经皮中心静脉置管感染预防指南课件

经皮中心静脉置管感染预防指南梁大伟天坛医院神经内科2005.8.20经皮中心静脉置管感染预防指南导管相关感染的诊断定义局部感染定义：（1）局部自发或经触压后有脓性渗出，无需细菌学证据。（2）穿刺部位的红肿、发热、硬结（三者中任两者），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导管相关感染的诊断定义菌血症感染的定义：（1）外周血培养结果阳性，且为一种微生物，导管片段（近端或远端）经定量或半定量方法分离出同一种微生物（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的菌株。（3）导管穿刺部位渗出的脓液、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种细菌（种类及耐药谱）。经皮中心静脉置管感染预防指南导管相关感染的诊断定义可能感染的定义包括：（1）两次或两次以上血培养（无论是外周血还是中心静脉回抽血）出同一种细菌（种类及耐药谱），且临床及实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（无论是外周血还是中心静脉回抽血），且临床及实验室证实无其它感染源。（3）免疫抑制或粒细胞减少（粒细胞<500ul）的病人，血培养阳性（凝固酶阴性的葡萄球菌，杆菌属，棒状杆菌属，糠秕马拉色霉菌等），临床及实验室证实无其它细菌感染源，只有中心静脉留置导管，通常与导管相关性菌血症有关。经皮中心静脉置管感染预防指南CVC引起相关感染的机制1.infectionoftheexitsite,followedbymigrationofthepathogenalongtheexternalcathetersurface.2.contaminationofthecatheterhub,leadingtointraluminalcathetercolonization.3.hematogenousseedingofthecatheter.

经皮中心静脉置管感染预防指南病原体若不幸感染,常见的菌种包括:

Coagulase-negativestaphylococci(37%),Staphylococcusaureus(13%),Enterococcus(13%),Gram-negativerods(14%).值得注意的是,抗药性强的菌种包括staph.以及Enterococcus都榜上有名..所以如果不幸发生感染..多半就非得要用上vancomycin..可能不行还要用上linezolid..相当的麻烦..另外一个值得注意的是..fungi..fungi的感染扮演部分角色(在NNIS的数据中是8%)..在Candidia的感染中,大约一半是non-albicanspecies造成的...包括C.glabrata与C.krusei..这些fungi对fluconazole容易产生抗药性.经皮中心静脉置管感染预防指南Guidelinesforpreventinginfectionsassociatedwiththeinsertionandmaintenanceofcentralvenouscatheters

中心静脉置管相关性感染的预防指南JournalofHospitalInfection(2001)47(Supplement):S5–S9经皮中心静脉置管感染预防指南Intervention1:Selectionofcathetertype

导管类型的选择Intervention2:Selectionofcatheterinsertionsite

置管点的选择Intervention3:Optimumaseptictechniqueduringcatheterinsertion

置管过程中无菌技术的最优化Intervention4:Cutaneousantisepsis

皮肤消毒Intervention5:Catheterandcathetersitecare

导管和置管点的护理Intervention6:Replacementstrategies

更换方法Intervention7:Antibioticprophylaxis

预防性使用抗生素经皮中心静脉置管感染预防指南Selectionofcathetertype1Useasingle-lumencatheterunlessmultipleportsareessentialforthemanagementofthepatient.

尽量采用单腔管，除非患者需要多通道治疗，2Iftotalparenteralnutritionisbeingadministered,useonecentralvenouscatheterorlumenexclusivelyforthatpurpose.

如果需要TPN，专用一根中心静脉导管或专用一个管腔3Useatunnelledcatheteroranimplantablevascularaccessdeviceforpatientsinwhomlong-term(30days)vascularaccessisanticipated.

如果预计要长时间（30天）保留血管通路，采用管道式导管或植入式血管通路4Considertheuseofanantimicrobialimpregnatedcentralvenouscatheterforadultpatientswhorequireshort-term(10days)centralvenouscatheterisationandwhoareathighriskforCR-BSI.需短期（10天）保留CVC者，并且是导管相关的血源性感染的高危患者，使用外涂抗菌素的CVC经皮中心静脉置管感染预防指南Selectionofcatheterinsertionsite5Inselectinganappropriateinsertionsite,assesstherisksforinfectionagainsttherisksofmechanicalcomplications.

选择置管位点时，要权衡感染风险和机械并发症的风险6Unlessmedicallycontraindicated,usethesubclaviansiteinpreferencetothejugularorfemoralsitesfornontunnelledcatheterplacement.

做非管道性置管，如无禁忌，采用锁骨下置管好于颈静脉或股静脉置管7Considertheuseofperipherallyinsertedcathetersasanalternativetosubclavianorjugularveincatheterisation.

外周静脉置管可作为锁骨下置管或颈静脉置管的替代方法经皮中心静脉置管感染预防指南Optimumaseptictechniqueduringcatheterinsertion8Useoptimumaseptictechnique,includingasterilegown,gloves,andalargesteriledrape,fortheinsertionofcentralvenouscatheters.

