中心静脉插管相关感染课件

中心静脉插管相关感染中心静脉插管相关感染中心静脉插管相关感染导管相关性感染:流行病学美国ICU每年16,000例CRBSI病死率18%(0–35%)每年死亡500–4,000例每例CRBSI医疗费用$28,690–56,000每年费用$60,000,000–460,000,000CDC.MMWR2002;HeiselmanJAMA1994;DimickArchSurg2001中心静脉插管相关感染中心静脉插管相关性感染发病率患者数 n=1,098中心静脉插管 n=1,263导管留置天 n=6,075细菌定植 n=333(26.3%)CRBSI n=35(2.7%) 5.9/1,000导管留置天SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心静脉插管相关感染中心静脉插管相关性感染:定义明确的导管相关性血行性感染:导管培养阳性(半定量或定量)拔除导管前外周血培养阳性上述培养中分离出相同微生物可能的导管相关性血行性感染:菌血症+插管部位脓性分泌物,或导管接头培养阳性,或导管血培养分离出相当于外周血培养5倍的微生物或培养阳性差异时间2小时CohenJ,Brun-BuissonC,TorresA,JorgensenJ.Diagnosisofinfectioninsepsis:Anevidence-basedreview.CritCareMed2004;32[Suppl.]:S466–S494中心静脉插管相关感染中心静脉插管相关性感染:定义非菌血症导管相关性感染导管培养阳性,且为感染来源没有发生菌血症为排除诊断(没有其他能够解释感染的明显病灶,且拔除导管48小时内感染表现缓解)导管局部感染导管培养(半定量或定量)(不)伴局部症状(红,痛)没有全身炎症反应CohenJ,Brun-BuissonC,TorresA,JorgensenJ.Diagnosisofinfectioninsepsis:Anevidence-basedreview.CritCareMed2004;32[Suppl.]:S466–S494)中心静脉插管相关感染中心静脉插管相关性感染:定义中心静脉插管相关性感染

原发性血行性感染(原发病灶不明)中心静脉插管相关感染中心静脉插管相关感染Renaud,etal.AmJRespirCritCareMed2001;163:1584-90中心静脉插管相关感染导管定植:单腔vs.多腔ZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心静脉插管相关感染CRBSI:单腔vs.多腔ZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心静脉插管相关感染CRBSI:单腔vs.多腔OR(95%CIfixed)Single-Lumenn/N(%)Multi-Lumenn/N(%)OR(95%CIfixed)13/99(13.1)2/78(2.6)3.88(1.34–11.2)5/61(8.2)5/68(7.4)Clark-ChristoffFarkas1.12(0.31–4.07)1/25(4.0)1/25(4.0)Gupta1.00(0.06–16.5)0/51(0)0/48(0)Johnsonn/a4/39(10.3)0/36(0)McCarthy7.42(1.00–54.9)23/275(8.4)8/255(3.1)Combined2.58(1.24–5.37)0.1110Favorsmulti-lumenFavorssinglei-lumenZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心静脉插管相关感染CRBSI:单腔vs.多腔ZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心静脉插管相关感染导管定植与感染:单腔vs.多腔DezfulianC,LavelleJ,NallamothuBK,KaufmanSR,SaintS.Ratesofinfectionforsingle-lumenversusmultilumencentralvenouscatheters:Ameta-analysis.CritCareMed2003;31:2385–2390中心静脉插管相关感染导管定植与感染:插管部位的影响LorenteL,VillegasJ,MartinMM,JimenezA,MoraML.Catheter-relatedinfectionincriticallyillpatients.IntensiveCareMed.2004Aug;30(8):1681-4.Epub2004May25.中心静脉插管相关感染中心静脉插管相关性感染:发病机制中心静脉插管相关感染中心静脉插管相关性感染:发病机制SafdarN,MakiDG.Thepathogenesisofcatheter-relatedbloodstreaminfectionwithnoncuffedshort-termcentralvenouscatheters.IntensiveCareMed.2004Jan;30(1):62-7.Epub2003Nov26.对照组治疗组**1%洗必太-75%酒精;含洗必太的敷料中心静脉插管相关感染中心静脉插管相关性感染:致病菌SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.致病菌N凝固酶阴性葡萄球菌27肠球菌4阴沟肠杆菌1肺炎克氏菌1洋葱伯克霍尔德菌1念珠菌属1中心静脉插管相关感染能否依靠临床表现鉴别菌血症菌血症与非菌血症患者的血流动力学、临床和实验室指标变量均值P值非菌血症(n=268)菌血症(n=197)体温,F100.7(2.9)101.1(3.1)0.22呼吸频率,bpm31(10)29(9)0.047PaCO2,mmHg33(11)31(9)0.051脉搏,bpm118(17)118(19)0.64收缩压,mmHg104(30)95(31)0.002白细胞计数,x10918(16)17(10)0.42中性粒细胞,%67(22)65(22)0.30未成熟中性粒细胞,%17(17)21(16)0.02血小板计数,x103279(186)219(145)0.0001PeduzziP,etal.PredictorsofbacteremiaandGram-negativebacteremiainpatientswithsepsis.ArchInternMed1992;152:529-535中心静脉插管相关感染能否依靠临床表现鉴别菌血症逻辑回归分析结果预测因素系数标准误

