經(jīng)皮中心靜脈置管感染預(yù)防指南課件

經(jīng)皮中心靜脈置管感染預(yù)防指南梁大偉天壇醫(yī)院神經(jīng)內(nèi)科2005.8.20經(jīng)皮中心靜脈置管感染預(yù)防指南導(dǎo)管相關(guān)感染的診斷定義局部感染定義：（1）局部自發(fā)或經(jīng)觸壓后有膿性滲出，無(wú)需細(xì)菌學(xué)證據(jù)。（2）穿刺部位的紅腫、發(fā)熱、硬結(jié)（三者中任兩者），及血清樣物質(zhì)自發(fā)或觸壓后滲出，穿刺部位細(xì)菌培養(yǎng)陽(yáng)性。經(jīng)皮中心靜脈置管感染預(yù)防指南導(dǎo)管相關(guān)感染的診斷定義菌血癥感染的定義：（1）外周血培養(yǎng)結(jié)果陽(yáng)性，且為一種微生物，導(dǎo)管片段（近端或遠(yuǎn)端）經(jīng)定量或半定量方法分離出同一種微生物（種類及耐藥譜），無(wú)其它感染源。（2）導(dǎo)管內(nèi)回抽血定量培養(yǎng)出10倍于同時(shí)外周血培養(yǎng)的菌株。（3）導(dǎo)管穿刺部位滲出的膿液、血清、血漿樣物質(zhì)或?qū)Ч芷は虏糠?、皮下埋植部分培養(yǎng)與外周血培養(yǎng)出同一種細(xì)菌（種類及耐藥譜）。經(jīng)皮中心靜脈置管感染預(yù)防指南導(dǎo)管相關(guān)感染的診斷定義可能感染的定義包括：（1）兩次或兩次以上血培養(yǎng)（無(wú)論是外周血還是中心靜脈回抽血）出同一種細(xì)菌（種類及耐藥譜），且臨床及實(shí)驗(yàn)室證實(shí)無(wú)其它感染源。（2）一次陽(yáng)性血培養(yǎng)結(jié)果為或念球菌（無(wú)論是外周血還是中心靜脈回抽血），且臨床及實(shí)驗(yàn)室證實(shí)無(wú)其它感染源。（3）免疫抑制或粒細(xì)胞減少（粒細(xì)胞<500ul）的病人，血培養(yǎng)陽(yáng)性（凝固酶陰性的葡萄球菌，桿菌屬，棒狀桿菌屬，糠秕馬拉色霉菌等），臨床及實(shí)驗(yàn)室證實(shí)無(wú)其它細(xì)菌感染源，只有中心靜脈留置導(dǎo)管，通常與導(dǎo)管相關(guān)性菌血癥有關(guān)。經(jīng)皮中心靜脈置管感染預(yù)防指南CVC引起相關(guān)感染的機(jī)制1.infectionoftheexitsite,followedbymigrationofthepathogenalongtheexternalcathetersurface.2.contaminationofthecatheterhub,leadingtointraluminalcathetercolonization.3.hematogenousseedingofthecatheter.

經(jīng)皮中心靜脈置管感染預(yù)防指南病原體若不幸感染,常見(jiàn)的菌種包括:

Coagulase-negativestaphylococci(37%),Staphylococcusaureus(13%),Enterococcus(13%),Gram-negativerods(14%).值得注意的是,抗藥性強(qiáng)的菌種包括staph.以及Enterococcus都榜上有名..所以如果不幸發(fā)生感染..多半就非得要用上vancomycin..可能不行還要用上linezolid..相當(dāng)?shù)穆闊?.另外一個(gè)值得注意的是..fungi..fungi的感染扮演部分角色(在NNIS的數(shù)據(jù)中是8%)..在Candidia的感染中,大約一半是non-albicanspecies造成的...包括C.glabrata與C.krusei..這些fungi對(duì)fluconazole容易產(chǎn)生抗藥性.經(jīng)皮中心靜脈置管感染預(yù)防指南Guidelinesforpreventinginfectionsassociatedwiththeinsertionandmaintenanceofcentralvenouscatheters

