1、中心靜脈插管相關(guān)感染,北京協(xié)和醫(yī)院 杜斌,導(dǎo)管相關(guān)性感染: 流行病學(xué),美國(guó)ICU每年16,000例CRBSI 病死率18% (0 35%) 每年死亡500 4,000例 每例CRBSI醫(yī)療費(fèi)用$28,690 56,000 每年費(fèi)用$60,000,000 460,000,000,CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001,中心靜脈插管相關(guān)性感染發(fā)病率,患者數(shù)n = 1,098 中心靜脈插管n = 1,263 導(dǎo)管留置天n = 6,075 細(xì)菌定植n = 333 (26.3%) CRBSIn = 35 (2.7%) 5.9

2、/ 1,000導(dǎo)管留置天,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30: 2632-2635.,中心靜脈插管相關(guān)性感染: 定義,明確的導(dǎo)管相關(guān)性血行性感染: 導(dǎo)管培養(yǎng)陽(yáng)性(半定量或定量) 拔除導(dǎo)管前外周血培養(yǎng)陽(yáng)性 上述培養(yǎng)中分離出相同微生物 可能的導(dǎo)管相關(guān)性血行性感

3、染: 菌血癥+ 插管部位膿性分泌物, 或 導(dǎo)管接頭培養(yǎng)陽(yáng)性, 或 導(dǎo)管血培養(yǎng)分離出相當(dāng)于外周血培養(yǎng)5倍的微生物或培養(yǎng)陽(yáng)性差異時(shí)間2小時(shí),Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: An evidence-based review. Crit Care Med 2004; 32Suppl.: S466 S494,中心靜脈插管相關(guān)性感染: 定義,非菌血癥導(dǎo)管相關(guān)性感染 導(dǎo)管培養(yǎng)陽(yáng)性, 且為感染來(lái)源 沒(méi)有發(fā)生菌血癥 為排除診斷(沒(méi)有其他能夠解釋感染的明顯病灶, 且拔除導(dǎo)管48小時(shí)內(nèi)

4、感染表現(xiàn)緩解) 導(dǎo)管局部感染 導(dǎo)管培養(yǎng)(半定量或定量) (不)伴局部癥狀(紅, 痛) 沒(méi)有全身炎癥反應(yīng),Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: An evidence-based review. Crit Care Med 2004; 32Suppl.: S466 S494),中心靜脈插管相關(guān)性感染: 定義,中心靜脈插管相關(guān)性感染 原發(fā)性血行性感染 (原發(fā)病灶不明),中心靜脈插管相關(guān)感染,Renaud, et al. Am J Respir Crit Care Med 2

5、001; 163: 1584-90,導(dǎo)管定植: 單腔 vs. 多腔,Zrcher M, Tramr MR, Walder B. Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review. Anesth Analg 2004;99:17782,CRBSI: 單腔 vs. 多腔,Zrcher M, Tramr MR, Walder B. Colonization and Bloodstream In

6、fection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review. Anesth Analg 2004;99:17782,CRBSI: 單腔 vs. 多腔,OR (95% CI fixed),Single- Lumen n/N (%),Multi- Lumen n/N (%),OR (95% CI fixed),13/99 (13.1),2/78 (2.6),3.88 (1.34 11.2),5/61 (8.2),5/68 (7.4),Clark-Christof

7、f,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,Favors multi-lumen,Favors singlei-lumen,Zrcher M, Tramr MR, Walder B. Colonization and Blood

8、stream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review. Anesth Analg 2004;99:17782,CRBSI: 單腔 vs. 多腔,Zrcher M, Tramr MR, Walder B. Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Syste

9、matic Review. Anesth Analg 2004;99:17782,導(dǎo)管定植與感染: 單腔 vs. 多腔,Dezfulian C, Lavelle J, Nallamothu BK, Kaufman SR, Saint S. Rates of infection for single-lumen versus multilumen central venous catheters: A meta-analysis. Crit Care Med 2003; 31:23852390,導(dǎo)管定植與感染: 插管部位的影響,Lorente L, Villegas J, Martin MM,

10、Jimenez A, Mora ML. Catheter-related infection in critically ill patients. Intensive Care Med. 2004 Aug; 30(8): 1681-4. Epub 2004 May 25.,中心靜脈插管相關(guān)性感染: 發(fā)病機(jī)制,中心靜脈插管相關(guān)性感染: 發(fā)病機(jī)制,Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous cathete

11、rs. Intensive Care Med. 2004 Jan;30(1):62-7. Epub 2003 Nov 26.,對(duì)照組,治療組*,*1%洗必太-75%酒精; 含洗必太的敷料,中心靜脈插管相關(guān)性感染: 致病菌,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30

