中心靜脈插管相關(guān)感染課件

中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)感染導(dǎo)管相關(guān)性感染:流行病學(xué)美國ICU每年16,000例CRBSI病死率18%(0–35%)每年死亡500–4,000例每例CRBSI醫(yī)療費(fèi)用$28,690–56,000每年費(fèi)用$60,000,000–460,000,000CDC.MMWR2002;HeiselmanJAMA1994;DimickArchSurg2001中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染發(fā)病率患者數(shù) n=1,098中心靜脈插管 n=1,263導(dǎo)管留置天 n=6,075細(xì)菌定植 n=333(26.3%)CRBSI n=35(2.7%) 5.9/1,000導(dǎo)管留置天SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:定義明確的導(dǎo)管相關(guān)性血行性感染:導(dǎo)管培養(yǎng)陽性(半定量或定量)拔除導(dǎo)管前外周血培養(yǎng)陽性上述培養(yǎng)中分離出相同微生物可能的導(dǎo)管相關(guān)性血行性感染:菌血癥+插管部位膿性分泌物,或?qū)Ч芙宇^培養(yǎng)陽性,或?qū)Ч苎囵B(yǎng)分離出相當(dāng)于外周血培養(yǎng)5倍的微生物或培養(yǎng)陽性差異時間2小時CohenJ,Brun-BuissonC,TorresA,JorgensenJ.Diagnosisofinfectioninsepsis:Anevidence-basedreview.CritCareMed2004;32[Suppl.]:S466–S494中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:定義非菌血癥導(dǎo)管相關(guān)性感染導(dǎo)管培養(yǎng)陽性,且為感染來源沒有發(fā)生菌血癥為排除診斷(沒有其他能夠解釋感染的明顯病灶,且拔除導(dǎo)管48小時內(nèi)感染表現(xiàn)緩解)導(dǎo)管局部感染導(dǎo)管培養(yǎng)(半定量或定量)(不)伴局部癥狀(紅,痛)沒有全身炎癥反應(yīng)CohenJ,Brun-BuissonC,TorresA,JorgensenJ.Diagnosisofinfectioninsepsis:Anevidence-basedreview.CritCareMed2004;32[Suppl.]:S466–S494)中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:定義中心靜脈插管相關(guān)性感染

原發(fā)性血行性感染(原發(fā)病灶不明)中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)感染Renaud,etal.AmJRespirCritCareMed2001;163:1584-90中心靜脈插管相關(guān)感染導(dǎo)管定植:單腔vs.多腔ZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心靜脈插管相關(guān)感染CRBSI:單腔vs.多腔ZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心靜脈插管相關(guān)感染CRBSI:單腔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中心靜脈插管相關(guān)感染CRBSI:單腔vs.多腔ZürcherM,TramèrMR,WalderB.ColonizationandBloodstreamInfectionwithSingle-VersusMulti-LumenCentralVenousCatheters:AQuantitativeSystematicReview.AnesthAnalg2004;99:177–82中心靜脈插管相關(guān)感染導(dǎo)管定植與感染:單腔vs.多腔DezfulianC,LavelleJ,NallamothuBK,KaufmanSR,SaintS.Ratesofinfectionforsingle-lumenversusmultilumencentralvenouscatheters:Ameta-analysis.CritCareMed2003;31:2385–2390中心靜脈插管相關(guān)感染導(dǎo)管定植與感染:插管部位的影響LorenteL,VillegasJ,MartinMM,JimenezA,MoraML.Catheter-relatedinfectionincriticallyillpatients.IntensiveCareMed.2004Aug;30(8):1681-4.Epub2004May25.