中心靜脈置管相關(guān)性感染的預(yù)防指南JournalofHospitalInfection(2001)47(Supplement):S5–S9經(jīng)皮中心靜脈置管感染預(yù)防指南Intervention1:Selectionofcathetertype

導(dǎo)管類型的選擇Intervention2:Selectionofcatheterinsertionsite

置管點(diǎn)的選擇Intervention3:Optimumaseptictechniqueduringcatheterinsertion

置管過(guò)程中無(wú)菌技術(shù)的最優(yōu)化Intervention4:Cutaneousantisepsis

皮膚消毒Intervention5:Catheterandcathetersitecare

導(dǎo)管和置管點(diǎn)的護(hù)理Intervention6:Replacementstrategies

更換方法Intervention7:Antibioticprophylaxis

預(yù)防性使用抗生素經(jīng)皮中心靜脈置管感染預(yù)防指南Selectionofcathetertype1Useasingle-lumencatheterunlessmultipleportsareessentialforthemanagementofthepatient.

盡量采用單腔管，除非患者需要多通道治療，2Iftotalparenteralnutritionisbeingadministered,useonecentralvenouscatheterorlumenexclusivelyforthatpurpose.

如果需要TPN，專用一根中心靜脈導(dǎo)管或?qū)Ｓ靡粋€(gè)管腔3Useatunnelledcatheteroranimplantablevascularaccessdeviceforpatientsinwhomlong-term(30days)vascularaccessisanticipated.

如果預(yù)計(jì)要長(zhǎng)時(shí)間（30天）保留血管通路，采用管道式導(dǎo)管或植入式血管通路4Considertheuseofanantimicrobialimpregnatedcentralvenouscatheterforadultpatientswhorequireshort-term(10days)centralvenouscatheterisationandwhoareathighriskforCR-BSI.需短期（10天）保留CVC者，并且是導(dǎo)管相關(guān)的血源性感染的高?；颊?，使用外涂抗菌素的CVC經(jīng)皮中心靜脈置管感染預(yù)防指南Selectionofcatheterinsertionsite5Inselectinganappropriateinsertionsite,assesstherisksforinfectionagainsttherisksofmechanicalcomplications.

選擇置管位點(diǎn)時(shí)，要權(quán)衡感染風(fēng)險(xiǎn)和機(jī)械并發(fā)癥的風(fēng)險(xiǎn)6Unlessmedicallycontraindicated,usethesubclaviansiteinpreferencetothejugularorfemoralsitesfornontunnelledcatheterplacement.

做非管道性置管，如無(wú)禁忌，采用鎖骨下置管好于頸靜脈或股靜脈置管7Considertheuseofperipherallyinsertedcathetersasanalternativetosubclavianorjugularveincatheterisation.

外周靜脈置管可作為鎖骨下置管或頸靜脈置管的替代方法經(jīng)皮中心靜脈置管感染預(yù)防指南Optimumaseptictechniqueduringcatheterinsertion8Useoptimumaseptictechnique,includingasterilegown,gloves,andalargesteriledrape,fortheinsertionofcentralvenouscatheters.

置管時(shí)采用最佳的無(wú)菌技術(shù)，穿無(wú)菌衣，戴無(wú)菌手套，蓋無(wú)菌單經(jīng)皮中心靜脈置管感染預(yù)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點(diǎn)皮膚，如對(duì)碘劑過(guò)敏，使用含酒精的聚維酮碘消毒，待消毒劑干燥后置管10Donotapplyorganicsolvents,e.g.,acetone,ether,totheskinbeforecatheterinsertion.

不要使用有機(jī)溶劑，如丙酮、乙醚等。11Donotroutinelyapplyantimicrobialointmenttothecatheterplacementsitepriortoinsertion.

