1、中心静脉插管相关感染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导管相关性感染:流行病学流行病学美国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.MMWR 2002;Heiselman JAMA 1994;Dimick Arch Surg 2001中心静脉插管相关性感染发病率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.
2、9/1,000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中心静脉插管相关性感染:定义定义明确的导管相关性血行性感染:n导管培养阳性(半定量或定量)n拔除导管前外周血培养阳性n上述培养中分离出相同微生物可能的导管相关性血行
3、性感染:菌血症+n插管部位脓性分泌物,或n导管接头培养阳性,或n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中心静脉插管相关性感染:定义定义非菌血症导管相关性感染n导管培养阳性,且为感染来源n没有发生菌血症n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
4、表现缓解)导管局部感染n导管培养(半定量或定量)n(不)伴局部症状(红,痛)n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中心静脉插管相关性感染:定义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,et al.Am J Respir Crit Care Med
5、2001;163:1584-90导管定植导管定植:单腔单腔 vs.多腔多腔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;99:17782CRBSI:单腔单腔 vs.多腔多腔Zrcher M,Tramr MR,Walder B.Colonization and Bloodstream Infectio
6、n with Single-Versus Multi-Lumen Central Venous Catheters:A Quantitative Systematic Review.Anesth Analg 2004;99:17782CRBSI:单腔单腔 vs.多腔多腔OR(95%CI fixed)Single-Lumenn/N(%)Multi-Lumenn/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-ChristoffFarkas1.12(0.31 4.07)1/25(4.0)1/
7、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-lumenZrcher M,Tramr MR,Walder B.Colonization and Bloodstream Infection with Single-Versus Multi-Lumen Central Venous Catheters:A
8、 Quantitative Systematic Review.Anesth Analg 2004;99:17782CRBSI:单腔单腔 vs.多腔多腔051015051015Zrcher 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导管定植与感染导管定植与感染:单腔单腔 vs.多腔多腔Dezf
9、ulian 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导管定植与感染导管定植与感染:插管部位的影响插管部位的影响13.156.291.81051015股静脉股静脉颈内静脉颈内静脉锁骨下静脉锁骨下静脉导管局部感染发病率导管局部感染发病率(/1000导管留置日导管留置日)Lorente L,Villega
10、s J,Martin MM,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中心静脉插管相关性感染:发病机制发病机制中心静脉插管相关性感染中心静脉插管相关性感染:发病机制发病机制Safdar N,Maki DG.The pathogenesis of catheter-related bloodstream infection with noncuffed sho
11、rt-term central venous catheters.Intensive Care Med.2004 Jan;30(1):62-7.Epub 2003 Nov 26.对照组治疗组*60%12%28%0%20%40%60%80%100%腔外腔外腔内腔内不明不明60%0%20%40%60%80%100%腔内腔内*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中心静脉插管相关性感染:致病菌致病菌Safdar N,Maki DG.Inflammation at the insertion site is not predictive of catheter-related b
12、loodstream infection with short-term,noncuffed central venous catheters.Crit Care Med 2002;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能否依靠临床表现鉴别菌血症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呼吸频率呼吸频率,bpm31(10)29(9)0.047PaCO2,mmHg33(11)
13、31(9)0.051脉搏,bpm118(17)118(19)0.64收缩压收缩压,mmHg104(30)95(31)0.002白细胞计数,x 10918(16)17(10)0.42中性粒细胞,%67(22)65(22)0.30未成熟中性粒细胞未成熟中性粒细胞,%17(17)21(16)0.02血小板计数血小板计数,x 103279(186)219(145)0.0001Peduzzi P,et al.Predictors of bacteremia and Gram-negative bacteremia in patients with sepsis.Arch Intern Med 1992;
14、152:529-535能否依靠临床表现鉴别菌血症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 值体温体温,线性线性-3.6831.1844.020.045体温体温,二次二次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血小板计数血小板计
15、数-0.0020.0018.350.004Peduzzi 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1Safdar N,Maki DG.Inflammation at the insertion site is not predictive of catheter-relat
16、ed 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)0.00.2 0.40.2 0.4红斑(0 2)25(2)0.00.1 0.30.1 0.2肿胀(0,1)126(10)0.2 0.40.1 0.40.1 0.4脓液(0,1)10(0.8)00.0 0.10总分(0
17、 5)126(10.0)0.2 0.40.1 0.10.1 0.1Safdar 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159
