ICU院内感染预防与控制的“Bundle”策略39张课件

ICU院内感染预防与控制的“Bundle”策略56、死去何所道，托体同山阿。57、春秋多佳日，登高赋新诗。58、种豆南山下，草盛豆苗稀。晨兴理荒秽，带月荷锄归。道狭草木长，夕露沾我衣。衣沾不足惜，但使愿无违。59、相见无杂言，但道桑麻长。60、迢迢新秋夕，亭亭月将圆。ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略56、死去何所道，托体同山阿。57、春秋多佳日，登高赋新诗。58、种豆南山下，草盛豆苗稀。晨兴理荒秽，带月荷锄归。道狭草木长，夕露沾我衣。衣沾不足惜，但使愿无违。59、相见无杂言，但道桑麻长。60、迢迢新秋夕，亭亭月将圆。ICU院内感染预防与控制的

“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Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院内感染预防与控制的“Bundle”策略56、死去何所1ICU院内感染预防与控制的

“Bundle”策略四川大学华西医院ICU薛欣盛ICU院内感染预防与控制的

“Bundle”策略四川大学华西2ICU院内感染的常见类型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院内感染的常见类型Hospital-Acquired3HAP和VAP定义HAP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。VAP是指气管内插管48－72小时以上发生的肺炎。病情转严重需接受气管内插管的HAP病人虽然不属于VAP的范畴，但治疗方案与VAP相同。ATS2005年指南HAP和VAP定义HAP是指住院48小时后发生的感染，但4Riskfactorsforthedevelopmentofventilator-associatedpneumoniaSeverityofillness(APACHEscore>16)Glasgowcomascale<9SevereburnsChroniclungdiseaseAcuteorchronicrespiratoryconditions

Supinebodyposition

Excessivesedation

Mechanicalventilationfor>7daysRiskfactorsforthedevelopme5MortalityofVAPLongerlengthofstay,highermortalitywithVAPvscontrolMortalityincreasesdramaticallyifinappropriatetherapiesareusedHeylandDK,etal.AmJRespirCritCareMed.1999;159:1249-1256.MortalityofVAPLongerlength6PrinciplesofAntibioticpolicies

inVAPConsiderpotentialpathogensConsiderlocalepidemiologyConsiderprevioustreatmentreceivedbythepatientColonisationVsinfectionAppropriateAntibioticTherapy

Rightornot？PrinciplesofAntibioticpoli7HAP和VAP的多重耐药现状多重耐药菌（MDR）感染发生率显著增加，尤其是更常见于迟发性的HAP和VAP患者死亡率增高与MDR感染有关。以铜绿假单胞菌为代表的MDR近年来耐药日趋严重。ATS/IDSA.GuidelinesforthemanagementofadultswithHAP,VAPandHCAP.AmRespirCritCareMed.2005;171:388-416.HAP和VAP的多重耐药现状多重耐药菌（MDR）感染发生率显8NPRS-2005绿脓杆菌的耐药变迁我们怎么做？NPRS-2005绿脓杆菌的耐药变迁我们怎么做？9ConventionalinfectioncontrolmeasuresHandwashinganduseofprotectivegownsandglovesChlorhexidineoralrinseStrategiesrelatedtothegastrointestinaltractStress-ulcerprophylaxisnasogastrictubes(Gastricoverdistension)EnteralnutritionStrategiesrelatedtopatientplacementSemirecumbentpositionRotationalbedtherapyStrategiesrelatedtotheartificialairwayRespiratoryairwaycareDesignofendotrachealtubes:continuoussubglotticaspirationStrategiesrelatedtomechanicalventilationMaintenanceofventilatorequipment.heatandmoistureexchangersAdjustmentofsedationNon-invasivemechanicalventilationFerrerR,etal.CritCare.2002Feb;6(1):45-51.Non-antibioticstrategiesforVAPConventionalinfectioncontrol10PhysicalstrategiesOralendotrachealtube

