ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略39張課件

ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略56、死去何所道，托體同山阿。57、春秋多佳日，登高賦新詩。58、種豆南山下，草盛豆苗稀。晨興理荒穢，帶月荷鋤歸。道狹草木長，夕露沾我衣。衣沾不足惜，但使愿無違。59、相見無雜言，但道桑麻長。60、迢迢新秋夕，亭亭月將圓。ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略56、死去何所道，托體同山阿。57、春秋多佳日，登高賦新詩。58、種豆南山下，草盛豆苗稀。晨興理荒穢，帶月荷鋤歸。道狹草木長，夕露沾我衣。衣沾不足惜，但使愿無違。59、相見無雜言，但道桑麻長。60、迢迢新秋夕，亭亭月將圓。ICU院內(nèi)感染預(yù)防與控制的

“Bundle”策略四川大學(xué)華西醫(yī)院ICU薛欣盛ICU院內(nèi)感染的常見類型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略56、死去何所1ICU院內(nèi)感染預(yù)防與控制的

“Bundle”策略四川大學(xué)華西醫(yī)院ICU薛欣盛ICU院內(nèi)感染預(yù)防與控制的

“Bundle”策略四川大學(xué)華西2ICU院內(nèi)感染的常見類型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院內(nèi)感染的常見類型Hospital-Acquired3HAP和VAP定義HAP是指住院48小時后發(fā)生的感染，但入院時并不處在感染的潛伏期，可在普通病房接受治療，僅當(dāng)病情加重時轉(zhuǎn)ICU治療。VAP是指氣管內(nèi)插管48－72小時以上發(fā)生的肺炎。病情轉(zhuǎn)嚴重需接受氣管內(nèi)插管的HAP病人雖然不屬于VAP的范疇，但治療方案與VAP相同。ATS2005年指南HAP和VAP定義HAP是指住院48小時后發(fā)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的多重耐藥現(xiàn)狀多重耐藥菌（MDR）感染發(fā)生率顯著增加，尤其是更常見于遲發(fā)性的HAP和VAP患者死亡率增高與MDR感染有關(guān)。以銅綠假單胞菌為代表的MDR近年來耐藥日趨嚴重。ATS/IDSA.GuidelinesforthemanagementofadultswithHAP,VAPandHCAP.AmRespirCritCareMed.2005;171:388-416.HAP和VAP的多重耐藥現(xiàn)狀多重耐藥菌（MDR）感染發(fā)生率顯8NPRS-2005綠膿桿菌的耐藥變遷我們怎么做？NPRS-2005綠膿桿菌的耐藥變遷我們怎么做？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院內(nèi)感染的類型Hospital-AcquiredInfectionVentilator-AssociatedPneumoniaVAP

VentilatorCareBundleCatheter-RelatedBloodstreamInfectionCentralLineBundleICU院內(nèi)感染的類型Hospital-AcquiredIn12捆綁式運載火箭神州“六號”Bundle捆綁式運載火箭神州“六號”Bundle13何謂“Bundle”一個組合治療計劃，當(dāng)同時實施時能比單一方案產(chǎn)生更好的臨床效果循證醫(yī)學(xué)為導(dǎo)向的治療，強調(diào)臨床實用性Bundle的產(chǎn)生需有幾個前提:1.組成必需有確定的臨床療效且適用于臨床治療2.所有的組成治療必需在同一個場所及時間內(nèi)完成3.每一項的組成完成與否可用”yes”或”no”回答4.Bundle的完成與否可用”yes”或”no”回答5.Bundle應(yīng)用的疾病要常見,而且效果能時常監(jiān)測何謂“Bundle”一個組合治療計劃，當(dāng)同時實施時能比單一14“Bundle”策略捆綁是有或無的概念，要么不用，要么全用。應(yīng)用以取得治療成功來判斷，每個病人、每個措施都要落實IndividualizedBundle“Bundle”策略捆綁是有或無的概念，要么不用，要么全用。15VentilatorCareBundleElevationoftheHeadoftheBedDaily"SedationVacations"andAssessmentofReadinesstoExtubatePepticUlcerDiseaseProphylaxisDeepVenousThrombosisProphylaxis

