耐藥譜〕。整理課件導(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?！?〕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<500ul〕的病人，血培養(yǎng)陽性〔凝固酶陰性的葡萄球菌，桿菌屬，棒狀桿菌屬，糠秕馬拉色霉菌等〕，臨床及實驗室證實無其它細菌感染源，只有中心靜脈留置導(dǎo)管，通常與導(dǎo)管相關(guān)性菌血癥有關(guān)。整理課件CVC引起相關(guān)感染的機制1.infectionoftheexitsite,followedbymigrationofthepathogenalongtheexternalcathetersurface.2.contaminationofthecatheterhub,leadingtointraluminalcathetercolonization.3.hematogenousseedingofthecatheter.

整理課件病原體假設(shè)不幸感染,常見的菌種包括:

Coagulase-negativestaphylococci(37%),Staphylococcusaureus(13%),Enterococcus(13%),Gram-negativerods(14%).值得注意的是,抗藥性強的菌種包括staph.以及Enterococcus都榜上有名..所以如果不幸發(fā)生感染..多半就非得要用上vancomycin..可能不行還要用上linezolid..相當(dāng)?shù)穆闊?.另外一個值得注意的是..fungi..fungi的感染扮演局部角色(在NNIS的數(shù)據(jù)中是8%)..在Candidia的感染中,大約一半是non-albicanspecies造成的...包括C.glabrata與C.krusei..這些fungi對fluconazole容易產(chǎn)生抗藥性.整理課件Guidelinesforpreventinginfectionsassociatedwiththeinsertionandmaintenanceofcentralvenouscatheters

中心靜脈置管相關(guān)性感染的預(yù)防指南JournalofHospitalInfection(2001)47(Supplement):S5–S9整理課件Intervention1:Selectionofcathetertype導(dǎo)管類型的選擇Intervention2:Selectionofcatheterinsertionsite置管點的選擇Intervention3:Optimumaseptictechniqueduringcatheterinsertion置管過程中無菌技術(shù)的最優(yōu)化Intervention4:Cutaneousantisepsis皮膚消毒Intervention5:Catheterandcathetersitecare導(dǎo)管和置管點的護理Intervention6:Replacementstrategies更換方法Intervention7:Antibioticprophylaxis預(yù)防性使用抗生素整理課件Selectionofcathetertype1Useasingle-lumencatheterunlessmultipleportsareessentialforthemanagementofthepatient.盡量采用單腔管，除非患者需要多通道治療，2Iftotalparenteralnutritionisbeingadministered,useonecentralvenouscatheterorlumenexclusivelyforthatpurpose.如果需要TPN，專用一根中心靜脈導(dǎo)管或?qū)Ｓ靡粋€管腔3Useatunnelledcatheteroranimplantablevascularaccessdeviceforpatientsinwhomlong-term(30days)vascularaccessisanticipated.如果預(yù)計要長時間〔30天〕保存血管通路，采用管道式導(dǎo)管或植入式血管通路4Considertheuseofanantimicrobialimpregnatedcentralvenouscatheterforadultpatientswhorequireshort-term(10days)centralvenouscatheterisationandwhoareathighriskforCR-BSI.需短期〔10天〕保存CVC者，并且是導(dǎo)管相關(guān)的血源性感染的高危患者，使用外涂抗菌素的CVC整理課件Selectionofcatheterinsertionsite5Inselectinganappropriateinsertionsite,assesstherisksforinfectionagainsttherisksofmechanicalcomplications.選擇置管位點時，要權(quán)衡感染風(fēng)險和機械并發(fā)癥的風(fēng)險6Unlessmedicallycontraindicated,usethesubclaviansiteinpreferencetothejugularorfemoralsitesfornontunnelledcatheterplacement.做非管道性置管，如無禁忌，采用鎖骨下置管好于頸靜脈或股靜脈置管7Considertheuseofperipherallyinsertedcathetersasanalternativetosubclavianorjugularveincatheterisation.外周靜脈置管可作為鎖骨下置管或頸靜脈置管的替代方法整理課件Optimumaseptictechniqueduringcatheterinsertion8Useoptimumaseptictechnique,includingasterilegown,gloves,andalargesteriledrape,fortheinsertionofcentralvenouscatheters.置管時采用最正確的無菌技術(shù)，穿無菌衣，戴無菌手套，蓋無菌單整理課件Cutaneousantisepsis9CleantheskinsitewithanalcoholicchlorhexidinegluconatesolutionpriortoCVCinsertion.Useanalcoholicpovidone-iodinesolutionforpatientswithahistoryofchlorhexidinesensitivity.Allowtheantiseptictodrybeforeinsertingthecatheter.置管前用含酒精的葡萄糖酸洗必泰清洗穿刺點皮膚，如對碘劑過敏，使用含酒精的聚維酮碘消毒，待消毒劑枯燥后置管10Donotapplyorganicsolvents,e.g.,acetone,ether,totheskinbeforecatheterinsertion.不要使用有機溶劑，如丙酮、乙醚等。11Donotroutinelyapplyantimicrobialointmenttothecatheterplacementsitepriortoinsertion.