临床医学血管导管和气管导管感染的相关问题

1、会计学1临床医学血管导管和气管导管感染的相临床医学血管导管和气管导管感染的相关问题关问题第1页/共86页第2页/共86页第3页/共86页国际医院感染控制协会（国际医院感染控制协会（INICC）公布的）公布的2002-2007院内院内感染的发生率感染的发生率第4页/共86页第5页/共86页第6页/共86页第7页/共86页INICC公布的公布的2002-2007CRBSI总的发生率总的发生率第8页/共86页相关性血源感染的严重程度整体死亡率相关死亡率医院住院天数延长相关费用第9页/共86页第10页/共86页第11页/共86页第12页/共86页 推荐意见：推荐意见：CRBSICRBSI的临床表现不典

2、型，诊断需的临床表现不典型，诊断需重视临床表现并结合实验室检查。重视临床表现并结合实验室检查。IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第13页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第14页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第15页

3、/共86页血管内导管相关感染的预防与治疗指南(2007)第16页/共86页第17页/共86页p帽子p口罩p无菌手套p无菌衣p大范围的无菌辅巾第18页/共86页第19页/共86页Time to CRBSIbetween baseline period and intervention(hand hygiene and catheter care) period (p0.02). CVC, central venous catheterCrit Care Med 2009 Vol. 37, No. 7第20页/共86页第21页/共86页第22页/共86页Use of Vancomycin-Cont

4、aining Lock or Flush can reduce CRBSI? Conclusions. Use of a vancomycin lock solution in high-risk patient populations being treated with long-term central IVDs reduces the risk of BSI. The use of an anti-infective lock solution warrants consideration for patients who require central access but who

5、are at high risk of BSI, such as patients with malignancy or low-birthweight neonates.第23页/共86页第24页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第25页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第26页/共86页IDSA Guidelines for Intr

6、avascular Catheter-Related Infection.CID 2009;49:1-45第27页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第28页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第29页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2

7、009;49:1-45第30页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第31页/共86页IDSA Guidelines for Intravascular Catheter-Related Infection.CID 2009;49:1-45第32页/共86页第33页/共86页n启动启动MV24h后发生的感染性肺炎，包后发生的感染性肺炎，包括撤停呼吸机和拔除人工气道导管后括撤停呼吸机和拔除人工气道导管后48h内发生的肺炎。内发生的肺炎。nMV最初最初4天内发生的肺炎为天内

8、发生的肺炎为早发性早发性VAP，5天者为天者为晚发性晚发性VAP。第34页/共86页European Respiratory Journal 1999; 13: 546551Journal of Clinical Microbiology 2007; 45:15881593第35页/共86页第36页/共86页Endotracheal Tube-associated Pneumonia（ETAP）第37页/共86页第38页/共86页第39页/共86页第40页/共86页第41页/共86页第42页/共86页第43页/共86页第44页/共86页第45页/共86页Am J Respir Crit Car

9、e Med, 2005；171:388416第46页/共86页第47页/共86页第48页/共86页nIn the largest trial to date , CASS was able to reduce the incidence density of VAP, median length of ICU stay, and antibiotic use, and led to overall cost savings in the postoperative course of patients undergoing major surgery. nThe recent Canadian

10、 Critical Care Trials group guideline update on VAP prevention recommends subglottic secretion drainage in patients predicted to require more than 72 h of mechanical ventilation. Muscedere J,et al.J Crit Care 2008; 23:126137Bouza E,et al.Chest 2008; 134:938946第49页/共86页 Patients receiving a silver-co

11、ated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.第50页/共86页Oral hygiene Lorraine B,et al. Journal of Neuroscience NursingSumma Health System VAP Rates 20032008第51页/共86页Man

12、zano F,et al.CCM 2008;36:2225-2231第52页/共86页Closed tracheal suctionz systemsuno beneficial effects on VAP incidence, mortality, or ICU stay. uhigher colonization of the respiratory tract.第53页/共86页 Two recent meta-analyses suggest that the prone position during mechanical ventilation does not reduce m

13、ortality or duration of ventilation and should not be used routinely for acute hypoxemic respiratory failure. The two reports are, nevertheless, contradictory in their appreciation of the VAP incidence reduction.第54页/共86页selective digestive tract decontamination (SDD) selective oropharyngeal deconta

14、mination (SOD)nDesign：Prospective observational study of determination the incidence rates of hospital acquired infections (HAI) during the first 14days after ICU discharge after treatment during ICU-stay with SDD, SOD or Standard Care (SC).nResults：Post-ICU incidences of HAI per 1,000days at risk w

15、ere 11.2(SDD), 12.9(SOD) and 8.3(SC) in ICU, yielding relative risks, as compared to SC, of 1.49 (0.92.47) for SOD and 1.44 (0.872.39) for SDD. Incidences of surgical site infections (per 100 surgical procedures) were 4(SC) and 11.8(SOD) and 8(SOD). Among patients that succumbed in the hospital afte

16、r ICU-stay (n=58) eight (14%) had developed HAI after ICU discharge; 3 of 21 after SDD, 3 of 15 after SOD and 2 of 22 after SC.nConclusions：Incidences of HAI in general wards tended to be higher in patients that had received either SDD or SOD during ICU-stay, but it seems unlikely that these infecti

17、ons have an effect on hospital mortality rates.第55页/共86页Does the orientation of the trachea effect bacterial colonization ？第56页/共86页Novel System for Complete Removal of Secretions within the Endotracheal Tube！nMucus Shaver can remove all mucus from the lumen of the ETT, restoring the appearance of t

18、he lumen to that of a new, unused ETT.第57页/共86页第58页/共86页第59页/共86页第60页/共86页?第61页/共86页第62页/共86页第63页/共86页第64页/共86页第65页/共86页第66页/共86页第67页/共86页第68页/共86页第69页/共86页第70页/共86页第71页/共86页第72页/共86页第73页/共86页第74页/共86页第75页/共86页第76页/共86页第77页/共86页第78页/共86页相关性血源感染的严重程度整体死亡率相关死亡率医院住院天数延长相关费用第79页/共86页第80页/共86页IDSA Guidelines for Intravascular Catheter-Related