置管前穿刺點(diǎn)不要使用抗生素軟膏經(jīng)皮中心靜脈置管感染預(yù)防指南Catheterandcathetersitecare12Beforeaccessingthesystem,disinfecttheexternalsurfacesofthecatheterhubandconnectionportswithanaqueoussolutionofchlorhexidinegluconateorpovidone-iodine,unlesscontraindicatedbythemanufacturer’srecommendations.

接觸前，要用葡萄糖酸洗必泰水溶液或聚維酮碘水溶液消毒導(dǎo)管活栓或接頭的外表面，除非廠家禁止這樣做13Useeitherasterilegauzeortransparentdressingtocoverthecathetersite.

用無(wú)菌紗布或透明貼膜覆蓋置管點(diǎn)14Ifagauzeandtapecathetersitedressingisused,itmustbereplacedwhenthedressingbecomesdamp,loosened,orsoiled,orwheninspectionoftheinsertionsiteisnecessary.

如果是使用紗布和膠布覆蓋的，一旦浸濕、松脫或弄臟，或需要查看穿刺點(diǎn)時(shí)，要及時(shí)更換。15DonotapplyantimicrobialointmenttoCVCinsertionsitesaspartofroutinecathetersitecare.

不要使用抗生素軟膏處理穿刺點(diǎn)。16Routinelyflushindwellingcentralvenouscatheterswithananticoagulantunlessadvisedotherwisebythemanufacturer.常規(guī)使用抗凝劑沖洗置入的CVC，除非廠家有其它建議經(jīng)皮中心靜脈置管感染預(yù)防指南Replacementstrategies17Donotroutinelyreplacenon-tunnelledCVCasamethodtopreventcatheter-relatedinfections.

不要把常規(guī)更換非管道性CVC作為預(yù)防導(dǎo)管相關(guān)感染的方法18Useguidewireassistedcatheterexchangetoreplaceamalfunctioningcatheter,ortoexchangeanexistingcatheterifthereisnoevidenceofinfectionatthecathetersiteorprovenCR-BSI.

借助導(dǎo)絲更換導(dǎo)管。19IfCR-infectionissuspected,butthereisnoevidenceofinfectionatthecathetersite,removetheexistingcatheterandinsertanewcatheteroveraguidewire;iftestsrevealCR-infection,thenewlyinsertedcathetershouldberemovedand,ifstillrequired,anewcatheterinsertedatadifferentsite.如果懷疑存在導(dǎo)管相關(guān)的感染，而置管點(diǎn)無(wú)明顯的感染跡象，去掉原來(lái)的導(dǎo)管，在導(dǎo)絲引導(dǎo)下置入新管；如果檢驗(yàn)顯示存在導(dǎo)管相關(guān)的感染，去掉新置入的導(dǎo)管，如仍然需要置管，另選穿刺點(diǎn)置入新管。經(jīng)皮中心靜脈置管感染預(yù)防指南Replacementstrategies20DonotuseguidewireassistedcatheterexchangeforpatientswithCR-infection.Ifcontinuedvascularaccessisrequired,removetheimplicatedcatheter,andreplaceitwithanothercatheteratadifferentinsertionsite.

患者有導(dǎo)管相關(guān)的感染時(shí)不采用借助導(dǎo)絲的導(dǎo)管更換。如果必須繼續(xù)保持血管通路，去掉受累導(dǎo)管，另取穿刺點(diǎn)置新管。21Replacealltubingwhenthevasculardeviceisreplaced.

更換血管裝置的同時(shí)更換所有管路。22Replaceintravenoustubingandstopcocksnomorefrequentlythanat72-hourintervals,unlessclinicallyindicated.

