ICU院内感染防与控制的“Bundle”策略

1、icu院内感染预防预防与控制与控制的“bundle”策略四川大学华西医院icu薛欣盛icu院内感染的常见类型vhospital-acquired infectionhospital-acquired pneumonia hap ventilator-associated pneumonia vap catheter-related bloodstream infection hap 和vap定义vhap是指住院48小时后发生的感染，但入院时并不处在感染的潜伏期，可在普通病房接受治疗，仅当病情加重时转icu治疗。vvap是指气管内插管4872小时以上发生的肺炎。病情转严重需接受气管内插管的hap

2、病人虽然不属于vap的范畴，但治疗方案与vap 相同。ats 2005年指南年指南risk factors for the development of ventilator-associated pneumoniav severity of illness (apache score 16)v glasgow coma scale 7 daysmortality of vapvlonger length of stay, higher mortality with vap vs controlmortality increases dramatically if inappropriate

3、therapies are usedheyland dk, et al. am j respir crit care med.1999;159:1249-1256.appropriate right or not？haphap和和vapvap的多重耐药现状的多重耐药现状多重耐药菌（多重耐药菌（mdrmdr）感染发生率显著增加，）感染发生率显著增加，尤其是更常见于迟发性的尤其是更常见于迟发性的haphap和和vapvap患者死亡率增高与患者死亡率增高与mdrmdr感染有关。感染有关。以铜绿假单胞菌为代表的以铜绿假单胞菌为代表的mdrmdr近年来耐药近年来耐药日趋严重。日趋严重。ats/idsa.

4、 guidelines for the management of adults with hap, vap and hcap. am respir crit care med. 2005;171:388-416.nprs-2005我们怎么做？我们怎么做？conventional infection control measureshand washing and use of protective gowns and gloveschlorhexidine oral rinsestrategies related to the gastrointestinal tractstress-ulc

5、er prophylaxisnasogastric tubes (gastric overdistension)enteral nutritionstrategies related to patient placementsemirecumbent positionrotational bed therapystrategies related to the artificial airwayrespiratory airway caredesign of endotracheal tubes: continuous subglottic aspirationstrategies relat

6、ed to mechanical ventilationmaintenance of ventilator equipment. heat and moisture exchangersadjustment of sedationnon-invasive mechanical ventilationferrer r, et al. crit care. 2002 feb;6(1):45-51. non-antibiotic strategies for vapvphysical strategies oral endotracheal tube recommended search for s

7、inusitis no recommendation frequency of humidifier changes recommended frequency of ventilator circuit changes recommended closed suction system recommended drainage of subglottic secretion consider chest physiotherapy no recommendation early tracheostomy no recommendationvposition strategies kineti

8、c beds consider semi-recumbent positioning recommended prone positioning no recommendationvpharmacologic strategies sucralfate not recommended intratracheal antibiotics not recommendedevidence-based clinical practice guideline for the prevention of vapcanadian critical care society ann intern med, 2

9、004, 141: 305icu院内感染的类型vhospital-acquired infectionventilator-associated pneumonia vap ventilator care bundlecatheter-related bloodstream infection central line bundle捆绑式运载火箭神州“六号”bundle何谓何谓“bundle”v 一个组合治疗计划，当同时实施时能比单一方案产生更好的临床效果v 循证医学为导向的治疗，强调临床实用性v bundle的产生需有几个前提:1. 组成必需有确定的临床疗效且适用于临床治疗2. 所有的组成治

10、疗必需在同一个场所及时间內完成3. 每一项的组成完成与否可用”yes”或”no”回答4. bundle的完成与否可用”yes”或”no”回答5. bundle应用的疾病要常见,而且效果能时常监测“bundle”策略v捆绑是有或无的概念，要么不用，要么全用。应用以取得治疗成功来判断，每个病人、每个措施都要落实vindividualized bundleventilator care bundle velevation of the head of the bed vdaily sedation vacations and assessment of readiness to extubate v