置管前穿刺點不要使用抗生素軟膏整理課件Catheterandcathetersitecare12Beforeaccessingthesystem,disinfecttheexternalsurfacesofthecatheterhubandconnectionportswithanaqueoussolutionofchlorhexidinegluconateorpovidone-iodine,unlesscontraindicatedbythemanufacturer’srecommendations.接觸前，要用葡萄糖酸洗必泰水溶液或聚維酮碘水溶液消毒導(dǎo)管活栓或接頭的外外表，除非廠家禁止這樣做13Useeitherasterilegauzeortransparentdressingtocoverthecathetersite.用無菌紗布或透明貼膜覆蓋置管點14Ifagauzeandtapecathetersitedressingisused,itmustbereplacedwhenthedressingbecomesdamp,loosened,orsoiled,orwheninspectionoftheinsertionsiteisnecessary.如果是使用紗布和膠布覆蓋的，一旦浸濕、松脫或弄臟，或需要查看穿刺點時，要及時更換。15DonotapplyantimicrobialointmenttoCVCinsertionsitesaspartofroutinecathetersitecare.不要使用抗生素軟膏處理穿刺點。16Routinelyflushindwellingcentralvenouscatheterswithananticoagulantunlessadvisedotherwisebythemanufacturer.常規(guī)使用抗凝劑沖洗置入的CVC，除非廠家有其它建議整理課件Replacementstrategies17Donotroutinelyreplacenon-tunnelledCVCasamethodtopreventcatheter-relatedinfections.不要把常規(guī)更換非管道性CVC作為預(yù)防導(dǎo)管相關(guān)感染的方法18Useguidewireassistedcatheterexchangetoreplaceamalfunctioningcatheter,ortoexchangeanexistingcatheterifthereisnoevidenceofinfectionatthecathetersiteorprovenCR-BSI.借助導(dǎo)絲更換導(dǎo)管。19IfCR-infectionissuspected,butthereisnoevidenceofinfectionatthecathetersite,removetheexistingcatheterandinsertanewcatheteroveraguidewire;iftestsrevealCR-infection,thenewlyinsertedcathetershouldberemovedand,ifstillrequired,anewcatheterinsertedatadifferentsite.如果疑心存在導(dǎo)管相關(guān)的感染，而置管點無明顯的感染跡象，去掉原來的導(dǎo)管，在導(dǎo)絲引導(dǎo)下置入新管；如果檢驗顯示存在導(dǎo)管相關(guān)的感染，去掉新置入的導(dǎo)管，如仍然需要置管，另選穿刺點置入新管。整理課件Replacementstrategies20DonotuseguidewireassistedcatheterexchangeforpatientswithCR-infection.Ifcontinuedvascularaccessisrequired,removetheimplicatedcatheter,andreplaceitwithanothercatheteratadifferentinsertionsite.患者有導(dǎo)管相關(guān)的感染時不采用借助導(dǎo)絲的導(dǎo)管更換。如果必須繼續(xù)保持血管通路，去掉受累導(dǎo)管，另取穿刺點置新管。21Replacealltubingwhenthevasculardeviceisreplaced.更換血管裝置的同時更換所有管路。22Replaceintravenoustubingandstopcocksnomorefrequentlythanat72-hourintervals,unlessclinicallyindicated.更換靜脈內(nèi)管道和活栓的間隔時間不能短于72小時，除非臨床需要。23Replaceintravenoustubingusedtoadministerblood,bloodproducts,orlipidemulsionsattheendoftheinfusionorwithin24hoursofinitiatingtheinfusion.假設(shè)更換用于輸血、血液制品、脂肪乳的靜脈內(nèi)管路，要在輸注末或開始輸注后24小時內(nèi)更換。整理課件Antibioticprophylaxis24Donotadministersystemicantimicrobialsroutinelybeforeinsertionorduringuseofacentralvenouscathetertopreventcathetercolonisationorbloodstreaminfection.不要為了預(yù)防導(dǎo)管細菌生長或血行感染而常規(guī)給予全身應(yīng)用抗菌素，不管是在插管前或在使用CVC中。整理課件PreventingComplicationsofCentralVenous

CatheterizationNEnglJMed2003;348:1123-33.整理課件InterventionstoPreventinfectionsUseantimicrobial-impregnatedcatheters使用外涂抗菌素的導(dǎo)管Insertcathetersatthesubclavianvenoussite取鎖骨下穿刺點置入導(dǎo)管Usemaximalsterile-barrierprecautionsduringcatheterinsertion在導(dǎo)管置入術(shù)中盡最大肯能采取無菌措施Avoidtheuseofantibioticointments防止使用抗生素軟膏Disinfectcatheterhubs消毒導(dǎo)管活栓Donotscheduleroutinecatheterchanges不要常規(guī)更換導(dǎo)管Removecatheterswhentheyarenolongerneeded如果不再需要，撤除導(dǎo)管整理課件Useantimicrobial-impregnatedcathetersTheuseofantimicrobial-impregnatedcathetersreducestheriskofcatheter-relatedbloodstreaminfectionsandreducescostswhentherateofcatheter-relatedbloodstreaminfection>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。