CrundenE,NursCritCare2005Sep-Oct;Vol.10(5),pp.242-6.應(yīng)用VentilatorCareBundle可降低VAP發(fā)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例芝加哥大學(xué)醫(yī)院內(nèi)科ICU進行氣管插管，并且?guī)Ч艹^48小時仍然成活的病人排除孕婦、轉(zhuǎn)入ICU前已接受鎮(zhèn)靜治療或發(fā)生心跳驟停的病人方法：暫時停止鎮(zhèn)靜藥物輸注,直至病人清醒并能正確回答至少3個簡單問題或者病人逐漸表現(xiàn)不適或燥動，同時評價拔管指征。然后以原來劑量的一半開始給藥重新鎮(zhèn)靜并滴定至需要的鎮(zhèn)靜水平(Ramsay3–4).KressJP,etal:NEnglJMed2000;342:1471–1477

Dailyinterruptionofsedative19Dailyinterruptionofsedatives每日喚醒組插管保留時間、ICU滯留時間明顯短于常規(guī)組，并有住院日更短的趨勢KressJP,etal:NEnglJMed2000;342:1471–1477Dailyinterruptionofsedative20Sedationvacationsrisks

Potentialcomplications：self-extubation,etcIncreasedpotentialforpainandanxietyassociatedwithlighteningsedationIncreasedtoneandpoorsynchronywiththeventilatorduringthemaneuvermayriskepisodesofdesaturation.

SedationvacationsrisksPoten21UlcerProphylaxis&VAP可能的是:：當(dāng)使用制酸劑使胃液PH上升≥4時,胃可成為細菌尤其是腸道細菌的貯存場所,逐步增殖并可能通過胃-肺途徑引起細菌上呼吸道定植。Controversial：whethertheuseofsucralfateandH2-receptorantagonistsincreasestheprobabilityofdevelopingVAP???NOidentifyanincreasedrateforpneumoniaintheranitidinegroupthanthesucralfategroupCookDJ,etal.NEnglJMed1998,338:791-797.UlcerProphylaxis&VAP可能的是:：當(dāng)22PepticUlcerDiseaseProphylaxisASHP應(yīng)激性潰瘍預(yù)防指南：ICU高?；颊邞?yīng)適時應(yīng)用H2受體阻滯劑、抗酸劑或PPI，以減少SU的發(fā)生具有以下一項危險因素以上的患者應(yīng)采取預(yù)防措施:①呼吸衰竭(機械通氣超過48h)；②凝血機制障礙,1年內(nèi)有消化道潰瘍病史或上消化道出血史。GCS評分≤10；③燒傷面積>30%。④器官移植。⑤多發(fā)傷(創(chuàng)傷程度積分≥16)。⑥肝腎功能不全。⑦脊髓損傷。具有以下2項的以上危險因素的患者應(yīng)采取預(yù)防措施：敗血癥,ICU住院時間>1周,潛血持續(xù)天數(shù)≥6,應(yīng)用大劑量皮質(zhì)醇(氫化可的松>250mgPd)PepticUlcerDiseaseProphylax23PepticUlcerDiseaseProphylaxisH2receptorinhibitorsaremoreefficaciousthansucralfateandarethepreferredagents.ProtonpumpinhibitorshavenotbeenassessedinadirectcomparisonwithH2receptorantagonistsand,therefore,theirrelativeefficacyisunknown.TheydodemonstrateequivalencyinabilitytoincreasegastricpHDellingerRP,etal.CritCareMed.Mar2004;32(3):858-873.PepticUlcerDiseaseProphylax24DeepVenousThrombosisProphylaxisRecommendsprophylaxisforpatientsundergoingsurgery,traumapatients,acutelyillmedicalpatients,andpatientsadmittedtotheintensivecareunit.深靜脈血栓(DVT)的預(yù)防：SevereSepsis應(yīng)使用小劑量肝素或低分子肝素預(yù)防DVT。有肝素使用禁忌證(血小板減少、重度凝血病、活動性出血、近期腦出血)者，推薦使用物理性的預(yù)防措施(彈力襪、間歇壓縮裝置)。既往有DVT史的SevereSepsis，應(yīng)聯(lián)合應(yīng)用抗凝藥物和物理性預(yù)防措施潛在并發(fā)癥：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“上醫(yī)治未病，中醫(yī)治欲病，下醫(yī)治已病”

預(yù)防感染SurvivingSepsisMODS/MOF謝謝大家!ICU院內(nèi)感染——我們怎么做？“上醫(yī)治未病，中醫(yī)治欲病，下醫(yī)治已病”預(yù)防感染Surviv38END16、業(yè)余生活要有意義，不要越軌?！A盛頓