11、peptic ulcer disease prophylaxis vdeep venous thrombosis prophylaxis crunden e,nurs crit care 2005 sep-oct; vol. 10 (5), pp. 242-6. 应用应用ventilator care bundle可降低可降低vap发病率发病率elevation of the head of the bedvdecreasing the risk of aspiration of gastrointestinal contents or oropharyngeal and nasopharyn

12、geal secretions.improve patients ventilation by aid ventilatory efforts and minimize atelectasis vdisadvantage: patients sliding down in bed and, if skin integrity is compromised, shearing of skin, possibility of patient discomfort. drakulovic mb , et al:. lancet. nov 27 1999;354(9193):1851-1858 ele

13、vation of the head of the bedvrandomized trialvmedical icu/ rcuvn=86 intubated and mv patientsvclinically suspected and microbiologically confirmed np was assesseddrakulovic mb, et al: lancet. nov 27 1999;354(9193):1851-1858.30daily interruption of sedativesv128128例芝加哥大学医院内科例芝加哥大学医院内科icuicu进行气管插管，并且

14、进行气管插管，并且带管超过带管超过4848小时仍然成活的病人小时仍然成活的病人 v排除孕妇、转入排除孕妇、转入icuicu前已接受镇静治疗或发生心跳前已接受镇静治疗或发生心跳骤停的病人骤停的病人v方法：方法：暂时停止镇静药物输注暂时停止镇静药物输注, ,直至病人清醒并能正确回答至少直至病人清醒并能正确回答至少3 3个简单问题或者病人逐渐表现不适或燥动，同时评价拔个简单问题或者病人逐渐表现不适或燥动，同时评价拔管指征。然后以原来剂量的一半开始给药重新镇静并滴管指征。然后以原来剂量的一半开始给药重新镇静并滴定至需要的镇静水平定至需要的镇静水平 (ramsay 34).(ramsay 34).kre

15、ss jp, et al: n engl j med 2000; 342: 14711477 daily interruption of sedativesv每日唤醒组插管保留时间、每日唤醒组插管保留时间、icu icu 滞留时间明显短滞留时间明显短于常规组，并有住院日更短的趋势于常规组，并有住院日更短的趋势kress jp, et al: n engl j med 2000; 342: 14711477sedation vacations risks vpotential complications：self-extubation,etcvincreased potential for pa

16、in and anxiety associated with lightening sedation vincreased tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation. ulcer prophylaxis & vapv可能的是:：当使用制酸剂使胃液ph上升 4时, 胃可成为细菌尤其是肠道细菌的贮存场所,逐步增殖并可能通过胃- 肺途径引起细菌上呼吸道定植。 vcontroversial ：whether the use of sucral

17、fate and h2-receptor antagonists increases the probability of developing vap?vno identify an increased rate for pneumonia in the ranitidine group than the sucralfate groupcook dj, et al. n engl j med 1998, 338:791-797. peptic ulcer disease prophylaxisvashp应激性溃疡预防指南：icu高危患者应适时应用h2受体阻滞剂、抗酸剂或ppi，以减少su的

18、发生v具有以下一项危险因素以上的患者应采取预防措施: 呼吸衰竭(机械通气超过48h) ；凝血机制障碍,1 年内有消化道溃疡病史或上消化道出血史。gcs评分10；烧伤面积 30 %。器官移植。多发伤(创伤程度积分16) 。肝肾功能不全。脊髓损伤。v具有以下2 项的以上危险因素的患者应采取预防措施：败血症,icu 住院时间1周,潜血持续天数6,应用大剂量皮质醇(氢化可的松 250mgpd) peptic ulcer disease prophylaxisvh2 receptor inhibitors are more efficacious than sucralfate and are the