整理課件InsertcathetersatthesubclavianvenoussiteTheriskofcatheter-relatedinfectionislowerwithsubclaviancatheterizationthanwithinternaljugularorfemoralcatheterization鎖骨下靜脈置管的導(dǎo)管相關(guān)感染風(fēng)險小于頸內(nèi)靜脈或股靜脈置管整理課件Usemaximalsterile-barrierprecautionsduringcatheterinsertionUseofamask,cap,sterilegown,sterilegloves,andlargesteriledrapereducestherateofinfectionsandreducescosts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。整理課件AvoidtheuseofantibioticointmentsTheapplicationofantibioticointmentsincreasestherateofcolonizationbyfungi,promotesthedevelopmentofantibiotic-resistantbacteria,andhasnotbeenshowntoaffecttheriskofcatheterrelatedbloodstreaminfections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)生率整理課件DisinfectcatheterhubsCatheterhubsarecommonsitesofcathetercontaminatio導(dǎo)管活栓是導(dǎo)管污染的常見部位整理課件DonotscheduleroutinecatheterchangesScheduled,routinereplacementofcentralvenouscathetersatanewsitedoesnotreducetheriskofcatheter-relatedbloodstreaminfection;scheduled,routineexchangeofcathetersoveraguidewireisassociatedwithatrendtowardincreasedcatheterrelatedinfections有方案的、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；有方案的、常規(guī)的導(dǎo)絲引導(dǎo)下的導(dǎo)管更換有可能增加導(dǎo)管相關(guān)感染。整理課件RemovecatheterswhentheyarenolongerneededTheprobabilityofcolonizationandcatheter-relatedbloodstreaminfectionincreasesovertime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。整理課件TypesofCatheter-AssociatedInfectionsCathetercolonization導(dǎo)管細菌定殖Growthoforganismsfromacathetersegmentbyeithersemiquantitativeorquantitativeculture通過半定量或定量培養(yǎng)，使導(dǎo)管片段的微生物生長Catheter-relatedbloodstreaminfection導(dǎo)管相關(guān)的血流感染Isolationofthesameorganismfromabloodcultureandfromasemiquantitativeorquantitativecultureofacathetersegment,accompaniedbyclinicalsymptomsofbloodstreaminfectionwithoutanyotherapparentsourceofinfection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病癥，而沒有其它明顯的感染源。Exit-siteinfection出口感染Erythema,tenderness,induration,orpurulencewithin2cmoftheexitsiteofthecatheter在導(dǎo)管出口2cm范圍內(nèi)出現(xiàn)紅腫、觸痛、硬結(jié)或化膿整理課件ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepsisisdefinedasasystemicresponsetoinfection,manifestedbytwoormoreofthefollowingconditions:temperatureabove38.5°Corbelow36.0°C;heartrateabove90beatsperminute;respiratoryrateabove20breathsperminuteorpartialpressureofarterialcarbondioxidebelow32mmHg;andwhite-cellcountgreaterthan12,000percubicmillimeterorlessthan4000percubicmillimeterorwith10percentimmature(band)forms.膿毒癥是指感染的全身反響，具有以下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或幼稚細胞到達10％。整理課件ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepticshockisdefinedassepsis-inducedhypotensionorarequirementforvasopressorsorinotropicagentstomaintainbloodpressuredespiteadequatefluidresuscitation,alongwiththepresenceofperfusionabnormalitiesthatmayinclude(butarenotlimitedto)lacticacidosis,oliguria,oracutealterationinmentalstatus.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)改變整理課件ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionWhenbloodculturesareobtained,samplesfromperipheralsitesarepreferred.Cathetertipculturesshouldbeperformedbythesemiquantitativeorquantitativetechnique.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。整理課件ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionEmpiricalantibiotictherapyforsuspectedcatheter-relatedbloodstreaminfectionshouldincludevancomycin.Antibioticsthatareeffectiveagainstgram-negativeorganismsshouldbeadded,especiallyifthepatientisimmunocompromisedor