√RecommendedSearchforsinusitis NorecommendationFrequencyofhumidifierchanges

√Recommended

Frequencyofventilatorcircuitchanges √RecommendedClosedsuctionsystem

√

RecommendedDrainageofsubglotticsecretion

ConsiderChestphysiotherapy NorecommendationEarlytracheostomy NorecommendationPositionstrategiesKineticbeds ConsiderSemi-recumbentpositioning

√

RecommendedPronepositioning NorecommendationPharmacologicstrategiesSucralfate NotrecommendedIntratrachealantibiotics NotrecommendedEvidence-basedclinicalpracticeguidelineforthepreventionofVAPCanadianCriticalCareSociety

AnnInternMed,2004,141:305PhysicalstrategiesEvidence-b11ICU院内感染的类型Hospital-AcquiredInfectionVentilator-AssociatedPneumoniaVAP

VentilatorCareBundleCatheter-RelatedBloodstreamInfectionCentralLineBundleICU院内感染的类型Hospital-AcquiredIn12捆绑式运载火箭神州“六号”Bundle捆绑式运载火箭神州“六号”Bundle13何谓“Bundle”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循证医学为导向的治疗，强调临床实用性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何谓“Bundle”一个组合治疗计划，当同时实施时能比单一14“Bundle”策略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IndividualizedBundle“Bundle”策略捆绑是有或无的概念，要么不用，要么全用。15VentilatorCareBundleElevationoftheHeadoftheBedDaily"SedationVacations"andAssessmentofReadinesstoExtubatePepticUlcerDiseaseProphylaxisDeepVenousThrombosisProphylaxis

CrundenE,NursCritCare2005Sep-Oct;Vol.10(5),pp.242-6.应用VentilatorCareBundle可降低VAP发病率VentilatorCareBundleElevati16ElevationoftheHeadoftheBedDecreasingtheriskofaspirationofgastrointestinalcontentsororopharyngealandnasopharyngealsecretions.improvepatients’ventilationbyaidventilatoryeffortsandminimizeatelectasisDisadvantage:Patientsslidingdowninbedand,ifskinintegrityiscompromised,shearingofskin,possibilityofpatientdiscomfort.

DrakulovicMB,etal:.Lancet.Nov271999;354(9193):1851-1858ElevationoftheHeadoftheB17ElevationoftheHeadoftheBedRandomizedtrialMedicalICU/RCUN=86intubatedandMVpatientsClinicallysuspectedandmicrobiologicallyconfirmedNPwasassessedDrakulovicMB,etal:Lancet.Nov271999;354(9193):1851-1858.>30°ElevationoftheHeadoftheB18Dailyinterruptionofsedatives128例芝加哥大学医院内科ICU进行气管插管，并且带管超过48小时仍然成活的病人排除孕妇、转入ICU前已接受镇静治疗或发生心跳骤停的病人方法：暂时停止镇静药物输注,直至病人清醒并能正确回答至少3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定至需要的镇静水平(Ramsay3–4).KressJP,etal:NEnglJMed2000;342:1471–1477

Dailyinterruptionofsedative19Dailyinterruptionofsedatives每日唤醒组插管保留时间、ICU滞留时间明显短于常规组，并有住院日更短的趋势KressJP,etal:NEnglJMed2000;342:1471–1477Dailyinterruptionofsedative20Sedationvacationsrisks

Potentialcomplications：self-extubation,etcIncreasedpotentialforpainandanxietyassociatedwithlighteningsedationIncreasedtoneandpoorsynchronywiththeventilatorduringthemaneuvermayriskepisodesofdesaturation.