17、一個人即使已登上頂峰，也仍要自強不息?！_素·貝克

18、最大的挑戰(zhàn)和突破在于用人，而用人最大的突破在于信任人?！R云

19、自己活著，就是為了使別人過得更美好?！卒h

20、要掌握書，莫被書掌握；要為生而讀，莫為讀而生?！紶栁諩ND16、業(yè)余生活要有意義，不要越軌?！A盛頓39ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略56、死去何所道，托體同山阿。57、春秋多佳日，登高賦新詩。58、種豆南山下，草盛豆苗稀。晨興理荒穢，帶月荷鋤歸。道狹草木長，夕露沾我衣。衣沾不足惜，但使愿無違。59、相見無雜言，但道桑麻長。60、迢迢新秋夕，亭亭月將圓。ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略56、死去何所道，托體同山阿。57、春秋多佳日，登高賦新詩。58、種豆南山下，草盛豆苗稀。晨興理荒穢，帶月荷鋤歸。道狹草木長，夕露沾我衣。衣沾不足惜，但使愿無違。59、相見無雜言，但道桑麻長。60、迢迢新秋夕，亭亭月將圓。ICU院內(nèi)感染預(yù)防與控制的

“Bundle”策略四川大學(xué)華西醫(yī)院ICU薛欣盛ICU院內(nèi)感染的常見類型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院內(nèi)感染預(yù)防與控制的“Bundle”策略56、死去何所40ICU院內(nèi)感染預(yù)防與控制的

“Bundle”策略四川大學(xué)華西醫(yī)院ICU薛欣盛ICU院內(nèi)感染預(yù)防與控制的

“Bundle”策略四川大學(xué)華西41ICU院內(nèi)感染的常見類型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAP

Catheter-RelatedBloodstreamInfection

ICU院內(nèi)感染的常見類型Hospital-Acquired42HAP和VAP定義HAP是指住院48小時后發(fā)生的感染，但入院時并不處在感染的潛伏期，可在普通病房接受治療，僅當(dāng)病情加重時轉(zhuǎn)ICU治療。VAP是指氣管內(nèi)插管48－72小時以上發(fā)生的肺炎。病情轉(zhuǎn)嚴重需接受氣管內(nèi)插管的HAP病人雖然不屬于VAP的范疇，但治療方案與VAP相同。ATS2005年指南HAP和VAP定義HAP是指住院48小時后發(fā)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的多重耐藥現(xiàn)狀多重耐藥菌（MDR）感染發(fā)生率顯著增加，尤其是更常見于遲發(fā)性的HAP和VAP患者死亡率增高與MDR感染有關(guān)。以銅綠假單胞菌為代表的MDR近年來耐藥日趨嚴重。ATS/IDSA.GuidelinesforthemanagementofadultswithHAP,VAPandHCAP.AmRespirCritCareMed.2005;171:388-416.HAP和VAP的多重耐藥現(xiàn)狀多重耐藥菌（MDR）感染發(fā)生率顯47NPRS-2005綠膿桿菌的耐藥變遷我們怎么做？NPRS-2005綠膿桿菌的耐藥變遷我們怎么做？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

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RecommendedPronepositioning NorecommendationPharmacologicstrategiesSucralfate NotrecommendedIntratrachealantibiotics NotrecommendedEvidence-basedclinicalpracticeguidelineforthepreventionofVAPCanadianCriticalCareSociety

AnnInternMed,2004,141:305PhysicalstrategiesEvidence-b50ICU院內(nèi)感染的類型Hospital-AcquiredInfectionVentilator-AssociatedPneumoniaVAP

VentilatorCareBundleCatheter-RelatedBloodstreamInfectionCentralLineBundleICU院內(nèi)感染的類型Hospital-AcquiredIn51捆綁式運載火箭神州“六號”Bundle捆綁式運載火箭神州“六號”Bundle52何謂“Bundle”一個組合治療計劃，當(dāng)同時實施時能比單一方案產(chǎn)生更好的臨床效果循證醫(yī)學(xué)為導(dǎo)向的治療，強調(diào)臨床實用性Bundle的產(chǎn)生需有幾個前提:1.組成必需有確定的臨床療效且適用于臨床治療2.所有的組成治療必需在同一個場所及時間內(nèi)完成3.每一項的組成完成與否可用”yes”或”no”回答4.Bundle的完成與否可用”yes”或”no”回答5.Bundle應(yīng)用的疾病要常見,而且效果能時常監(jiān)測何謂“Bundle”一個組合治療計劃，當(dāng)同時實施時能比單一53“Bundle”策略捆綁是有或無的概念，要么不用，要么全用。應(yīng)用以取得治療成功來判斷，每個病人、每個措施都要落實IndividualizedBundle“Bundle”策略捆綁是有或無的概念，要么不用，要么全用。54VentilatorCareBundleElevationoftheHeadoftheBedDaily"SedationVacations"andAssessmentofReadinesstoExtubatePepticUlcerDiseaseProphylaxisDeepVenousThrombosisProphylaxis