2P值体温,线性-3.6831.1844.020.045体温,二次0.0190.0094.160.041呼吸频率-0.0210.0113.410.065PaCO2-0.0170.0102.620.105脉搏0.0030.0060.240.625收缩压-0.0100.0039.260.002白细胞计数-0.0010.0070.010.942中性粒细胞计数0.0040.0050.490.484未成熟中性粒细胞计数0.0130.0073.400.065血小板计数-0.0020.0018.350.004PeduzziP,etal.PredictorsofbacteremiaandGram-negativebacteremiainpatientswithsepsis.ArchInternMed1992;152:529-535中心静脉插管相关感染能否依靠临床表现鉴别CRBSI项目评分红斑无红斑0轻度红斑1重度红斑2脓性分泌物无0有1肿胀无0有1疼痛无0有1SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心静脉插管相关感染能否依靠临床表现鉴别CRBSI指标指标阳性导管数(%)CRBSIN=35细菌定植的导管N=333无感染无定植的导管N=894疼痛(0,1)25(2)0.00.20.40.20.4红斑(0–2)25(2)0.00.10.30.10.2肿胀(0,1)126(10)0.20.40.10.40.10.4脓液(0,1)10(0.8)00.00.10总分(0–5)126(10.0)0.20.40.10.10.10.1SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心静脉插管相关感染能否依靠临床表现鉴别CRBSI敏感性%特异性%PPV%NPV%导管定植(n=333)红4941773肿6924647痛15913080脓1994073CRBSI(n=35)红398497肿095094痛094097脓099097SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心静脉插管相关感染能否依靠临床表现鉴别导管相关感染插管部位炎症表现不敏感(多数导管感染并无相应表现)不特异(出现相应表现亦无需拔除导管)提示导管感染的症状和体征插管部位脓性分泌物插管部位蜂窝织炎超过4mm中心静脉插管相关感染血培养的临床价值:导管血真正菌血症培养结果是(n=34)否(n=266)阳性2820阴性6246敏感性82.4%(69.7–95.1)特异性92.5%(89.4–95.6)阳性预期值58.3%(44.4–72.2)阴性预期值97.6%(95.7–99.5)BeutzM,ShermanG,MayfieldJ,FraserVJ,KollefMH.Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients.Chest2003;123:854-861中心静脉插管相关感染血培养的临床价值:外周血真正菌血症培养结果是(n=34)否(n=266)阳性2211阴性12255敏感性64.7%(48.6–80.8)特异性95.9%(93.5–98.3)阳性预期值66.7%(50.6–82.8)阴性预期值95.5%(93.0–98.0)BeutzM,ShermanG,MayfieldJ,FraserVJ,KollefMH.Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients.Chest2003;123:854-861中心静脉插管相关感染血培养的临床价值:导管血vs.外周血BeutzM,ShermanG,MayfieldJ,FraserVJ,KollefMH.Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients.Chest2003;123:854-861中心静脉插管相关感染三腔CVC应当从哪个腔取血DobbinsBM,CattonJA,KiteP,McMahonMJ,WilcoxMH.Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed2003;31:1688–1690对照组CVC怀疑CRBSI的CVC无CRBSIN=50无CRBSIN=25CRBSIN=25明显细菌定植的导管腔数16410233103005导管外表面细菌定植的导管数281420中心静脉插管相关感染三腔CVC应当从哪个腔取血在CRBSI的病例,40%的CVC仅一个导管腔有细菌的明显定植随机从一个导管腔留取血培养,阴性结果的可能性为66%(2/3)总体而言,对于CRBSI病例,随机从一个导管腔留取血培养,阴性结果可能性为40%60%的机会发现细菌定植DobbinsBM,CattonJA,KiteP,McMahonMJ,WilcoxMH.Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed2003;31:1688–1690中心静脉插管相关感染DTD对于诊断CRBSI的意义目的:证实同时从外周静脉和中心静脉采取的血培养阳性时间差(DTD)对于鉴别CRBSI和非CRBSI的作用设计:前瞻性临床试验研究对象:15个月内总共9例CRBSI和24例非CRBSIGaurAH,FlynnPM,GianniniMA,etal.Differenceintimetodetection:asimplemethodtodifferentiatecatheter-relatedfromnon-catheter-relatedbloodstreaminfectioninimmunocompromisedpediatricpatients.ClinInfectDis.2003Aug15;37(4):469-75中心静脉插管相关感染DTD对于诊断CRBSI的意义结果与非CRBSI相比,CRBSI的DTD显著增加(457vs.-4min;P<.001)采用DTD