SedationvacationsrisksPoten21UlcerProphylaxis&VAP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。Controversial：whethertheuseofsucralfateandH2-receptorantagonistsincreasestheprobabilityofdevelopingVAP???NOidentifyanincreasedrateforpneumoniaintheranitidinegroupthanthesucralfategroupCookDJ,etal.NEnglJMed1998,338:791-797.UlcerProphylaxis&VAP可能的是:：当22PepticUlcerDiseaseProphylaxisASHP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的发生具有以下一项危险因素以上的患者应采取预防措施:①呼吸衰竭(机械通气超过48h)；②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；③烧伤面积>30%。④器官移植。⑤多发伤(创伤程度积分≥16)。⑥肝肾功能不全。⑦脊髓损伤。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)PepticUlcerDiseaseProphylax23PepticUlcerDiseaseProphylaxisH2receptorinhibitorsaremoreefficaciousthansucralfateandarethepreferredagents.ProtonpumpinhibitorshavenotbeenassessedinadirectcomparisonwithH2receptorantagonistsand,therefore,theirrelativeefficacyisunknown.TheydodemonstrateequivalencyinabilitytoincreasegastricpHDellingerRP,etal.CritCareMed.Mar2004;32(3):858-873.PepticUlcerDiseaseProphylax24DeepVenousThrombosisProphylaxisRecommendsprophylaxisforpatientsundergoingsurgery,traumapatients,acutelyillmedicalpatients,andpatientsadmittedtotheintensivecareunit.深静脉血栓(DVT)的预防：SevereSepsis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)。既往有DVT史的SevereSepsis，应联合应用抗凝药物和物理性预防措施潜在并发症：出血GeertsWH,etal.Chest.Sep2004;126(3Suppl):338S-400SDeepVenousThrombosisProphyl25CentralLineBundleHandHygieneMaximalBarrierPrecautionsUponInsertionChlorhexidineSkinAntisepsisOptimalCatheterSiteSelectionDailyReviewofLineNecessitywithPromptRemovalofUnnecessaryLinesCentralLineBundleHandHygie26handhygieneProperwashinghandsorusinganalcohol-basedwaterlesshandcleanercanhelpto

preventcontaminationofcentrallinesitesandbloodstreaminfections.Someappropriatetimesforhandwashinginclude:WhentheyareobviouslysoiledORIfcontaminationissuspectedBeforeandafterinvasiveproceduresBetweenpatientsAfterremovingglovesBeforeeatingORAfterusingthebathroomO'GradyNPetal.MMWRRecommRep.Aug92002;51(RR-10):1-29.handhygieneProperwashinghan27MaximalBarrierPrecautionsUponInsertionMaximalbarrierprecautionsclearlydecreasetheoddsofdevelopingcatheter-relatedbloodstreaminfections.Fortheoperatorandassistant,maximalbarrierprecautionsmeansstrictcompliancewithhandwashing,wearingacap,mask,sterilegownandgloves.

Thecapshouldcoverallhairandthemaskshouldcoverthenoseandmouthtightly.

Forthepatient,maximalbarrierprecautionsmeanscoveringthepatientfromheadtotoewithasteriledrapewithasmallopeningforthesiteofinsertionMermelLA,etal.AmJMed.Sep161991;91(3B):197S-205SRaad,II,etal.InfectControlHospEpidemiol.Apr1994;15(4Pt1):231-238MaximalBarrierPrecautionsUp28ChlorhexidineSkinAntisepsisChlorhexadineskinantisepsishasbeenproventoprovidebetterskinantisepsisthanotherantisepticagentssuchaspovidone-iodinesolutions.

Prepareskinwithantiseptic/detergentchlorhexidine2%

in70%

isopropylalcohol.Presschlorhexadineapplicatorspongeagainstskin,applychlorhexidinesolutionusingabackandforthfrictionscrubforatleast30seconds.

Donotwipeorblot.Allowantisepticsolutiontimetodry

completelybeforepuncturingthesite(~2minutes).ChlorhexidineSkinAntisepsisC29OptimalCatheterSiteSelectionThegreatmajorityofinfectionsdevelopattheinsertionsite.Moreriskfactorsofthejugularinsertionsiteoverthesubclaviansite.

Wheneverpossible,andnotcontraindicated,SubclavianVeinasthePreferredSiteMermelLA,etal.AmJMed.Sep161991;91(3B):197S-205SMcCarthyMC,etal.JParenterEnteralNutr.1987May-Jun;11(3):259-62.OptimalCatheterSiteSelectio30DailyReviewofLineNecessityDailyreviewofcentrallinenecessitywillpreventunnecessarydelaysinremovinglinesthatarenolongerclearlynecessaryinthecareofthepatient.

