中心静脉插管相关感染

1、中心静脉插管相关感染,北京协和医院 杜斌,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$60,000,000 460,000,000,CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001,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%) CRBSIn = 35 (2.7%) 5.9

2、/ 1,000导管留置天,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30: 2632-2635.,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

3、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,Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: An evidence-based review. Crit Care Med 2004; 32Suppl.: S466 S494,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

4、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,Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: An evidence-based review. Crit Care Med 2004; 32Suppl.: S466 S494),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,Renaud, et al. Am J Respir Crit Care Med 2

5、001; 163: 1584-90,导管定植: 单腔 vs. 多腔,Zrcher M, Tramr MR, Walder B. Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review. Anesth Analg 2004;99:17782,CRBSI: 单腔 vs. 多腔,Zrcher M, Tramr MR, Walder B. Colonization and Bloodstream In

6、fection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review. Anesth Analg 2004;99:17782,CRBSI: 单腔 vs. 多腔,OR (95% CI fixed),Single- Lumen n/N (%),Multi- Lumen n/N (%),OR (95% CI fixed),13/99 (13.1),2/78 (2.6),3.88 (1.34 11.2),5/61 (8.2),5/68 (7.4),Clark-Christof

7、f,Farkas,1.12 (0.31 4.07),1/25 (4.0),1/25 (4.0),Gupta,1.00 (0.06 16.5),0/51 (0),0/48 (0),Johnson,n/a,4/39 (10.3),0/36 (0),McCarthy,7.42 (1.00 54.9),23/275 (8.4),8/255 (3.1),Combined,2.58 (1.24 5.37),0.1,1,10,Favors multi-lumen,Favors singlei-lumen,Zrcher M, Tramr MR, Walder B. Colonization and Blood

8、stream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review. Anesth Analg 2004;99:17782,CRBSI: 单腔 vs. 多腔,Zrcher M, Tramr MR, Walder B. Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Syste

9、matic Review. Anesth Analg 2004;99:17782,导管定植与感染: 单腔 vs. 多腔,Dezfulian C, Lavelle J, Nallamothu BK, Kaufman SR, Saint S. Rates of infection for single-lumen versus multilumen central venous catheters: A meta-analysis. Crit Care Med 2003; 31:23852390,导管定植与感染: 插管部位的影响,Lorente L, Villegas J, Martin MM,

10、Jimenez A, Mora ML. Catheter-related infection in critically ill patients. Intensive Care Med. 2004 Aug; 30(8): 1681-4. Epub 2004 May 25.,中心静脉插管相关性感染: 发病机制,中心静脉插管相关性感染: 发病机制,Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous cathete

11、rs. Intensive Care Med. 2004 Jan;30(1):62-7. Epub 2003 Nov 26.,对照组,治疗组*,*1%洗必太-75%酒精; 含洗必太的敷料,中心静脉插管相关性感染: 致病菌,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30

12、: 2632-2635.,能否依靠临床表现鉴别菌血症,Peduzzi P, et al. Predictors of bacteremia and Gram-negative bacteremia in patients with sepsis. Arch Intern Med 1992; 152: 529-535,能否依靠临床表现鉴别菌血症,Peduzzi P, et al. Predictors of bacteremia and Gram-negative bacteremia in patients with sepsis. Arch Intern Med 1992; 152: 529

13、-535,能否依靠临床表现鉴别CRBSI,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30: 2632-2635.,能否依靠临床表现鉴别CRBSI,Safdar N, Maki DG. Inflammation at the insertion site is not

14、predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 2002; 30: 2632-2635.,能否依靠临床表现鉴别CRBSI,Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed ce

15、ntral venous catheters. Crit Care Med 2002; 30: 2632-2635.,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4 mm,血培养的临床价值: 导管血,Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central venous catheters a

16、nd peripheral venipuncture in critically ill medical patients. Chest 2003; 123: 854-861,血培养的临床价值: 外周血,Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central venous catheters and peripheral venipuncture in critically ill medical patients. Chest 200

17、3; 123: 854-861,血培养的临床价值: 导管血vs. 外周血,Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central venous catheters and peripheral venipuncture in critically ill medical patients. Chest 2003; 123: 854-861,三腔CVC应当从哪个腔取血,Dobbins BM, Catton JA, Kite P, McMa

18、hon MJ, Wilcox MH. Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 2003; 31:1688 1690,三腔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,Dobbins BM, Catton

19、JA, Kite P, McMahon MJ, Wilcox MH. Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 2003; 31:1688 1690,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CRBSI,Gaur AH, Flynn PM, Giannini

20、MA, et al. Difference in time to detection: a simple method to differentiate catheter-related from non-catheter-related bloodstream infection in immunocompromised pediatric patients. Clin Infect Dis. 2003 Aug 15;37(4):469-75,DTD对于诊断CRBSI的意义,结果 与非CRBSI相比, CRBSI的DTD显著增加(457 vs. -4 min; P .001) 采用DTD 1

21、20 min作为诊断CRBSI的临界值 敏感性, 88.9% 特异性, 100% PPV, 100% NPV 89 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,Gaur AH, Flynn PM, Giannini MA, et al. Difference in time to detection: a simple method to differentiate catheter-related from non-catheter-related bloodstream infection in im