12、: 2632-2635.,能否依靠臨床表現(xiàn)鑒別菌血癥,Peduzzi P, et al. Predictors of bacteremia and Gram-negative bacteremia in patients with sepsis. Arch Intern Med 1992; 152: 529-535,能否依靠臨床表現(xiàn)鑒別菌血癥,Peduzzi P, et al. Predictors of bacteremia and Gram-negative bacteremia in patients with sepsis. Arch Intern Med 1992; 152: 529

13、-535,能否依靠臨床表現(xiàn)鑒別CRBSI,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30: 2632-2635.,能否依靠臨床表現(xiàn)鑒別CRBSI,Safdar N, Maki DG. Inflammation at the insertion site is not

14、predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30: 2632-2635.,能否依靠臨床表現(xiàn)鑒別CRBSI,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed ce

15、ntral venous catheters. Crit Care Med 2002; 30: 2632-2635.,能否依靠臨床表現(xiàn)鑒別導(dǎo)管相關(guān)感染,插管部位炎癥表現(xiàn) 不敏感(多數(shù)導(dǎo)管感染并無(wú)相應(yīng)表現(xiàn)) 不特異(出現(xiàn)相應(yīng)表現(xiàn)亦無(wú)需拔除導(dǎo)管) 提示導(dǎo)管感染的癥狀和體征 插管部位膿性分泌物 插管部位蜂窩織炎超過(guò)4 mm,血培養(yǎng)的臨床價(jià)值: 導(dǎo)管血,Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central venous catheters a

16、nd peripheral venipuncture in critically ill medical patients. Chest 2003; 123: 854-861,血培養(yǎng)的臨床價(jià)值: 外周血,Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central venous catheters and peripheral venipuncture in critically ill medical patients. Chest 200

17、3; 123: 854-861,血培養(yǎng)的臨床價(jià)值: 導(dǎo)管血vs. 外周血,Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central venous catheters and peripheral venipuncture in critically ill medical patients. Chest 2003; 123: 854-861,三腔CVC應(yīng)當(dāng)從哪個(gè)腔取血,Dobbins BM, Catton JA, Kite P, McMa

18、hon MJ, Wilcox MH. Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 2003; 31:1688 1690,三腔CVC應(yīng)當(dāng)從哪個(gè)腔取血,在CRBSI的病例, 40%的CVC僅一個(gè)導(dǎo)管腔有細(xì)菌的明顯定植 隨機(jī)從一個(gè)導(dǎo)管腔留取血培養(yǎng), 陰性結(jié)果的可能性為66% (2/3) 總體而言, 對(duì)于CRBSI病例, 隨機(jī)從一個(gè)導(dǎo)管腔留取血培養(yǎng), 陰性結(jié)果可能性為40% 60%的機(jī)會(huì)發(fā)現(xiàn)細(xì)菌定植,Dobbins BM, Catton

19、JA, Kite P, McMahon MJ, Wilcox MH. Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 2003; 31:1688 1690,DTD對(duì)于診斷CRBSI的意義,目的: 證實(shí)同時(shí)從外周靜脈和中心靜脈采取的血培養(yǎng)陽(yáng)性時(shí)間差(DTD)對(duì)于鑒別CRBSI和非CRBSI的作用 設(shè)計(jì): 前瞻性臨床試驗(yàn) 研究對(duì)象: 15個(gè)月內(nèi)總共9例CRBSI和24例非CRBSI,Gaur AH, Flynn PM, Giannini

20、MA, et al. Difference in time to detection: a simple method to differentiate catheter-related from non-catheter-related bloodstream infection in immunocompromised pediatric patients. Clin Infect Dis. 2003 Aug 15;37(4):469-75,DTD對(duì)于診斷CRBSI的意義,結(jié)果 與非CRBSI相比, CRBSI的DTD顯著增加(457 vs. -4 min; P .001) 采用DTD 1

21、20 min作為診斷CRBSI的臨界值 敏感性, 88.9% 特異性, 100% PPV, 100% NPV 89 96% (試驗(yàn)前CRBSI概率28 54%) 結(jié)論: 在應(yīng)用持續(xù)讀數(shù)血培養(yǎng)系統(tǒng)的醫(yī)院中, DTD是診斷CRBSI的一種簡(jiǎn)單可靠的方法,Gaur AH, Flynn PM, Giannini MA, et al. Difference in time to detection: a simple method to differentiate catheter-related from non-catheter-related bloodstream infection in im

