中心静脉导管相关血流感染预防策略PPT.ppt

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每年有15,00万个CVC 带管日,每年院内血液感染约超过,25,万例，在,ICU,中，,每年,发生,CR-BSI,约为,8,万例,10%-35%，归因死亡率：1%-25%（2%）,住院日延长：5-20 天,每病例花费$8000-50000 以上,(2011版CDC关于预防导管相关性血流感染指南),增加了护理工作负担、医疗事故、职业风险、心理压力,6,6,Skin,皮肤,Vein,静脉,Fibrin Sheath,Thrombus,纤维鞘血栓,2,导管接口受污染,内源性,:,皮肤菌群,外源性,:,HCW,手部,1,皮肤生物体,内源性,:,皮肤菌群,外源性,:,医护人员手部,消毒剂受污染,注入液受污染,外在污染,:,液体药物,内在污染,:,生产商,导管定植和,CRBSI,的细菌与真菌,2,个最重要的来源是导管置入部位和接头,7,管腔外：第一周,管腔外生物膜是短期导管置入后第,1,周内的主要,CRBSI,来源。,管腔外生物膜是长期导管隧道型感染的主要来源。,对于短期导管（留置时间少于,10,天），导管置入部位是污染最重要的来源。人们认为患者皮肤上的细菌会随着导管的外表面从置入部位向导管尖迁移。导管表面导管定植形成生物膜：嵌入细胞外细菌聚合物的保护矩阵中的微生物,。,7,导管相关性血流感染（,CR-BSI,）的微生物来源,皮肤,静脉,Catheter,导管,Hub,导管接口,Skin,皮肤,管腔内：第一周后,管腔内生物膜是短期和长期导管置入,1,周后的主要,CRBSI,来源,。,对于长期导管（留置时间超过,10,天），导管接头是污染最重要的来源。在这种情况下，人们认为医护人员受污染的手接触导管接头时，在导管操作期间引入了生物。生物然后沿着导管管腔内表面从接头迁移到导管尖。如外部定植一样，形成生物膜。生物会嵌入在生物膜中或分离开在导管腔内自由浮动。,Jol Mossong,et.al,.PLOS Medicine,2009,.,Lenie Dijkshoorn,et.al.Nature Reviews Microbiology 5,939-951,2007,80%,的传染性疾病是通过接触造成的,Bright side:,至少,70%,的院感是可以预防的,.,That is why we are here today!,有效的干预措施可以使,CLA-BSI,明显减少,These guidelines also emphasize performance improvement by implementing bundled strategies,and documenting and reporting rates of compliance with all components of the bundle as benchmarks for quality assurance and performance improvement.,2011,年指南强调了,改进后的集束化实施策略（加入了维护集束化策略）,记录和报告集束化策略中项目的,依从性,，作为质量改进的一项内容,2011,年,预防血管内置管相关感染指南,集束化,即执行一系列有循证基础的治疗和护理措施来预防导管相关性血流感染,10,10,置管措施集,仅临床需要时置入导管。,采用导管置入清单。,采用导管置入车或套件。,置管人员手部卫生。,氯己定,-,酒精皮肤消毒。,最大屏障预防措施（盖、衣服、口罩和患者手术被单）。,选择正确的导管，置入正确的位置。,11,11,维护措施集,最大程度降低导管部位皮肤生物负载,氯己定浸渍海绵敷料。,设备选择（最佳的导管和接头）。,导管接头无菌操作,采用医院批准的消毒剂消毒无针接头,擦洗接头。,无菌冲洗接头,/,导管（每隔,8,小时）。,抗生素,/,抗菌剂封存,抗菌剂浸渍导管,12,12,预防中心导管相关血流感染（,CLA-BSI,）,研究设计：,PICC,团队评价并选择了减少,CLA-BSI,相关的行为实践与技术的组合，包括：,通过超声引导置入选择部位,所有置管时完整最大屏障预防措施,置管和每周敷料改变时的,CHG,皮肤准备与,BIOPATCH Disk,无夹紧顺序要求的无针接头系统,接头隔膜,70%,异丙醇消毒,8,小时和,PRN,生理盐水冲洗方案,日常监测经外周静脉中心导管（,PICC,）,结果：,实施新措施集降低了,CLA-BSI,发生率。