Manytimes,centrallinesremaininplacesimplybecauseoftheirreliableaccessandbecausepersonnelhavenotconsideredremovingtheline.

However,itisclearthattheriskofinfectionincreasesovertimeasthelineremainsinplaceandthattheriskofinfectionisdecreasedifremovedDailyReviewofLineNecessity31100,000LIVESCAMPAIGNAcampaigntomakehealthcaresaferandmoreeffective—toensurethathospitalsachievethebestpossibleoutcomesforallpatientsAremarkablyfewproveninterventions,ifimplementedonawideenoughscale,canavoid100,000deathseveryyearthereafter.100,000LIVESCAMPAIGNTheInstituteforHealthcareImprovement(IHI)100,000LIVESCAMPAIGNAcampai32Unit2002CR-BSIrateper1,000devicedays2004CR-BSIrateper1,000devicedays2005CR-BSIrateper1,000

devicedaysMedicalICU8.23.40SurgicalICU10.74.5N/ABurnCenter9.51.850In1997VAPratesintheSurgicalICUwere29/1,000ventilatordays;in2004,thatratehaddroppedtojustunder18/1,000ventilatordays.SimilardeclineshavebeenseenintheMedicalICUandBurnCenter.TheuseofVAP&CVPbundlesisassociatedwithreductionsininfections

100,000LIVESCAMPAIGNTheInstituteforHealthcareImprovement(IHI)Unit2002CR-BSIrate2004CR-B33Levelofreliability(compliancewithelements):allReductioninVAPrateUnchanged22%<95%compliance40%>95%compliance61%VentilatorBundlecompliance100,000LIVESCAMPAIGNTheInstituteforHealthcareImprovement(IHI)Levelofreliability(complian34STOPSepsisBundleStrategiestoTimelyObviatetheProgressionofSepsisintheEmergencyDepartmentFOR:TwoormoresignsofinflammationAndSuspectedorconfirmedinfectionAndSBP<90mmHgafter20ml/kgfluidbolusorLactate≥4mmol/LH.BryantNguyen,MD,MS.etal.DepartmentofEmergencyMedicineLomaLindaUniversityfortheSTOPSepsisWorkingGroupSTOPSepsisBundleStrategiest35SepsisResuscitationBundle

(first6hours)1.Checklactate2.B/Cpriortoantibiotcs3.Antibioticswithin4hours4.Hypotensionand/orlactate>4mmol/L(36mg/dl)a)Crystalloid20ml/kgb)Vasopressorfornon-responder:MAP≥65mmHg5.Septicshockand/orlactate>4mmol/L(36mg/dl)a)CVP≥8mmHgb)ScvO2≥70%SepsisResuscitationBundle

(36SepsisManagementBundle

(first24hours)LowdosesteroidsforsepticshockGlucosecontrol>lowerlimitofnormal,but<150mg/dl(8.3mmol/L).Inspiratoryplateaupressure<30cmH2ODrotrecoginalfa(activated)SepsisManagementBundle

(fir37“上医治未病，中医治欲病，下医治已病”

预防感染SurvivingSepsisMODS/MOF谢谢大家!ICU院内感染——我们怎么做？“上医治未病，中医治欲病，下医治已病”预防感染Surviv38END16、业余生活要有意义，不要越轨。——华盛顿

17、一个人即使已登上顶峰，也仍要自强不息。——罗素·贝克

18、最大的挑战和突破在于用人，而用人最大的突破在于信任人。——马云

19、自己活着，就是为了使别人过得更美好。——雷锋

20、要掌握书，莫被书掌握；要为生而读，莫为读而生。——布尔沃END16、业余生活要有意义，不要越轨。——华盛顿39ICU院内感染预防与控制的“Bundle”策略56、死去何所道，托体同山阿。57、春秋多佳日，登高赋新诗。58、种豆南山下，草盛豆苗稀。晨兴理荒秽，带月荷锄归。道狭草木长，夕露沾我衣。衣沾不足惜，但使愿无违。59、相见无杂言，但道桑麻长。60、迢迢新秋夕，亭亭月将圆。ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略56、死去何所道，托体同山阿。57、春秋多佳日，登高赋新诗。58、种豆南山下，草盛豆苗稀。晨兴理荒秽，带月荷锄归。道狭草木长，夕露沾我衣。衣沾不足惜，但使愿无违。59、相见无杂言，但道桑麻长。60、迢迢新秋夕，亭亭月将圆。ICU院内感染预防与控制的