CrundenE,NursCritCare2005Sep-Oct;Vol.10(5),pp.242-6.應(yīng)用VentilatorCareBundle可降低VAP發(fā)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例芝加哥大學(xué)醫(yī)院內(nèi)科ICU進行氣管插管，并且?guī)Ч艹^48小時仍然成活的病人排除孕婦、轉(zhuǎn)入ICU前已接受鎮(zhèn)靜治療或發(fā)生心跳驟停的病人方法：暫時停止鎮(zhèn)靜藥物輸注,直至病人清醒并能正確回答至少3個簡單問題或者病人逐漸表現(xiàn)不適或燥動，同時評價拔管指征。然后以原來劑量的一半開始給藥重新鎮(zhèn)靜并滴定至需要的鎮(zhèn)靜水平(Ramsay3–4).KressJP,etal:NEnglJMed2000;342:1471–1477

Dailyinterruptionofsedative58Dailyinterruptionofsedatives每日喚醒組插管保留時間、ICU滯留時間明顯短于常規(guī)組，并有住院日更短的趨勢KressJP,etal:NEnglJMed2000;342:1471–1477Dailyinterruptionofsedative59Sedationvacationsrisks

Potentialcomplications：self-extubation,etcIncreasedpotentialforpainandanxietyassociatedwithlighteningsedationIncreasedtoneandpoorsynchronywiththeventilatorduringthemaneuvermayriskepisodesofdesaturation.

SedationvacationsrisksPoten60UlcerProphylaxis&VAP可能的是:：當(dāng)使用制酸劑使胃液PH上升≥4時,胃可成為細菌尤其是腸道細菌的貯存場所,逐步增殖并可能通過胃-肺途徑引起細菌上呼吸道定植。Controversial：whethertheuseofsucralfateandH2-receptorantagonistsincreasestheprobabilityofdevelopingVAP???NOidentifyanincreasedrateforpneumoniaintheranitidinegroupthanthesucralfategroupCookDJ,etal.NEnglJMed1998,338:791-797.UlcerProphylaxis&VAP可能的是:：當(dāng)61PepticUlcerDiseaseProphylaxisASHP應(yīng)激性潰瘍預(yù)防指南：ICU高?；颊邞?yīng)適時應(yīng)用H2受體阻滯劑、抗酸劑或PPI，以減少SU的發(fā)生具有以下一項危險因素以上的患者應(yīng)采取預(yù)防措施:①呼吸衰竭(機械通氣超過48h)；②凝血機制障礙,1年內(nèi)有消化道潰瘍病史或上消化道出血史。GCS評分≤10；③燒傷面積>30%。④器官移植。⑤多發(fā)傷(創(chuàng)傷程度積分≥16)。⑥肝腎功能不全。⑦脊髓損傷。具有以下2項的以上危險因素的患者應(yīng)采取預(yù)防措施：敗血癥,ICU住院時間>1周,潛血持續(xù)天數(shù)≥6,應(yīng)用大劑量皮質(zhì)醇(氫化可的松>250mgPd)PepticUlcerDiseaseProphylax62PepticUlcerDiseaseProphylaxisH2receptorinhibitorsaremoreefficaciousthansucralfateandarethepreferredagents.ProtonpumpinhibitorshavenotbeenassessedinadirectcomparisonwithH2receptorantagonistsand,therefore,theirrelativeefficacyisunknown.TheydodemonstrateequivalencyinabilitytoincreasegastricpHDellingerRP,etal.CritCareMed.Mar2004;32(3):858-873.PepticUlcerDiseaseProphylax63DeepVenousThrombosisProphylaxisRecommendsprophylaxisforpatientsundergoingsurgery,traumapatients,acutelyillmedicalpatients,andpatientsadmittedtotheintensivecareunit.深靜脈血栓(DVT)的預(yù)防：SevereSepsis應(yīng)使用小劑量肝素或低分子肝素預(yù)防DVT。有肝素使用禁忌證(血小板減少、重度凝血病、活動性出血、近期腦出血)者，推薦使用物理性的預(yù)防措施(彈力襪、間歇壓縮裝置)。既往有DVT史的SevereSepsis，應(yīng)聯(lián)合應(yīng)用抗凝藥物和物理性預(yù)防措施潛在并發(fā)癥：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