120min作为诊断CRBSI的临界值敏感性,88.9%特异性,100%PPV,100%NPV89–96%(试验前CRBSI概率28–54%)结论:在应用持续读数血培养系统的医院中,DTD是诊断CRBSI的一种简单可靠的方法GaurAH,FlynnPM,GianniniMA,etal.Differenceintimetodetection:asimplemethodtodifferentiatecatheter-relatedfromnon-catheter-relatedbloodstreaminfectioninimmunocompromisedpediatricpatients.ClinInfectDis.2003Aug15;37(4):469-75中心静脉插管相关感染中心静脉插管相关感染:治疗立即拔除导管选择新的部位插管在原部位经导丝重新置入导管拔除导管进行培养培养阳性时拔除新置入导管应用抗生素中心静脉插管相关感染拔除导管实际感染的比例MerrerJ,DeJongheB,GolliotF,etal.(2001)Complicationsoffemoralandsubclavianvenouscatheterizationincriticallyillpatients:arandomizedcontrolledtrial.JAMA286:700–707.LeonC,Alvarez-LermaF,Ruiz-SantanaS,etal.(2003)Antisepticchamber-containinghubreducescentralvenouscatheter-relatedinfection:aprospective,randomizedstudy.CritCareMed31:1318–1324.RanucciM,IsgroG,GiomarelliPP,etal.(2003)Impactofoligoncentralvenouscathetersoncathetercolonizationandcatheter-relatedbloodstreaminfection.CritCareMed31:52–59.DobbinsBM,CattonJA,KiteP,etal.(2003)Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed31:1688–1690.DarouicheRO,RaadII,HeardSO,etal.(1999)Acomparisonoftwoantimicrobial-impregnatedcentralvenouscatheters.CatheterStudyGroup.NEnglJMed340:1–8.中心静脉插管相关感染患者发热时能否保留中心静脉导管RijndersBJ,PeetermansWE,VerwaestC,WilmerA,VanWijngaerdenE.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed(2004)30:1073–1080.DOI10.1007/s00134-004-2212-x医生怀疑CRI,计划拔除CVC研究组标准治疗组留取血培养x2拔除CVCCVC继续留置5天血培养阳性或血流动力学不稳定拔除CVC感染好转感染持续保留CVC中心静脉插管相关感染血流动力学不稳定收缩压<90mmHg或较基础值降低40mmHg以上,且无导致低血压的其他原因.平均动脉压<60mmHg需要应用多巴胺或多巴酚丁胺维持血压,或在过去12小时内上述药物剂量增加超过5

g/kg/min开始应用去甲肾上腺素维持血压,或在过去12小时内上述药物剂量增加超过0.25

g/kg/minRijndersBJ,PeetermansWE,VerwaestC,WilmerA,VanWijngaerdenE.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed(2004)30:1073–1080.DOI10.1007/s00134-004-2212-x中心静脉插管相关感染患者发热时能否保留中心静脉导管研究组标准治疗组P值更换CVC16/4238/38<.01CRBSI32>.20住院日3442>.20ICU病死率8/3210/32>.20RijndersBJ,PeetermansWE,VerwaestC,WilmerA,VanWijngaerdenE.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed(2004)30:1073–1080.DOI10.1007/s00134-004-2212-x中心静脉插管相关感染中心静脉插管相关性感染:预防GuidelinesforthePreventionofIntravascularCatheter-RelatedInfections.August2002.MermelLA.PreventionofIntravascularCatheter-relatedInfections.AnnInternMed2000;132:391-402中心静脉插管相关感染中心静脉插管相关性感染:治疗不符合IDSA治疗指南的比例第一阶段34%(24/71)普通病房(23/52[44%])明显高于ICU(1/19[5%])(p<.01)第二阶段44%(23/52)

