经皮中心静脉置管感染预防指南专家讲座.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,by reflexhammer,导管相关感染诊疗定义,局部感染定义：,（1）局部自发或经触压后有脓性渗出，无需细菌学证据。,（2）穿刺部位红肿、发烧、硬结（三者中任二者），及血清样物质自发或触压后渗出，穿刺部位细菌培养阳性。,经皮中心静脉置管感染预防指南专家讲座,第1页,导管相关感染诊疗定义,菌血症感染定义：,（1）外周血培养结果阳性，且为一个微生物，导管片段（近端或远端）经定量或半定量方法分离出同一个微生物（种类及耐药谱），无其它感染源。,（2）导管内回抽血定量培养出 10 倍于同时外周血培养菌株。,（3）导管穿刺部位渗出脓液、血清、血浆样物质或导管皮下部分、皮下埋植部分培养与外周血培养出同一个细菌（种类及耐药谱）。,经皮中心静脉置管感染预防指南专家讲座,第2页,导管相关感染诊疗定义,可能感染定义包含：,（1）两次或两次以上血培养（不论是外周血还是中心静脉回抽血）出同一个细菌（种类及耐药谱），且临床及试验室证实无其它感染源。,（2）一次阳性血培养结果为 或念球菌（不论是外周血还是中心静脉回抽血），且临床及试验室证实无其它感染源。,（3）免疫抑制或粒细胞降低（粒细胞 2%,使用涂有抗菌素导管降低导管相关血流感染，当导管相关血流感染2%时降低花费。,经皮中心静脉置管感染预防指南专家讲座,第18页,Insert catheters at the subclavian venous site,The risk of catheter-related infection is lower with subclavian catheterization than with internal jugular or femoral catheterization,锁骨下静脉置管导管相关感染风险小于颈内静脉或股静脉置管,经皮中心静脉置管感染预防指南专家讲座,第19页,Use maximal sterile-barrier precautions during catheter insertion,Use of a mask,cap,sterile gown,sterile gloves,and large sterile drape reduces the rate of infections and reduces costs,戴口罩、帽子、无菌手套，穿无菌衣，覆盖无菌大单等能降低感染发生率，降低花费。,经皮中心静脉置管感染预防指南专家讲座,第20页,Avoid the use of antibiotic ointments,The application of antibiotic ointments increases the rate of colonization by fungi,promotes the development of antibiotic-resistant bacteria,and has not been shown to affect the risk of catheterrelated bloodstream infections,使用抗生素软膏增加真菌定殖率，增加耐药菌产生，并不能降低导管相关血流感染发生率,经皮中心静脉置管感染预防指南专家讲座,第21页,Disinfect catheter hubs,Catheter hubs are common sites of catheter contaminatio,导管活栓是导管污染常见部位,经皮中心静脉置管感染预防指南专家讲座,第22页,Do not schedule routine catheter changes,Scheduled,routine replacement 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,有计划、常规CVC更换到新位置并不能降低导管相关血流感染发生率；有计划、常规导丝引导下导管更换有可能增加导管相关感染。,经皮中心静脉置管感染预防指南专家讲座,第23页,Remove catheters when they are no longer needed,The probability of colonization and catheter-related bloodstream infection increases over time,伴随时间推移，细菌定殖和导管相关血流感染可能性增大。,经皮中心静脉置管感染预防指南专家讲座,第24页,Types of Catheter-Associated Infections,Catheter colonization导管细菌定殖,Growth of organisms from a catheter segment by either semiquantitative or quantitative culture,经过半定量或定量培养，使导管片段微生物生长,Catheter-related bloodstream infection导管相关血流感染,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 without any other apparent source of infection,血培养分理出细菌与导管片段半定量或定量培养得到细菌相同，并伴有血流感染临床症状，而没有其它显著感染源。,Exit-site infection出口感染,Erythema,tenderness,induration,or purulence within 2 cm of the exit site of the catheter,在导管出口2cm范围内出现红肿、触痛、硬结或化脓,经皮中心静脉置管感染预防指南专家讲座,第25页,Management of Suspected Catheter-Related Bloodstream Infection,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 white-cell count greater than 12,000 per cubic millimeter or less than 4000 per cubic millimeter or with 10 percent immature(band)forms.,脓毒症是指感染全身反应，含有以下两条或两条以上表现：体温高于38.5度或低于36度；心率高于90次/分；呼吸频率高于20次/分或动脉二氧化碳分压低于32mmHg；白细胞计数超出1/mm,3,或低于4000/mm,3,或幼稚细胞到达10。,经皮中心静脉置管感染预防指南专家讲座,第26页,Management of Suspected Catheter-Related Bloodstream Infection,Septic 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 acidosis,oliguria,or acute alteration in mental status.,脓毒症性休克是指脓毒症诱发低血压或在充分液体复苏下仍需要血管升压药或血管收缩药维持血压，伴有灌注异常，包含（但不限于）乳酸酸中毒、少尿、急性精神状态改变,经皮中心静脉置管感染预防指南专家讲座,第27页,Management of Suspected Catheter-Related Bloodstream Infection,When blood cultures are obtained,samples from peripheral sites are preferred.Cathetertip cultures should be performed by the semiquantitative or quantitative technique.,假如做血培养，最好是取周围位点样本。导管尖培养应该采取定量或半定量方法。,经皮中心静脉置管感染预防指南专家讲座,第28页,Management of Suspected Catheter-Related Bloodstream Infection,Empirical antibiotic therapy for suspected catheter-related bloodstream infection should include vancomycin.Antibiotics that are effective 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 for 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).,怀疑导管相关血流感染时，进行经验性抗生素治疗要包含万古霉素。还要包含能有效反抗革兰氏阴性菌抗生素，尤其是当患者有免疫受损或中性粒细胞降低症时。有患者最少治疗14天，有心内膜炎时治疗期为4-6周，金黄色葡萄球菌菌血症治疗2-3周。,经皮中心静脉置管感染预防指南专家讲座,第29页,经皮中心静脉置管感染预防指南专家讲座,第30页,临床路径,经皮中心静脉置管感染预防指南专家讲座,第31页,Guidelines for the Prevention of Intravascular Catheter Related Infections,Clinical Infectious Diseases;35:1281-1307,MMWR;51(No.RR-10):1-29,经皮中心静脉置管感染预防指南专家讲座,第32页,Eliminating catheter-related bloodstream infections in the intensive care unit,.,Crit Care Med;32(10):-,经皮中心静脉置管感染预防指南专家讲座,第33页,这是一篇由John Hopkins HospitalICU团体.利用一些实际intervention将practice guidelines转换为ICU里面实际作为.包含每日执行checklist,评定病患需要CVCindications,建立标准CVC catheterizationSOP,对于相关人员连续教育等等.对于整个ICU CRBSI感染率影响.,经皮中心静脉置管感染预防指南专家讲座,第34页,The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infection in a Medical ICU,Chest;126:1612-1618.,经皮中心静脉置管感染预防指南专家讲座,第35页,也是类似研究汇报.能够提供对这个有兴趣ICU组员们.想要setup相关program者一个很好参考.,经皮中心静脉置管感染预防指南专家讲座,第36页,谢谢！,经皮中心静脉置管感染预防指南专家讲座,第37页,