中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:發(fā)病機(jī)制中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:發(fā)病機(jī)制SafdarN,MakiDG.Thepathogenesisofcatheter-relatedbloodstreaminfectionwithnoncuffedshort-termcentralvenouscatheters.IntensiveCareMed.2004Jan;30(1):62-7.Epub2003Nov26.對照組治療組**1%洗必太-75%酒精;含洗必太的敷料中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:致病菌SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.致病菌N凝固酶陰性葡萄球菌27腸球菌4陰溝腸桿菌1肺炎克氏菌1洋蔥伯克霍爾德菌1念珠菌屬1中心靜脈插管相關(guān)感染能否依靠臨床表現(xiàn)鑒別菌血癥菌血癥與非菌血癥患者的血流動力學(xué)、臨床和實(shí)驗室指標(biāo)變量均值P值非菌血癥(n=268)菌血癥(n=197)體溫,F100.7(2.9)101.1(3.1)0.22呼吸頻率,bpm31(10)29(9)0.047PaCO2,mmHg33(11)31(9)0.051脈搏,bpm118(17)118(19)0.64收縮壓,mmHg104(30)95(31)0.002白細(xì)胞計數(shù),x10918(16)17(10)0.42中性粒細(xì)胞,%67(22)65(22)0.30未成熟中性粒細(xì)胞,%17(17)21(16)0.02血小板計數(shù),x103279(186)219(145)0.0001PeduzziP,etal.PredictorsofbacteremiaandGram-negativebacteremiainpatientswithsepsis.ArchInternMed1992;152:529-535中心靜脈插管相關(guān)感染能否依靠臨床表現(xiàn)鑒別菌血癥邏輯回歸分析結(jié)果預(yù)測因素系數(shù)標(biāo)準(zhǔn)誤

2P值體溫,線性-3.6831.1844.020.045體溫,二次0.0190.0094.160.041呼吸頻率-0.0210.0113.410.065PaCO2-0.0170.0102.620.105脈搏0.0030.0060.240.625收縮壓-0.0100.0039.260.002白細(xì)胞計數(shù)-0.0010.0070.010.942中性粒細(xì)胞計數(shù)0.0040.0050.490.484未成熟中性粒細(xì)胞計數(shù)0.0130.0073.400.065血小板計數(shù)-0.0020.0018.350.004PeduzziP,etal.PredictorsofbacteremiaandGram-negativebacteremiainpatientswithsepsis.ArchInternMed1992;152:529-535中心靜脈插管相關(guān)感染能否依靠臨床表現(xiàn)鑒別CRBSI項目評分紅斑無紅斑0輕度紅斑1重度紅斑2膿性分泌物無0有1腫脹無0有1疼痛無0有1SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心靜脈插管相關(guān)感染能否依靠臨床表現(xiàn)鑒別CRBSI指標(biāo)指標(biāo)陽性導(dǎo)管數(shù)(%)CRBSIN=35細(xì)菌定植的導(dǎo)管N=333無感染無定植的導(dǎo)管N=894疼痛(0,1)25(2)0.00.20.40.20.4紅斑(0–2)25(2)0.00.10.30.10.2腫脹(0,1)126(10)0.20.40.10.40.10.4膿液(0,1)10(0.8)00.00.10總分(0–5)126(10.0)0.20.40.10.10.10.1SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心靜脈插管相關(guān)感染能否依靠臨床表現(xiàn)鑒別CRBSI敏感性%特異性%PPV%NPV%導(dǎo)管定植(n=333)紅4941773腫6924647痛15913080膿1994073CRBSI(n=35)紅398497腫095094痛094097膿099097SafdarN,MakiDG.Inflammationattheinsertionsiteisnotpredictiveofcatheter-relatedbloodstreaminfectionwithshort-term,noncuffedcentralvenouscatheters.CritCareMed2002;30:2632-2635.