“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Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院内感染预防与控制的“Bundle”策略56、死去何所40ICU院内感染预防与控制的

“Bundle”策略四川大学华西医院ICU薛欣盛ICU院内感染预防与控制的

“Bundle”策略四川大学华西41ICU院内感染的常见类型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院内感染的常见类型Hospital-Acquired42HAP和VAP定义HAP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。VAP是指气管内插管48－72小时以上发生的肺炎。病情转严重需接受气管内插管的HAP病人虽然不属于VAP的范畴，但治疗方案与VAP相同。ATS2005年指南HAP和VAP定义HAP是指住院48小时后发生的感染，但43Riskfactorsforthedevelopmentofventilator-associatedpneumoniaSeverityofillness(APACHEscore>16)Glasgowcomascale<9SevereburnsChroniclungdiseaseAcuteorchronicrespiratoryconditions

Supinebodyposition

Excessivesedation

Mechanicalventilationfor>7daysRiskfactorsforthedevelopme44MortalityofVAPLongerlengthofstay,highermortalitywithVAPvscontrolMortalityincreasesdramaticallyifinappropriatetherapiesareusedHeylandDK,etal.AmJRespirCritCareMed.1999;159:1249-1256.MortalityofVAPLongerlength45PrinciplesofAntibioticpolicies

inVAPConsiderpotentialpathogensConsiderlocalepidemiologyConsiderprevioustreatmentreceivedbythepatientColonisationVsinfectionAppropriateAntibioticTherapy

Rightornot？PrinciplesofAntibioticpoli46HAP和VAP的多重耐药现状多重耐药菌（MDR）感染发生率显著增加，尤其是更常见于迟发性的HAP和VAP患者死亡率增高与MDR感染有关。以铜绿假单胞菌为代表的MDR近年来耐药日趋严重。ATS/IDSA.GuidelinesforthemanagementofadultswithHAP,VAPandHCAP.AmRespirCritCareMed.2005;171:388-416.HAP和VAP的多重耐药现状多重耐药菌（MDR）感染发生率显47NPRS-2005绿脓杆菌的耐药变迁我们怎么做？NPRS-2005绿脓杆菌的耐药变迁我们怎么做？48ConventionalinfectioncontrolmeasuresHandwashinganduseofprotectivegownsandglovesChlorhexidineoralrinseStrategiesrelatedtothegastrointestinaltractStress-ulcerprophylaxisnasogastrictubes(Gastricoverdistension)EnteralnutritionStrategiesrelatedtopatientplacementSemirecumbentpositionRotationalbedtherapyStrategiesrelatedtotheartificialairwayRespiratoryairwaycareDesignofendotrachealtubes:continuoussubglotticaspirationStrategiesrelatedtomechanicalventilationMaintenanceofventilatorequipment.heatandmoistureexchangersAdjustmentofsedationNon-invasivemechanicalventilationFerrerR,etal.CritCare.2002Feb;6(1):45-51.Non-antibioticstrategiesforVAPConventionalinfectioncontrol49PhysicalstrategiesOralendotrachealtube

√RecommendedSearchforsinusitis NorecommendationFrequencyofhumidifierchanges

√Recommended

Frequencyofventilatorcircuitchanges √RecommendedClosedsuctionsystem

√

RecommendedDrainageofsubglotticsecretion

ConsiderChestphysiotherapy NorecommendationEarlytracheostomy NorecommendationPositionstrategiesKineticbeds ConsiderSemi-recumbentpositioning