置管时采用最佳的无菌技术，穿无菌衣，戴无菌手套，盖无菌单经皮中心静脉置管感染预防指南Cutaneousantisepsis9CleantheskinsitewithanalcoholicchlorhexidinegluconatesolutionpriortoCVCinsertion.Useanalcoholicpovidone-iodinesolutionforpatientswithahistoryofchlorhexidinesensitivity.Allowtheantiseptictodrybeforeinsertingthecatheter.

置管前用含酒精的葡萄糖酸洗必泰清洗穿刺点皮肤，如对碘剂过敏，使用含酒精的聚维酮碘消毒，待消毒剂干燥后置管10Donotapplyorganicsolvents,e.g.,acetone,ether,totheskinbeforecatheterinsertion.

不要使用有机溶剂，如丙酮、乙醚等。11Donotroutinelyapplyantimicrobialointmenttothecatheterplacementsitepriortoinsertion.

置管前穿刺点不要使用抗生素软膏经皮中心静脉置管感染预防指南Catheterandcathetersitecare12Beforeaccessingthesystem,disinfecttheexternalsurfacesofthecatheterhubandconnectionportswithanaqueoussolutionofchlorhexidinegluconateorpovidone-iodine,unlesscontraindicatedbythemanufacturer’srecommendations.

接触前，要用葡萄糖酸洗必泰水溶液或聚维酮碘水溶液消毒导管活栓或接头的外表面，除非厂家禁止这样做13Useeitherasterilegauzeortransparentdressingtocoverthecathetersite.

用无菌纱布或透明贴膜覆盖置管点14Ifagauzeandtapecathetersitedressingisused,itmustbereplacedwhenthedressingbecomesdamp,loosened,orsoiled,orwheninspectionoftheinsertionsiteisnecessary.

如果是使用纱布和胶布覆盖的，一旦浸湿、松脱或弄脏，或需要查看穿刺点时，要及时更换。15DonotapplyantimicrobialointmenttoCVCinsertionsitesaspartofroutinecathetersitecare.

不要使用抗生素软膏处理穿刺点。16Routinelyflushindwellingcentralvenouscatheterswithananticoagulantunlessadvisedotherwisebythemanufacturer.常规使用抗凝剂冲洗置入的CVC，除非厂家有其它建议经皮中心静脉置管感染预防指南Replacementstrategies17Donotroutinelyreplacenon-tunnelledCVCasamethodtopreventcatheter-relatedinfections.

不要把常规更换非管道性CVC作为预防导管相关感染的方法18Useguidewireassistedcatheterexchangetoreplaceamalfunctioningcatheter,ortoexchangeanexistingcatheterifthereisnoevidenceofinfectionatthecathetersiteorprovenCR-BSI.

借助导丝更换导管。19IfCR-infectionissuspected,butthereisnoevidenceofinfectionatthecathetersite,removetheexistingcatheterandinsertanewcatheteroveraguidewire;iftestsrevealCR-infection,thenewlyinsertedcathetershouldberemovedand,ifstillrequired,anewcatheterinsertedatadifferentsite.如果怀疑存在导管相关的感染，而置管点无明显的感染迹象，去掉原来的导管，在导丝引导下置入新管；如果检验显示存在导管相关的感染，去掉新置入的导管，如仍然需要置管，另选穿刺点置入新管。经皮中心静脉置管感染预防指南Replacementstrategies20DonotuseguidewireassistedcatheterexchangeforpatientswithCR-infection.Ifcontinuedvascularaccessisrequired,removetheimplicatedcatheter,andreplaceitwithanothercatheteratadifferentinsertionsite.

患者有导管相关的感染时不采用借助导丝的导管更换。如果必须继续保持血管通路，去掉受累导管，另取穿刺点置新管。21Replacealltubingwhenthevasculardeviceisreplaced.

更换血管装置的同时更换所有管路。22Replaceintravenoustubingandstopcocksnomorefrequentlythanat72-hourintervals,unlessclinicallyindicated.

更换静脉内管道和活栓的间隔时间不能短于72小时，除非临床需要。23Replaceintravenoustubingusedtoadministerblood,bloodproducts,orlipidemulsionsattheendoftheinfusionorwithin24hoursofinitiatingtheinfusion.若更换用于输血、血液制品、脂肪乳的静脉内管路，要在输注末或开始输注后24小时内更换。经皮中心静脉置管感染预防指南Antibioticprophylaxis24Donotadministersystemicantimicrobialsroutinelybeforeinsertionorduringuseofacentralvenouscathetertopreventcathetercolonisationorbloodstreaminfection.不要为了预防导管细菌生长或血行感染而常规给予全身应用抗菌素，不论是在插管前或在使用CVC中。经皮中心静脉置管感染预防指南PreventingComplicationsofCentralVenous

CatheterizationNEnglJMed2003;348:1123-33.经皮中心静脉置管感染预防指南InterventionstoPreventinfectionsUseantimicrobial-impregnatedcatheters