中心靜脈插管相關(guān)感染能否依靠臨床表現(xiàn)鑒別導(dǎo)管相關(guān)感染插管部位炎癥表現(xiàn)不敏感(多數(shù)導(dǎo)管感染并無相應(yīng)表現(xiàn))不特異(出現(xiàn)相應(yīng)表現(xiàn)亦無需拔除導(dǎo)管)提示導(dǎo)管感染的癥狀和體征插管部位膿性分泌物插管部位蜂窩織炎超過4mm中心靜脈插管相關(guān)感染血培養(yǎng)的臨床價值:導(dǎo)管血真正菌血癥培養(yǎng)結(jié)果是(n=34)否(n=266)陽性2820陰性6246敏感性82.4%(69.7–95.1)特異性92.5%(89.4–95.6)陽性預(yù)期值58.3%(44.4–72.2)陰性預(yù)期值97.6%(95.7–99.5)BeutzM,ShermanG,MayfieldJ,FraserVJ,KollefMH.Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients.Chest2003;123:854-861中心靜脈插管相關(guān)感染血培養(yǎng)的臨床價值:外周血真正菌血癥培養(yǎng)結(jié)果是(n=34)否(n=266)陽性2211陰性12255敏感性64.7%(48.6–80.8)特異性95.9%(93.5–98.3)陽性預(yù)期值66.7%(50.6–82.8)陰性預(yù)期值95.5%(93.0–98.0)BeutzM,ShermanG,MayfieldJ,FraserVJ,KollefMH.Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients.Chest2003;123:854-861中心靜脈插管相關(guān)感染血培養(yǎng)的臨床價值:導(dǎo)管血vs.外周血BeutzM,ShermanG,MayfieldJ,FraserVJ,KollefMH.Clinicalutilityofbloodculturesdrawnfromcentralvenouscathetersandperipheralvenipunctureincriticallyillmedicalpatients.Chest2003;123:854-861中心靜脈插管相關(guān)感染三腔CVC應(yīng)當(dāng)從哪個腔取血DobbinsBM,CattonJA,KiteP,McMahonMJ,WilcoxMH.Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed2003;31:1688–1690對照組CVC懷疑CRBSI的CVC無CRBSIN=50無CRBSIN=25CRBSIN=25明顯細(xì)菌定植的導(dǎo)管腔數(shù)16410233103005導(dǎo)管外表面細(xì)菌定植的導(dǎo)管數(shù)281420中心靜脈插管相關(guān)感染三腔CVC應(yīng)當(dāng)從哪個腔取血在CRBSI的病例,40%的CVC僅一個導(dǎo)管腔有細(xì)菌的明顯定植隨機(jī)從一個導(dǎo)管腔留取血培養(yǎng),陰性結(jié)果的可能性為66%(2/3)總體而言,對于CRBSI病例,隨機(jī)從一個導(dǎo)管腔留取血培養(yǎng),陰性結(jié)果可能性為40%60%的機(jī)會發(fā)現(xiàn)細(xì)菌定植DobbinsBM,CattonJA,KiteP,McMahonMJ,WilcoxMH.Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed2003;31:1688–1690中心靜脈插管相關(guān)感染DTD對于診斷CRBSI的意義目的:證實(shí)同時從外周靜脈和中心靜脈采取的血培養(yǎng)陽性時間差(DTD)對于鑒別CRBSI和非CRBSI的作用設(shè)計:前瞻性臨床試驗研究對象:15個月內(nèi)總共9例CRBSI和24例非CRBSIGaurAH,FlynnPM,GianniniMA,etal.Differenceintimetodetection:asimplemethodtodifferentiatecatheter-relatedfromnon-catheter-relatedbloodstreaminfectioninimmunocompromisedpediatricpatients.ClinInfectDis.2003Aug15;37(4):469-75中心靜脈插管相關(guān)感染DTD對于診斷CRBSI的意義結(jié)果與非CRBSI相比,CRBSI的DTD顯著增加(457vs.-4min;P<.001)采用DTD