√

RecommendedPronepositioning NorecommendationPharmacologicstrategiesSucralfate NotrecommendedIntratrachealantibiotics NotrecommendedEvidence-basedclinicalpracticeguidelineforthepreventionofVAPCanadianCriticalCareSociety

AnnInternMed,2004,141:305PhysicalstrategiesEvidence-b50ICU院内感染的类型Hospital-AcquiredInfectionVentilator-AssociatedPneumoniaVAP

VentilatorCareBundleCatheter-RelatedBloodstreamInfectionCentralLineBundleICU院内感染的类型Hospital-AcquiredIn51捆绑式运载火箭神州“六号”Bundle捆绑式运载火箭神州“六号”Bundle52何谓“Bundle”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循证医学为导向的治疗，强调临床实用性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何谓“Bundle”一个组合治疗计划，当同时实施时能比单一53“Bundle”策略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IndividualizedBundle“Bundle”策略捆绑是有或无的概念，要么不用，要么全用。54VentilatorCareBundleElevationoftheHeadoftheBedDaily"SedationVacations"andAssessmentofReadinesstoExtubatePepticUlcerDiseaseProphylaxisDeepVenousThrombosisProphylaxis

CrundenE,NursCritCare2005Sep-Oct;Vol.10(5),pp.242-6.应用VentilatorCareBundle可降低VAP发病率VentilatorCareBundleElevati55ElevationoftheHeadoftheBedDecreasingtheriskofaspirationofgastrointestinalcontentsororopharyngealandnasopharyngealsecretions.improvepatients’ventilationbyaidventilatoryeffortsandminimizeatelectasisDisadvantage:Patientsslidingdowninbedand,ifskinintegrityiscompromised,shearingofskin,possibilityofpatientdiscomfort.

DrakulovicMB,etal:.Lancet.Nov271999;354(9193):1851-1858ElevationoftheHeadoftheB56ElevationoftheHeadoftheBedRandomizedtrialMedicalICU/RCUN=86intubatedandMVpatientsClinicallysuspectedandmicrobiologicallyconfirmedNPwasassessedDrakulovicMB,etal:Lancet.Nov271999;354(9193):1851-1858.>30°ElevationoftheHeadoftheB57Dailyinterruptionofsedatives128例芝加哥大学医院内科ICU进行气管插管，并且带管超过48小时仍然成活的病人排除孕妇、转入ICU前已接受镇静治疗或发生心跳骤停的病人方法：暂时停止镇静药物输注,直至病人清醒并能正确回答至少3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定至需要的镇静水平(Ramsay3–4).KressJP,etal:NEnglJMed2000;342:1471–1477

Dailyinterruptionofsedative58Dailyinterruptionofsedatives每日唤醒组插管保留时间、ICU滞留时间明显短于常规组，并有住院日更短的趋势KressJP,etal:NEnglJMed2000;342:1471–1477Dailyinterruptionofsedative59Sedationvacationsrisks

Potentialcomplications：self-extubation,etcIncreasedpotentialforpainandanxietyassociatedwithlighteningsedationIncreasedtoneandpoorsynchronywiththeventilatorduringthemaneuvermayriskepisodesofdesaturation.