22、munocompromised pediatric patients. Clin Infect Dis. 2003 Aug 15;37(4):469-75,中心靜脈插管相關(guān)感染: 治療,立即拔除導(dǎo)管 選擇新的部位插管 在原部位經(jīng)導(dǎo)絲重新置入導(dǎo)管 拔除導(dǎo)管進(jìn)行培養(yǎng) 培養(yǎng)陽(yáng)性時(shí)拔除新置入導(dǎo)管 應(yīng)用抗生素,拔除導(dǎo)管實(shí)際感染的比例,Merrer J, De Jonghe B, Golliot F, et al. (2001) Complications of femoral and subclavian venous catheterization in critically ill patients

23、: a randomized controlled trial. JAMA 286:700707. Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. (2003) Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study. Crit Care Med 31:13181324. Ranucci M, Isgro G, Giomarelli PP, et al. (2003) I

24、mpact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection. Crit Care Med 31:5259. Dobbins BM, Catton JA, Kite P, et al. (2003) Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 31:16881690. Daro

25、uiche RO, Raad II, Heard SO, et al. (1999) A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med 340:18.,患者發(fā)熱時(shí)能否保留中心靜脈導(dǎo)管,Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU

26、 patients with suspected catheter-related infection: a randomized trial. Intensive Care Med (2004) 30:10731080. DOI 10.1007/s00134-004-2212-x,醫(yī)生懷疑CRI, 計(jì)劃拔除CVC,研究組,標(biāo)準(zhǔn)治療組,留取血培養(yǎng) x 2,拔除CVC,CVC繼續(xù)留置5天,血培養(yǎng)陽(yáng)性或 血流動(dòng)力學(xué)不穩(wěn)定,拔除CVC,感染好轉(zhuǎn),感染持續(xù),保留CVC,血流動(dòng)力學(xué)不穩(wěn)定,收縮壓 90 mmHg或較基礎(chǔ)值降低40 mmHg以上, 且無(wú)導(dǎo)致低血壓的其他原因. 平均動(dòng)脈壓 60 mmHg 需

27、要應(yīng)用多巴胺或多巴酚丁胺維持血壓, 或在過(guò)去12小時(shí)內(nèi)上述藥物劑量增加超過(guò)5 g/kg/min 開(kāi)始應(yīng)用去甲腎上腺素維持血壓, 或在過(guò)去12小時(shí)內(nèi)上述藥物劑量增加超過(guò)0.25 g/kg/min,Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Inte

28、nsive Care Med (2004) 30:10731080. DOI 10.1007/s00134-004-2212-x,患者發(fā)熱時(shí)能否保留中心靜脈導(dǎo)管,Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med (

29、2004) 30:10731080. DOI 10.1007/s00134-004-2212-x,中心靜脈插管相關(guān)性感染: 預(yù)防,Guidelines for the Prevention of Intravascular Catheter-Related Infections. August 2002. Mermel LA. Prevention of Intravascular Catheter-related Infections. Ann Intern Med 2000; 132: 391-402,中心靜脈插管相關(guān)性感染: 治療,不符合IDSA治療指南的比例 第

30、一階段 34% (24/71) 普通病房(23/52 44%)明顯高于ICU (1/19 5%) (p .01) 第二階段 44% (23/52) 15% (7/46) (p = .004),Rijnders BJA, Vandecasteele SJ, Van Wijngaerden E, De Munter P, Peetermans WE. Use of Semiautomatic Treatment Advice to Improve Compliance with Infectious Diseases Society of America Guidelines for Treatm

31、ent of Intravascular Catheter-Related Infection: A Before-After Study. Clinical Infectious Diseases 2003; 37: 9803,如何改進(jìn)依從性,發(fā)現(xiàn)CRBSI后, 向主治醫(yī)生發(fā)送有關(guān)標(biāo)準(zhǔn)化治療的電子郵件(作為電子病歷的一部分) 將打印文件放在病房醫(yī)生的桌上 不進(jìn)行面對(duì)面的討論 對(duì)于非白色念珠菌引發(fā)的CRBSI, 建議主治醫(yī)生找感染科醫(yī)生會(huì)診以確定個(gè)體化治療方案,Rijnders BJA, Vandecasteele SJ, Van Wijngaerden E, De Munter P, Pee

32、termans WE. Use of Semiautomatic Treatment Advice to Improve Compliance with Infectious Diseases Society of America Guidelines for Treatment of Intravascular Catheter-Related Infection: A Before-After Study. Clinical Infectious Diseases 2003; 37: 9803,如何改進(jìn)依從性,Rijnders BJA, Vandecasteele SJ, Van Wijn

33、gaerden E, De Munter P, Peetermans WE. Use of Semiautomatic Treatment Advice to Improve Compliance with Infectious Diseases Society of America Guidelines for Treatment of Intravascular Catheter-Related Infection: A Before-After Study. Clinical Infectious Diseases 2003; 37: 9803,中心靜脈插管相關(guān)感染: 宣教,Lobo R