120min作為診斷CRBSI的臨界值敏感性,88.9%特異性,100%PPV,100%NPV89–96%(試驗前CRBSI概率28–54%)結(jié)論:在應(yīng)用持續(xù)讀數(shù)血培養(yǎng)系統(tǒng)的醫(yī)院中,DTD是診斷CRBSI的一種簡單可靠的方法GaurAH,FlynnPM,GianniniMA,etal.Differenceintimetodetection:asimplemethodtodifferentiatecatheter-relatedfromnon-catheter-relatedbloodstreaminfectioninimmunocompromisedpediatricpatients.ClinInfectDis.2003Aug15;37(4):469-75中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)感染:治療立即拔除導(dǎo)管選擇新的部位插管在原部位經(jīng)導(dǎo)絲重新置入導(dǎo)管拔除導(dǎo)管進(jìn)行培養(yǎng)培養(yǎng)陽性時拔除新置入導(dǎo)管應(yīng)用抗生素中心靜脈插管相關(guān)感染拔除導(dǎo)管實(shí)際感染的比例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.中心靜脈插管相關(guān)感染患者發(fā)熱時能否保留中心靜脈導(dǎo)管RijndersBJ,PeetermansWE,VerwaestC,WilmerA,VanWijngaerdenE.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed(2004)30:1073–1080.DOI10.1007/s00134-004-2212-x醫(yī)生懷疑CRI,計劃拔除CVC研究組標(biāo)準(zhǔn)治療組留取血培養(yǎng)x2拔除CVCCVC繼續(xù)留置5天血培養(yǎng)陽性或血流動力學(xué)不穩(wěn)定拔除CVC感染好轉(zhuǎn)感染持續(xù)保留CVC中心靜脈插管相關(guān)感染血流動力學(xué)不穩(wěn)定收縮壓<90mmHg或較基礎(chǔ)值降低40mmHg以上,且無導(dǎo)致低血壓的其他原因.平均動脈壓<60mmHg需要應(yīng)用多巴胺或多巴酚丁胺維持血壓,或在過去12小時內(nèi)上述藥物劑量增加超過5

g/kg/min開始應(yīng)用去甲腎上腺素維持血壓,或在過去12小時內(nèi)上述藥物劑量增加超過0.25

g/kg/minRijndersBJ,PeetermansWE,VerwaestC,WilmerA,VanWijngaerdenE.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed(2004)30:1073–1080.DOI10.1007/s00134-004-2212-x中心靜脈插管相關(guān)感染患者發(fā)熱時能否保留中心靜脈導(dǎo)管研究組標(biāo)準(zhǔn)治療組P值更換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中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:預(yù)防GuidelinesforthePreventionofIntravascularCatheter-RelatedInfections.August2002.MermelLA.PreventionofIntravascularCatheter-relatedInfections.AnnInternMed2000;132:391-402中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)性感染:治療不符合IDSA治療指南的比例第一階段34%(24/71)普通病房(23/52[44%])明顯高于ICU(1/19[5%])(p<.01)第二階段44%(23/52)

15%(7/46)(p=.004)RijndersBJA,VandecasteeleSJ,VanWijngaerdenE,DeMunterP,PeetermansWE.UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter-RelatedInfection:ABefore-AfterStudy.ClinicalInfectiousDiseases2003;37:980–3中心靜脈插管相關(guān)感染如何改進(jìn)依從性發(fā)現(xiàn)CRBSI后,向主治醫(yī)生發(fā)送有關(guān)標(biāo)準(zhǔn)化治療的電子郵件(作為電子病歷的一部分)將打印文件放在病房醫(yī)生的桌上不進(jìn)行面對面的討論對于非白色念珠菌引發(fā)的CRBSI,建議主治醫(yī)生找感染科醫(yī)生會診以確定個體化治療方案RijndersBJA,VandecasteeleSJ,VanWijngaerdenE,DeMunterP,PeetermansWE.UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter-RelatedInfection:ABefore-AfterStudy.ClinicalInfectiousDiseases2003;37:980–3中心靜脈插管相關(guān)感染如何改進(jìn)依從性RijndersBJA,VandecasteeleSJ,VanWijngaerdenE,DeMunterP,PeetermansWE.UseofSemiautomaticTreatmentAdvicetoImproveCompliancewithInfectiousDiseasesSocietyofAmericaGuidelinesforTreatmentofIntravascularCatheter-RelatedInfection:ABefore-AfterStudy.ClinicalInfectiousDiseases2003;37:980–3中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)感染:宣教LoboRD,LevinAS,GomesLMP,CursinoR,ParkM,FigueiredoVB,TaniguchiL,PolidoCG,CostaSF.ImpactofaneducationalprogramandpolicychangesondecreasingcatheterassociatedbloodstreaminfectionsinamedicalintensivecareunitinBrazil.AmJInfectControl2005;33:83-7繼續(xù)教育項目,操作規(guī)程標(biāo)準(zhǔn)化中心靜脈插管相關(guān)感染預(yù)防策略:5Key“BestPractice”Issues拔除不必要的中心靜脈插管手部清潔采取最嚴(yán)格的消毒隔離措施應(yīng)用洗必太進(jìn)行皮膚消毒避免應(yīng)用股靜脈插管MMWR.2002;51:RR-10中心靜脈插管相關(guān)感染手部清潔1977以來,共有7項前瞻性研究顯示,改進(jìn)手部清潔能夠顯著減少各種感染并發(fā)癥Larsen.ClinInfectDis1999;29:1287-94Lancet2000;356:1307-1312中心靜脈插管相關(guān)感染中心靜脈插管相關(guān)感染最嚴(yán)格的隔離措施(maximalbarrierprecautions)對于醫(yī)生而言手部清潔非無菌帽子和口罩帽子應(yīng)覆蓋所有頭發(fā)口罩應(yīng)當(dāng)罩緊口鼻無菌手套和隔離衣對于患者而言使用大的無菌鋪巾覆蓋患者頭部和身體中心靜脈插管相關(guān)感染最嚴(yán)格的隔離措施(maximalbarrierprecautions)中心靜脈插管相關(guān)感染最嚴(yán)格的隔離措施(MBP):文獻(xiàn)回顧作者及年份研究設(shè)計導(dǎo)管種類無MBP時感染的ORMermel,1991前瞻橫斷面PAC2.2(p=0.03)Raad1994前瞻隨機(jī)CVC3.3(p=0.03)AmJMed1991;91(3B):197S-205SInfectControlHospEpidemiol1994;15:231-8中心靜脈插管相關(guān)感染皮膚消毒:洗必太AnnInternMed.2002;136:792-801中心靜脈插管相關(guān)感染皮膚消毒:洗必太AnnInternMed.2002;136:792-801中心靜脈插管相關(guān)感染選擇哪個部位進(jìn)行插管ICU股靜脈和鎖骨下靜脈插管的RCT145名患者股靜脈插管/144名患者鎖骨下靜脈插管預(yù)后股靜脈插管組感染并發(fā)癥更高:19.8%vs4.5%(p<.001)股靜脈插管組血栓并發(fā)癥更多:21.5%vs.1.9%(p<.001);完全性血栓栓塞6%vs.0%機(jī)械并發(fā)癥發(fā)生率相似:17.3%vs18.8%(p=NS)JAMA2001,286:700-7中心靜脈插管相關(guān)感染ICU醫(yī)生的依從性為期2周的觀察期對醫(yī)生設(shè)盲26根導(dǎo)管8(31%)根新置入中心靜脈插管18(69%)根通過導(dǎo)絲更換的導(dǎo)管沒有緊急插管BerenholtzSM,PronovostPJ,LipsettPA,HobsonD,EarsingK,FarleyJE,MilanovichS,Garrett-MayerE,WintersBD,RubinHR,DormanT,PerlTM.Eliminatingcatheter-relatedbloodstreaminfectionsintheintensivecareunit.CritCareMed.2004Oct;32(10):2014-20.中心靜脈插管相關(guān)感染ICU醫(yī)生的依從性BerenholtzSM,PronovostPJ,LipsettPA,HobsonD,EarsingK,FarleyJE,MilanovichS,Garrett-MayerE,WintersBD,RubinHR,DormanT,PerlTM.Eliminatingcatheter-relatedbloodstreaminfectionsintheintensivecareunit.CritCareMed.2004Oct;32(10):2014-20.中心靜脈插管相關(guān)感染消除CRBSI醫(yī)務(wù)人員的宣教VAD政策以及網(wǎng)絡(luò)教育項目避免煩瑣的準(zhǔn)備過程:插管車反復(fù)檢查每日詢問導(dǎo)管是否可以拔除清單觀察到醫(yī)生違反操作規(guī)程時,護(hù)士有權(quán)終止其操作BerenholtzS