更換靜脈內(nèi)管道和活栓的間隔時(shí)間不能短于72小時(shí)，除非臨床需要。23Replaceintravenoustubingusedtoadministerblood,bloodproducts,orlipidemulsionsattheendoftheinfusionorwithin24hoursofinitiatingtheinfusion.若更換用于輸血、血液制品、脂肪乳的靜脈內(nèi)管路，要在輸注末或開(kāi)始輸注后24小時(shí)內(nèi)更換。經(jīng)皮中心靜脈置管感染預(yù)防指南Antibioticprophylaxis24Donotadministersystemicantimicrobialsroutinelybeforeinsertionorduringuseofacentralvenouscathetertopreventcathetercolonisationorbloodstreaminfection.不要為了預(yù)防導(dǎo)管細(xì)菌生長(zhǎng)或血行感染而常規(guī)給予全身應(yīng)用抗菌素，不論是在插管前或在使用CVC中。經(jīng)皮中心靜脈置管感染預(yù)防指南PreventingComplicationsofCentralVenous

CatheterizationNEnglJMed2003;348:1123-33.經(jīng)皮中心靜脈置管感染預(yù)防指南InterventionstoPreventinfectionsUseantimicrobial-impregnatedcatheters

使用外涂抗菌素的導(dǎo)管Insertcathetersatthesubclavianvenoussite

取鎖骨下穿刺點(diǎn)置入導(dǎo)管Usemaximalsterile-barrierprecautionsduringcatheterinsertion

在導(dǎo)管置入術(shù)中盡最大肯能采取無(wú)菌措施Avoidtheuseofantibioticointments

避免使用抗生素軟膏Disinfectcatheterhubs

消毒導(dǎo)管活栓Donotscheduleroutinecatheterchanges

不要常規(guī)更換導(dǎo)管Removecatheterswhentheyarenolongerneeded如果不再需要，撤除導(dǎo)管經(jīng)皮中心靜脈置管感染預(yù)防指南Useantimicrobial-impregnatedcathetersTheuseofantimicrobial-impregnatedcathetersreducestheriskofcatheter-relatedbloodstreaminfectionsandreducescostswhentherateofcatheter-relatedbloodstreaminfection>2%

使用涂有抗菌素的導(dǎo)管減少導(dǎo)管相關(guān)的血流感染，當(dāng)導(dǎo)管相關(guān)血流感染>2%時(shí)減少花費(fèi)。經(jīng)皮中心靜脈置管感染預(yù)防指南InsertcathetersatthesubclavianvenoussiteTheriskofcatheter-relatedinfectionislowerwithsubclaviancatheterizationthanwithinternaljugularorfemoralcatheterization

鎖骨下靜脈置管的導(dǎo)管相關(guān)感染風(fēng)險(xiǎn)小于頸內(nèi)靜脈或股靜脈置管經(jīng)皮中心靜脈置管感染預(yù)防指南Usemaximalsterile-barrierprecautionsduringcatheterinsertionUseofamask,cap,sterilegown,sterilegloves,andlargesteriledrapereducestherateofinfectionsandreducescosts

戴口罩、帽子、無(wú)菌手套，穿無(wú)菌衣，覆蓋無(wú)菌大單等能減少感染發(fā)生率，降低花費(fèi)。經(jīng)皮中心靜脈置管感染預(yù)防指南AvoidtheuseofantibioticointmentsTheapplicationofantibioticointmentsincreasestherateofcolonizationbyfungi,promotesthedevelopmentofantibiotic-resistantbacteria,andhasnotbeenshowntoaffecttheriskofcatheterrelatedbloodstreaminfections

使用抗生素軟膏增加真菌定殖率，增加耐藥菌的產(chǎn)生，并不能降低導(dǎo)管相關(guān)血流感染的發(fā)生率經(jīng)皮中心靜脈置管感染預(yù)防指南DisinfectcatheterhubsCatheterhubsarecommonsitesofcathetercontaminatio

導(dǎo)管活栓是導(dǎo)管污染的常見(jiàn)部位經(jīng)皮中心靜脈置管感染預(yù)防指南DonotscheduleroutinecatheterchangesScheduled,routinereplacementofcentralvenouscathetersatanewsitedoesnotreducetheriskofcatheter-relatedbloodstreaminfection;scheduled,routineexchangeofcathetersoveraguidewireisassociatedwithatrendtowardincreasedcatheterrelatedinfections有計(jì)劃的、常規(guī)的CVC更換到新位置并不能降低導(dǎo)管相關(guān)血流感染的發(fā)生率；有計(jì)劃的、常規(guī)的導(dǎo)絲引導(dǎo)下的導(dǎo)管更換有可能增加導(dǎo)管相關(guān)感染。經(jīng)皮中心靜脈置管感染預(yù)防指南RemovecatheterswhentheyarenolongerneededTheprobabilityofcolonizationandcatheter-relatedbloodstreaminfectionincreasesovertime