19、preferred agents. vproton pump inhibitors have not been assessed in a direct comparison with h2 receptor antagonists and, therefore, their relative efficacy is unknown. they do demonstrate equivalency in ability to increase gastric ph dellinger rp, et al. crit care med. mar 2004;32(3):858-873.deep v

20、enous thrombosis prophylaxisvrecommends prophylaxis for patients undergoing surgery, trauma patients, acutely ill medical patients, and patients admitted to the intensive care unit.v深静脉血栓(dvt)的预防：severe sepsis应使用小剂量肝素或低分子肝素预防dvt。有肝素使用禁忌证(血小板减少、重度凝血病、活动性出血、近期脑出血)者，推荐使用物理性的预防措施(弹力袜、间歇压缩装置)。v既往有dvt史的se

21、vere sepsis ，应联合应用抗凝药物和物理性预防措施v潜在并发症：出血geerts wh, et al. chest. sep 2004;126(3 suppl):338s-400s central line bundle hand hygiene maximal barrier precautions upon insertion chlorhexidine skin antisepsis optimal catheter site selectiondaily review of line necessity with prompt removal of unnecessary l

22、ineshand hygienevproper washing hands or using an alcohol-based waterless hand cleaner can help to prevent contamination of central line sites and bloodstream infections. vsome appropriate times for handwashing include: when they are obviously soiled or if contamination is suspectedbefore and after

23、invasive procedures between patients after removing gloves before eating or after using the bathroom ogrady np et al. mmwr recomm rep. aug 9 2002;51(rr-10):1-29. maximal barrier precautions upon insertionvmaximal barrier precautions clearly decrease the odds of developing catheter-related bloodstrea

24、m infections. vfor the operator and assistant, maximal barrier precautions means strict compliance with handwashing, wearing a cap, mask, sterile gown and gloves. the cap should cover all hair and the mask should cover the nose and mouth tightly. vfor the patient, maximal barrier precautions means c

25、overing the patient from head to toe with a sterile drape with a small opening for the site of insertion mermel la, et al. am j med. sep 16 1991;91(3b):197s-205sraad, ii , et al. infect control hosp epidemiol. apr 1994;15(4 pt 1):231-238 chlorhexidine skin antisepsisvchlorhexadine skin antisepsis ha

26、s been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions. prepare skin with antiseptic/detergent chlorhexidine 2% in 70 % isopropyl alcohol. press chlorhexadine applicator sponge against skin, apply chlorhexidine solution using a back and forth f

27、riction scrub for at least 30 seconds. do not wipe or blot. allow antiseptic solution time to dry completely before puncturing the site ( 2 minutes).optimal catheter site selectionvthe great majority of infections develop at the insertion site. vmore risk factors of the jugular insertion site over t

28、he subclavian site. vwhenever possible, and not contraindicated, subclavian vein as the preferred site mermel la, et al. am j med. sep 16 1991;91(3b):197s-205s mccarthy mc, et al. j parenter enteral nutr. 1987 may-jun;11(3):259-62. daily review of line necessityvdaily review of central line necessit

29、y will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of the patient. vmany times, central lines remain in place simply because of their reliable access and because personnel have not considered removing the line. vhowever, it is clear that the risk of

30、infection increases over time as the line remains in place and that the risk of infection is decreased if removed100,000 lives campaignva campaign to make health care safer and more effectiveto ensure that hospitals achieve the best possible outcomes for all patientsva remarkably few proven interven

31、tions, if implemented on a wide enough scale, can avoid 100,000 deaths every year thereafter.100,000 lives campaign the institute for healthcare improvement (ihi) unit2002 cr-bsi rate per 1,000 device days2004 cr-bsi rate per 1,000 device days2005 cr-bsi rate per 1,000 device days medical icu8.23.40surgical icu10.74.5n/aburn center9.51.850l in 1997 vap rates in the surgical icu were 29/1,000 ventilator days; l in 2004, that rate had dropped to just under 18/1,000 ventilator days. l similar decli