22、munocompromised pediatric patients. Clin Infect Dis. 2003 Aug 15;37(4):469-75,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,拔除导管实际感染的比例,Merrer J, De Jonghe B, Golliot F, et al. (2001) Complications of femoral and subclavian venous catheterization in critically ill patients

23、: a randomized controlled trial. JAMA 286:700707. Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. (2003) Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study. Crit Care Med 31:13181324. Ranucci M, Isgro G, Giomarelli PP, et al. (2003) I

24、mpact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection. Crit Care Med 31:5259. Dobbins BM, Catton JA, Kite P, et al. (2003) Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 31:16881690. Daro

25、uiche RO, Raad II, Heard SO, et al. (1999) A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med 340:18.,患者发热时能否保留中心静脉导管,Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU

26、 patients with suspected catheter-related infection: a randomized trial. Intensive Care Med (2004) 30:10731080. DOI 10.1007/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 x 2,拔除CVC,CVC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,血流动力学不稳定,收缩压 90 mmHg或较基础值降低40 mmHg以上, 且无导致低血压的其他原因. 平均动脉压 60 mmHg 需

27、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/min,Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Inte

28、nsive Care Med (2004) 30:10731080. DOI 10.1007/s00134-004-2212-x,患者发热时能否保留中心静脉导管,Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med (

29、2004) 30:10731080. DOI 10.1007/s00134-004-2212-x,中心静脉插管相关性感染: 预防,Guidelines for the Prevention of Intravascular Catheter-Related Infections. August 2002. Mermel LA. Prevention of Intravascular Catheter-related Infections. Ann Intern Med 2000; 132: 391-402,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

30、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),Rijnders BJA, Vandecasteele SJ, Van Wijngaerden E, De Munter P, Peetermans WE. Use of Semiautomatic Treatment Advice to Improve Compliance with Infectious Diseases Society of America Guidelines for Treatm

31、ent of Intravascular Catheter-Related Infection: A Before-After Study. Clinical Infectious Diseases 2003; 37: 9803,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,Rijnders BJA, Vandecasteele SJ, Van Wijngaerden E, De Munter P, Pee

32、termans WE. Use of Semiautomatic Treatment Advice to Improve Compliance with Infectious Diseases Society of America Guidelines for Treatment of Intravascular Catheter-Related Infection: A Before-After Study. Clinical Infectious Diseases 2003; 37: 9803,如何改进依从性,Rijnders BJA, Vandecasteele SJ, Van Wijn

33、gaerden E, De Munter P, Peetermans WE. Use of Semiautomatic Treatment Advice to Improve Compliance with Infectious Diseases Society of America Guidelines for Treatment of Intravascular Catheter-Related Infection: A Before-After Study. Clinical Infectious Diseases 2003; 37: 9803,中心静脉插管相关感染: 宣教,Lobo R

34、D, Levin AS, Gomes LMP, Cursino R, Park M, Figueiredo VB, Taniguchi L, Polido CG, Costa SF. Impact of an educational program and policy changes on decreasing catheter associated bloodstream infections in a medical intensive care unit in Brazil. Am J Infect Control 2005; 33: 83-7,继续教育项目, 操作规程标准化,预防策略

35、: 5 Key “Best Practice” 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,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. Clin Infect Dis 1999;29:1287-94 Lancet 2000;356:1307-1312,最严格的隔离措施(maximal barrier precautions),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

36、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,最严格的隔离措施(maximal barrier precautions),最严格的隔离措施(MBP): 文献回顾,Am J Med 1991;91(3B):197S-205S Infect Control Hosp Epidemiol 1994;15:231-8,皮肤消毒: 洗必太,Ann Intern Med. 2002;136:792-801,皮肤消毒: 洗必太,Ann Intern Med. 2002;136:792-801,选择哪个部位进行插管,ICU股静脉和锁骨下静脉插管的RCT 145名患者股静脉插管/144名患者锁骨下静脉

37、插管 预后 股静脉插管组感染并发症更高: 19.8% vs 4.5% (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% vs 18.8% (p = NS),JAMA 2001, 286: 700-7,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,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farl

38、ey JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,ICU医生的依从性,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garr

39、ett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,消除CRBSI,医务人员的宣教 VAD政策以及网络教育项目 /prevention/vad.html 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

40、止其操作,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,CRBSI清单,操作前, 医生是否: 洗手 消毒操作部位 在

41、无菌情况下铺巾覆盖患者全身 操作过程中, 医生是否: 使用无菌手套, 口罩和无菌隔离衣 保持无菌区域 所有操作辅助人员是否均遵从上述要求,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit C

42、are Med. 2004 Oct;32(10):2014-20.,CRBSI,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014

43、-20.,CSICU CRBSI: 2002,干预措施,NNIS均值,Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,

44、CSICU CRBSI: 2002,每年预防43例CRBSI 每年减少8例(0 15)患者死亡 节约医疗费用$1,945,922 ($1,483,844 $2,408,000),Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20.,Central Line Bundle,手部清洁 插管时最严格的隔离措施 洗必太皮肤消毒 选择适当的插管部位 普通中心静脉插管选择锁骨下静脉 每日评估留置导管的必要性 立即拔除不必要的导管,Central Line Bundle,授权护士强调使用中心静