隨著時(shí)間推移，細(xì)菌定殖和導(dǎo)管相關(guān)血流感染的可能性增大。經(jīng)皮中心靜脈置管感染預(yù)防指南TypesofCatheter-AssociatedInfectionsCathetercolonization導(dǎo)管細(xì)菌定殖

Growthoforganismsfromacathetersegmentbyeithersemiquantitativeorquantitativeculture

通過(guò)半定量或定量培養(yǎng)，使導(dǎo)管片段的微生物生長(zhǎng)Catheter-relatedbloodstreaminfection導(dǎo)管相關(guān)的血流感染

Isolationofthesameorganismfromabloodcultureandfromasemiquantitativeorquantitativecultureofacathetersegment,accompaniedbyclinicalsymptomsofbloodstreaminfectionwithoutanyotherapparentsourceofinfection

血培養(yǎng)分理出的細(xì)菌與導(dǎo)管片段半定量或定量培養(yǎng)得到的細(xì)菌相同，并伴有血流感染的臨床癥狀，而沒(méi)有其它明顯的感染源。Exit-siteinfection出口感染

Erythema,tenderness,induration,orpurulencewithin2cmoftheexitsiteofthecatheter

在導(dǎo)管出口2cm范圍內(nèi)出現(xiàn)紅腫、觸痛、硬結(jié)或化膿經(jīng)皮中心靜脈置管感染預(yù)防指南ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepsisisdefinedasasystemicresponsetoinfection,manifestedbytwoormoreofthefollowingconditions:temperatureabove38.5°Corbelow36.0°C;heartrateabove90beatsperminute;respiratoryrateabove20breathsperminuteorpartialpressureofarterialcarbondioxidebelow32mmHg;andwhite-cellcountgreaterthan12,000percubicmillimeterorlessthan4000percubicmillimeterorwith10percentimmature(band)forms.膿毒癥是指感染的全身反應(yīng)，具有下列兩條或兩條以上的表現(xiàn)：體溫高于38.5度或低于36度；心率高于90次/分；呼吸頻率高于20次/分或動(dòng)脈二氧化碳分壓低于32mmHg；白細(xì)胞計(jì)數(shù)超過(guò)12000/mm3或低于4000/mm3或幼稚細(xì)胞達(dá)到10％。經(jīng)皮中心靜脈置管感染預(yù)防指南ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepticshockisdefinedassepsis-inducedhypotensionorarequirementforvasopressorsorinotropicagentstomaintainbloodpressuredespiteadequatefluidresuscitation,alongwiththepresenceofperfusionabnormalitiesthatmayinclude(butarenotlimitedto)lacticacidosis,oliguria,oracutealterationinmentalstatus.膿毒癥性休克是指膿毒癥誘發(fā)的低血壓或在充分液體復(fù)蘇下仍需要血管升壓藥或血管收縮藥維持血壓，伴有灌注異常，包括（但不限于）乳酸酸中毒、少尿、急性精神狀態(tài)改變經(jīng)皮中心靜脈置管感染預(yù)防指南ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionWhenbloodculturesareobtained,samplesfromperipheralsitesarepreferred.Cathetertipculturesshouldbeperformedbythesemiquantitativeorquantitativetechnique.如果做血培養(yǎng)，最好是取周圍位點(diǎn)的樣本。導(dǎo)管尖培養(yǎng)應(yīng)當(dāng)采用定量或半定量方法。經(jīng)皮中心靜脈置管感染預(yù)防指南ManagementofSuspectedCatheter-

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