34、D, Levin AS, Gomes LMP, Cursino R, Park M, Figueiredo VB, Taniguchi L, Polido CG, Costa SF. Impact of an educational program and policy changes on decreasing catheter associated bloodstream infections in a medical intensive care unit in Brazil. Am J Infect Control 2005; 33: 83-7,繼續(xù)教育項(xiàng)目, 操作規(guī)程標(biāo)準(zhǔn)化,預(yù)防策略

35、: 5 Key “Best Practice” Issues,拔除不必要的中心靜脈插管 手部清潔 采取最嚴(yán)格的消毒隔離措施 應(yīng)用洗必太進(jìn)行皮膚消毒 避免應(yīng)用股靜脈插管,MMWR. 2002;51:RR-10,手部清潔,1977以來(lái), 共有7項(xiàng)前瞻性研究顯示, 改進(jìn)手部清潔能夠顯著減少各種感染并發(fā)癥,Larsen. Clin Infect Dis 1999;29:1287-94 Lancet 2000;356:1307-1312,最嚴(yán)格的隔離措施(maximal barrier precautions),對(duì)于醫(yī)生而言 手部清潔 非無(wú)菌帽子和口罩 帽子應(yīng)覆蓋所有頭發(fā) 口罩應(yīng)當(dāng)罩緊口鼻 無(wú)菌手套和隔

36、離衣 對(duì)于患者而言 使用大的無(wú)菌鋪巾覆蓋患者頭部和身體,最嚴(yán)格的隔離措施(maximal barrier precautions),最嚴(yán)格的隔離措施(MBP): 文獻(xiàn)回顧,Am J Med 1991;91(3B):197S-205S Infect Control Hosp Epidemiol 1994;15:231-8,皮膚消毒: 洗必太,Ann Intern Med. 2002;136:792-801,皮膚消毒: 洗必太,Ann Intern Med. 2002;136:792-801,選擇哪個(gè)部位進(jìn)行插管,ICU股靜脈和鎖骨下靜脈插管的RCT 145名患者股靜脈插管/144名患者鎖骨下靜脈

37、插管 預(yù)后 股靜脈插管組感染并發(fā)癥更高: 19.8% vs 4.5% (p .001) 股靜脈插管組血栓并發(fā)癥更多: 21.5% vs. 1.9% (p .001); 完全性血栓栓塞6% vs. 0% 機(jī)械并發(fā)癥發(fā)生率相似: 17.3% vs 18.8% (p = NS),JAMA 2001, 286: 700-7,ICU醫(yī)生的依從性,為期2周的觀察期 對(duì)醫(yī)生設(shè)盲 26根導(dǎo)管 8 (31%)根新置入中心靜脈插管 18 (69%)根通過(guò)導(dǎo)絲更換的導(dǎo)管 沒(méi)有緊急插管,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farl

38、ey JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,ICU醫(yī)生的依從性,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garr

39、ett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,消除CRBSI,醫(yī)務(wù)人員的宣教 VAD政策以及網(wǎng)絡(luò)教育項(xiàng)目 /prevention/vad.html 避免煩瑣的準(zhǔn)備過(guò)程: 插管車(chē) 反復(fù)檢查 每日詢(xún)問(wèn)導(dǎo)管是否可以拔除 清單 觀察到醫(yī)生違反操作規(guī)程時(shí), 護(hù)士有權(quán)終

40、止其操作,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,CRBSI清單,操作前, 醫(yī)生是否: 洗手 消毒操作部位 在

41、無(wú)菌情況下鋪巾覆蓋患者全身 操作過(guò)程中, 醫(yī)生是否: 使用無(wú)菌手套, 口罩和無(wú)菌隔離衣 保持無(wú)菌區(qū)域 所有操作輔助人員是否均遵從上述要求,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit C

42、are Med. 2004 Oct;32(10):2014-20.,CRBSI,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014

43、-20.,CSICU CRBSI: 2002,干預(yù)措施,NNIS均值,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,

44、CSICU CRBSI: 2002,每年預(yù)防43例CRBSI 每年減少8例(0 15)患者死亡 節(jié)約醫(yī)療費(fèi)用$1,945,922 ($1,483,844 $2,408,000),Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,Central Line Bundle,手部清潔 插管時(shí)最嚴(yán)格的隔離措施 洗必太皮膚消毒 選擇適當(dāng)?shù)牟骞懿课?普通中心靜脈插管選擇鎖骨下靜脈 每日評(píng)估留置導(dǎo)管的必要性 立即拔除不必要的導(dǎo)管,Central Line Bundle,授權(quán)護(hù)士強(qiáng)調(diào)使用中心靜