15%(7/46)(p=.004)RijndersBJA,VandecasteeleSJ,VanWijngaerdenE,DeMunterP,PeetermansWE.UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter-RelatedInfection:ABefore-AfterStudy.ClinicalInfectiousDiseases2003;37:980–3中心静脉插管相关感染如何改进依从性发现CRBSI后,向主治医生发送有关标准化治疗的电子邮件(作为电子病历的一部分)将打印文件放在病房医生的桌上不进行面对面的讨论对于非白色念珠菌引发的CRBSI,建议主治医生找感染科医生会诊以确定个体化治疗方案RijndersBJA,VandecasteeleSJ,VanWijngaerdenE,DeMunterP,PeetermansWE.UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter-RelatedInfection:ABefore-AfterStudy.ClinicalInfectiousDiseases2003;37:980–3中心静脉插管相关感染如何改进依从性RijndersBJA,VandecasteeleSJ,VanWijngaerdenE,DeMunterP,PeetermansWE.UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter-RelatedInfection:ABefore-AfterStudy.ClinicalInfectiousDiseases2003;37:980–3中心静脉插管相关感染中心静脉插管相关感染:宣教LoboRD,LevinAS,GomesLMP,CursinoR,ParkM,FigueiredoVB,TaniguchiL,PolidoCG,CostaSF.ImpactofaneducationalprogramandpolicychangesondecreasingcatheterassociatedbloodstreaminfectionsinamedicalintensivecareunitinBrazil.AmJInfectControl2005;33:83-7继续教育项目,操作规程标准化中心静脉插管相关感染预防策略:5Key“BestPractice”Issues拔除不必要的中心静脉插管手部清洁采取最严格的消毒隔离措施应用洗必太进行皮肤消毒避免应用股静脉插管MMWR.2002;51:RR-10中心静脉插管相关感染手部清洁1977以来,共有7项前瞻性研究显示,改进手部清洁能够显著减少各种感染并发症Larsen.ClinInfectDis1999;29:1287-94Lancet2000;356:1307-1312中心静脉插管相关感染中心静脉插管相关感染最严格的隔离措施(maximalbarrierprecautions)对于医生而言手部清洁非无菌帽子和口罩帽子应覆盖所有头发口罩应当罩紧口鼻无菌手套和隔离衣对于患者而言使用大的无菌铺巾覆盖患者头部和身体中心静脉插管相关感染最严格的隔离措施(maximalbarrierprecautions)中心静脉插管相关感染最严格的隔离措施(MBP):文献回顾作者及年份研究设计导管种类无MBP时感染的ORMermel,1991前瞻横断面PAC2.2(p=0.03)Raad1994前瞻随机CVC3.3(p=0.03)AmJMed1991;91(3B):197S-205SInfectControlHospEpidemiol1994;15:231-8中心静脉插管相关感染皮肤消毒:洗必太AnnInternMed.2002;136:792-801中心静脉插管相关感染皮肤消毒:洗必太AnnInternMed.2002;136:792-801中心静脉插管相关感染选择哪个部位进行插管ICU股静脉和锁骨下静脉插管的RCT145名患者股静脉插管/144名患者锁骨下静脉插管预后股静脉插管组感染并发症更高:19.8%vs4.5%(p<.001)股静脉插管组血栓并发症更多:21.5%vs.1.9%(p<.001);完全性血栓栓塞6%vs.0%机械并发症发生率相似:17.3%vs18.8%(p=NS)JAMA2001,286:700-7中心静脉插管相关感染ICU医生的依从性为期2周的观察期对医生设盲26根导管8(31%)根新置入中心静脉插管18(69%)根通过导丝更换的导管没有紧急插管BerenholtzSM,PronovostPJ,LipsettPA,HobsonD,EarsingK,FarleyJE,MilanovichS,Garrett-MayerE,WintersBD,RubinHR,DormanT,PerlTM.Eliminatingcatheter-relatedbloodstreaminfectionsintheintensivecareunit.CritCareMed.2004Oct;32(10):2014-20.中心静脉插管相关感染ICU医生的依从性BerenholtzSM,PronovostPJ,LipsettPA,HobsonD,EarsingK,FarleyJE,MilanovichS,Garrett-MayerE,WintersBD,RubinHR,DormanT,PerlTM.Eliminatingcatheter-relatedbloodstreaminfectionsintheintensivecareunit.CritCareMed.2004Oct;32(10):2014-20.中心静脉插管相关感染消除CRBSI医务人员的宣教VAD政策以及网络教育项目避免烦琐的准备过程:插管车反复检查每日询问导管是否可以拔除清单观察到医生违反操作规程时,护士有权终止其操作BerenholtzS