,从,2006,年,1,月到,2014,年,1,月（更新），仅有,1,例,CLA-BSI,。,1.无针装置至少应与输液装置同时更换。频于每72小时更换，不能带来额外益处。（类）,2.无针装置接口更换频率不应频于每72小时更换或根据制造厂家的建议更换，以减少感染率。（类）,3.保证系统各成分相匹配，以减少渗漏或破裂。（类）,4.使用合适的消毒剂（氯己定、聚维酮碘、碘剂或70%酒精）擦拭接触的端口对其进行消毒，以减少污染风险。（A类）,5.,使用无针系统连接静脉输液管。（C类）,6.在使用无针装置时，劈裂式活瓣可能优于其他机械瓣，因为后者机械瓣可增加感染风险。（类）,(2011版CDC关于预防导管相关性血流感染指南),无针导管系统,14,14,一种既有效又经济实惠的简单干预：,使用无针静脉输液系统,无针输液接头（无针接入端口）,一次性使用预充冲洗装置（鲁尔锁接头）,简单的无针接头，密闭表面，螺口连接设计,一次性预填充式注射器，用于静脉注射或管路冲洗,15,医护人员针刺伤（,按照操作分类总结,）,50.1%,16,16,如何取消或减少针头使用？,使用无针静脉输液系统,鲁尔锁接头,无针接入端口,17,17,安全装置可使针刺伤减半,减少使用传统装置，以降低锐器伤发生率,2004,年期间，安全设计装置的使用达到,94%,，,EPINet,数据表明,IV,导管相关性损伤下降,63%,。,18,18,无针接头的特征,接入液体通路,：,针或钝针？,鲁尔接口激活通路,密闭防止细菌污染的效果如何？,内部设计：复杂或简单？,复杂内部结构产生了一项意想不到的设计后果，即在接头内部、液体通路外部形成了一个空间；,液体和污染物会渗入到这个空间内；,污染鲁尔接口，并进入液体通路。,通路表面,和内部设计,19,19,无针接头的特征,能见度：透明或不透明,如果透明，可提高整个导管的冲洗效果,接头通路表面：,紧实、密闭、平整,通路表面的复杂设计会导致无法充分消毒。,20,20,无针接头的特征：通路表面,密闭,接入或鲁尔接口激活,未密闭,鲁尔接口激活,21,21,无针接头的特征：能见度,能见度可以增强导管冲洗效果和通畅性。,透明，可增强冲洗效果,透明，不增强冲洗效果,荟萃分析,采用新,工艺,设计的无针,输液接头,相关的中心导管相关性血流感染的荟萃分析,CLABSI的研究,报告,分析：比较正,压无针接头,（研究,无针接头,）与负,压,或,平衡压无针接头在患者中的使用,。,固定效果汇总结果表明,MaxPlus,接头使得,CLA-BSI,风险下降达,59%,（,RR,：,0.41,；,95%CI,：,0.26-0.65,）。,随机效果汇总结果表明,MaxPlus,使得,CLA-BSI,风险下降达,62%,（,RR,：,0.38,；,95%CI,：,0.21-0.68,）。,随机效果泊松模型表明,MaxPlus,使得,CLA-BSI,风险下降达,69%,（,RR,：,0.31,95%CI,：,0.19-0.47,）。,22,23,23,密闭式静脉系统对患者结局的影响,目的：,比较以下两种组合在中心导管相关性血流感染（,CLA-BSI,）发生率方面的临床意义和成本效益：分隔膜无针接头（,SS,）,+,一次性预充冲洗装置（,SUF,）与三通（,3WSC,）,+,多用途液袋（,MUC,）。,研究设计：,印度两个城市的,5,个重症监护病房（,ICU,）。随机临床试验（,RCT,）；临床和成本效益分析。,患者组：,将,1096,名需要中心导管的成年,ICU,患者进行随机化分组。,使用,SS+SUF,的患者（密闭式静脉系统,),使用,3WSC+MUC,的患者,(,开放式静脉系统,),2012,年,4,月至,2014,年,8,月招募的患者；,9937,床天；,7680,中心导管天数（,CLD,）,结果：,CLA-BSI,发生率：,2.21/1000 CL,天（,SS+SUF,）与,6.40/1000 CL,天（,3WSC+MUC,）；,p=0.006,。,使用,SS+SUF,节省费用：,$402.88,结论：,引入密闭式系统（,SS+SUF,）显著降低了,CLA-BSI,，且节省费用。,24,24,结论：,导管相关感染（,CRI,）是全球性的问题。,置管和维护措施集可显著减少,/,预防,CRI,。,.,医护人员的安全性也是全球性的问题。,针刺伤是医护人员安全危害，可通过采用无针和安全设计设备（例如安全设计,IV,导管和无针接头）来显著减少这一危害,在过去几十年中引入了几代无针接头，最后研究将不同的无针接头设计与较高或较低风险联系起来。,CRI,是可预防的，我们应该对这些感染,零容忍,。,