SedationvacationsrisksPoten60UlcerProphylaxis&VAP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。Controversial：whethertheuseofsucralfateandH2-receptorantagonistsincreasestheprobabilityofdevelopingVAP???NOidentifyanincreasedrateforpneumoniaintheranitidinegroupthanthesucralfategroupCookDJ,etal.NEnglJMed1998,338:791-797.UlcerProphylaxis&VAP可能的是:：当61PepticUlcerDiseaseProphylaxisASHP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的发生具有以下一项危险因素以上的患者应采取预防措施:①呼吸衰竭(机械通气超过48h)；②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；③烧伤面积>30%。④器官移植。⑤多发伤(创伤程度积分≥16)。⑥肝肾功能不全。⑦脊髓损伤。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)PepticUlcerDiseaseProphylax62PepticUlcerDiseaseProphylaxisH2receptorinhibitorsaremoreefficaciousthansucralfateandarethepreferredagents.ProtonpumpinhibitorshavenotbeenassessedinadirectcomparisonwithH2receptorantagonistsand,therefore,theirrelativeefficacyisunknown.TheydodemonstrateequivalencyinabilitytoincreasegastricpHDellingerRP,etal.CritCareMed.Mar2004;32(3):858-873.PepticUlcerDiseaseProphylax63DeepVenousThrombosisProphylaxisRecommendsprophylaxisforpatientsundergoingsurgery,traumapatients,acutelyillmedicalpatients,andpatientsadmittedtotheintensivecareunit.深静脉血栓(DVT)的预防：SevereSepsis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)。既往有DVT史的SevereSepsis，应联合应用抗凝药物和物理性预防措施潜在并发症：出血GeertsWH,etal.Chest.Sep2004;126(3Suppl):338S-400SDeepVenousThrombosisProphyl64CentralLineBundleHandHygieneMaximalBarrierPrecautionsUponInsertionChlorhexidineSkinAntisepsisOptimalCatheterSiteSelectionDailyReviewofLineNecessitywithPromptRemovalofUnnecessaryLinesCentralLineBundleHandHygie65handhygieneProperwashinghandsorusinganalcohol-basedwaterlesshandcleanercanhelpto

preventcontaminationofcentrallinesitesandbloodstreaminfections.Someappropriatetimesforhandwashinginclude:WhentheyareobviouslysoiledORIfcontaminationissuspectedBeforeandafterinvasiveproceduresBetweenpatientsAfterremovingglovesBeforeeatingORAfterusingthebathroomO'GradyNPetal.MMWRRecommRep.Aug92002;51(RR-10):1-29.handhygieneProperwashinghan66MaximalBarrierPrecautionsUponInsertionMaximalbarrierprecautionsclearlydecreasetheoddsofdevelopingcatheter-relatedbloodstreaminfections.Fortheoperatorandassistant,maximalbarrierprecautionsmeansstrictcompliancewithhandwashing,wearingacap,mask,sterilegownandgloves.

Thecapshouldcoverallhairandthemaskshouldcoverthenoseandmouthtightly.

Forthepatient,maximalbarrierprecautionsmeanscoveringthepatientfromheadtotoewithasteriledrapewithasmallopeningforthesiteofinsertionMermelLA,etal.AmJMed.Sep161991;91(3B):197S-205SRaad,II,etal.InfectControlHospEpidemiol.Apr1994;15(4Pt1):231-238MaximalBarrierPrecautionsUp67ChlorhexidineSkinAntisepsisChlorhexadineskinantisepsishasbeenproventoprovidebetterskinantisepsisthanotherantisepticagentssuchaspovidone-iodinesolutions.

Prepareskinwithantiseptic/detergentchlorhexidine2%

in70%

isopropylalcohol.Presschlorhexadineapplicatorspongeagainstskin,applychlorhexidinesolutionusingabackandforthfrictionscrubforatleast30seconds.

Donotwipeorblot.Allowantisepticsolutiontimetodry

completelybeforepuncturingthesite(~2minutes).ChlorhexidineSkinAntisepsisC68OptimalCatheterSiteSelectionThegreatmajorityofinfectionsdevelopattheinsertionsite.Moreriskfactorsofthejugularinsertionsiteoverthesubclaviansite.

Wheneverpossible,andnotcontraindicated,SubclavianVeinasthePreferredSiteMermelLA,etal.AmJMed.Sep161991;91(3B):197S-205SMcCarthyMC,etal.JParenterEnteralNutr.1987May-Jun;11(3):259-62.OptimalCatheterSiteSelectio69DailyReviewofLineNecessityDailyreviewofcentrallinenecessitywillpreventunnecessarydelaysinremovinglinesthatarenolongerclearlynecessaryinthecareofthepatient.

Manytimes,centrallinesremaininplacesimplybecauseoftheirreliableaccessandbecausepersonnelhavenotconsideredremovingtheline.

However,itiscleartha