使用外涂抗菌素的导管Insertcathetersatthesubclavianvenoussite

取锁骨下穿刺点置入导管Usemaximalsterile-barrierprecautionsduringcatheterinsertion

在导管置入术中尽最大肯能采取无菌措施Avoidtheuseofantibioticointments

避免使用抗生素软膏Disinfectcatheterhubs

消毒导管活栓Donotscheduleroutinecatheterchanges

不要常规更换导管Removecatheterswhentheyarenolongerneeded如果不再需要，撤除导管经皮中心静脉置管感染预防指南Useantimicrobial-impregnatedcathetersTheuseofantimicrobial-impregnatedcathetersreducestheriskofcatheter-relatedbloodstreaminfectionsandreducescostswhentherateofcatheter-relatedbloodstreaminfection>2%

使用涂有抗菌素的导管减少导管相关的血流感染，当导管相关血流感染>2%时减少花费。经皮中心静脉置管感染预防指南InsertcathetersatthesubclavianvenoussiteTheriskofcatheter-relatedinfectionislowerwithsubclaviancatheterizationthanwithinternaljugularorfemoralcatheterization

锁骨下静脉置管的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Usemaximalsterile-barrierprecautionsduringcatheterinsertionUseofamask,cap,sterilegown,sterilegloves,andlargesteriledrapereducestherateofinfectionsandreducescosts

戴口罩、帽子、无菌手套，穿无菌衣，覆盖无菌大单等能减少感染发生率，降低花费。经皮中心静脉置管感染预防指南AvoidtheuseofantibioticointmentsTheapplicationofantibioticointmentsincreasestherateofcolonizationbyfungi,promotesthedevelopmentofantibiotic-resistantbacteria,andhasnotbeenshowntoaffecttheriskofcatheterrelatedbloodstreaminfections

使用抗生素软膏增加真菌定殖率，增加耐药菌的产生，并不能降低导管相关血流感染的发生率经皮中心静脉置管感染预防指南DisinfectcatheterhubsCatheterhubsarecommonsitesofcathetercontaminatio

导管活栓是导管污染的常见部位经皮中心静脉置管感染预防指南DonotscheduleroutinecatheterchangesScheduled,routinereplacementofcentralvenouscathetersatanewsitedoesnotreducetheriskofcatheter-relatedbloodstreaminfection;scheduled,routineexchangeofcathetersoveraguidewireisassociatedwithatrendtowardincreasedcatheterrelatedinfections有计划的、常规的CVC更换到新位置并不能降低导管相关血流感染的发生率；有计划的、常规的导丝引导下的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RemovecatheterswhentheyarenolongerneededTheprobabilityofcolonizationandcatheter-relatedbloodstreaminfectionincreasesovertime

随着时间推移，细菌定殖和导管相关血流感染的可能性增大。经皮中心静脉置管感染预防指南TypesofCatheter-AssociatedInfectionsCathetercolonization导管细菌定殖

Growthoforganismsfromacathetersegmentbyeithersemiquantitativeorquantitativeculture

通过半定量或定量培养，使导管片段的微生物生长Catheter-relatedbloodstreaminfection导管相关的血流感染

Isolationofthesameorganismfromabloodcultureandfromasemiquantitativeorquantitativecultureofacathetersegment,accompaniedbyclinicalsymptomsofbloodstreaminfectionwithoutanyotherapparentsourceofinfection

血培养分理出的细菌与导管片段半定量或定量培养得到的细菌相同，并伴有血流感染的临床症状，而没有其它明显的感染源。Exit-siteinfection出口感染

Erythema,tenderness,induration,orpurulencewithin2cmoftheexitsiteofthecatheter

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ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepsisisdefinedasasystemicresponsetoinfection,manifestedbytwoormoreofthefollowingconditions:temperatureabove38.5°Corbelow36.0°C;heartrateabove90beatsperminute;respiratoryrateabove20breathsperminuteorpartialpressureofarterialcarbondioxidebelow32mmHg;andwhite-cellcountgreaterthan12,000percubicmillimeterorlessthan4000percubicmillimeterorwith10percentimmature(band)forms.脓毒症是指感染的全身反应，具有下列两条或两条以上的表现：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；白细胞计数超过12000/mm3或低于4000/mm3或幼稚细胞达到10％。经皮中心静脉置管感染预防指南ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepticshockisdefinedassepsis-inducedhypotensionorarequirementforvasopressorsorinotropicagentstomaintainbloodpressuredespiteadequatefluidresuscitation,alongwiththepresenceofperfusionabnormalitiesthatmayinclude(butarenotlimitedto)lacticacidosis,oliguria,oracutealterationinmentalstatus.脓毒症性休克是指脓毒症诱发的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，包括（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ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionWhenbloodculturesareobtained,samplesfromperipheralsitesarepreferred.Cathetertipculturesshouldbeperformedbythesemiquantitativeorquantitativetechnique.如果做血培养，最好是取周围位点的样本。导管尖培养应当采用定量或半定量方法。经皮中心静脉置管感染预防指南ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionEmpiricalantibiotictherapyforsuspectedcatheter-relatedbloodstreaminfectionshouldincludevancomycin.Antibioticsthatareeffectiveagainstgram-negativeorganismsshouldbeadded,especiallyifthepatientisimmunocompromisedorhasneutropenia,isinfectedwithgram-negativeorganisms,