18、13080脓1994073CRBSI(n=35)红398497肿095094痛094097脓099097Safdar 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导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n不敏感(多数导管感染并无
19、相应表现)n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n插管部位脓性分泌物n插管部位蜂窝织炎超过4 mm血培养的临床价值血培养的临床价值:导管血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)Beutz M,Sherman G,Mayfield J,Fraser VJ,Kollef MH.Clinical utility of blood cultures drawn from centr
20、al venous catheters and peripheral venipuncture in critically ill medical patients.Chest 2003;123:854-861血培养的临床价值血培养的临床价值:外周血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)Beutz M,Sherman G,Mayfield J,Fraser VJ,Kollef MH.Clinic
21、al utility of blood cultures drawn from central venous catheters and peripheral venipuncture in critically ill medical patients.Chest 2003;123:854-861血培养的临床价值血培养的临床价值:导管血导管血vs.外周血外周血Beutz M,Sherman G,Mayfield J,Fraser VJ,Kollef MH.Clinical utility of blood cultures drawn from central venous catheter
22、s and peripheral venipuncture in critically ill medical patients.Chest 2003;123:854-861三腔三腔CVC应当从哪个腔取血应当从哪个腔取血Dobbins BM,Catton 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对照组CVC怀疑CRBSI的CVC无CR
23、BSIN=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281420三腔三腔CVC应当从哪个腔取血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n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%n60%的机会发现细菌定植Dobbins BM,Catton JA,Kite P,McMahon MJ,Wilcox MH.Each lumen is a potential source of centra
24、l venous catheter-related bloodstream infection.Crit Care Med 2003;31:1688 1690DTD对于诊断对于诊断CRBSI的意义的意义目的:n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:n前瞻性临床试验研究对象:n15个月内总共9例CRBSI和24例非CRBSIGaur AH,Flynn PM,Giannini MA,et al.Difference in time to detection:a simple method to differentiate cathe
25、ter-related from non-catheter-related bloodstream infection in immunocompromised pediatric patients.Clin Infect Dis.2003 Aug 15;37(4):469-75DTD对于诊断对于诊断CRBSI的意义的意义结果n与非CRBSI相比,CRBSI的DTD显著增加(457 vs.-4 min;P .001)n采用DTD 120 min作为诊断CRBSI的临界值u敏感性,88.9%u特异性,100%uPPV,100%uNPV 89 96%(试验前CRBSI概率28 54%)结论:n在应
26、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 immunocompromised pediatric patients.Clin Infect Dis.2003 Aug 15;37(4):469-75中心静脉插管相关感染中心静脉插管相关感
27、染:治疗治疗立即拔除导管n选择新的部位插管n在原部位经导丝重新置入导管u拔除导管进行培养u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拔除导管实际感染的比例52%50%29%22%9%0%10%20%30%40%50%60%Merrer J,et alLeon C,et alRanucci M,et alDobbins BM,et alDarouiche RO,et alMerrer J,De Jonghe B,Golliot F,et al.(2001)Complications of femoral and subclavian venous catheterization i
28、n critically ill patients: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
29、.(2003)Impact 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.Darou
30、iche 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
31、 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血流动力学不稳定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需要应用多巴胺或多巴酚丁胺维持血
32、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/minRijnders 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(2004)30:107
33、31080.DOI 10.1007/s00134-004-2212-x患者发热时能否保留中心静脉导管患者发热时能否保留中心静脉导管研究组研究组标准治疗组标准治疗组P值值更换CVC16/4238/38.20住院日3442.20ICU病死率8/3210/32.20Rijnders BJ,Peetermans WE,Verwaest C,Wilmer A,Van Wijngaerden E.Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infecti
34、on:a randomized trial.Intensive Care Med(2004)30:10731080.DOI 10.1007/s00134-004-2212-x中心静脉插管相关性感染中心静脉插管相关性感染:预防预防Guidelines for the Prevention of Intravascular Catheter-Related Infections.August 2002.www.cdc.govMermel LA.Prevention of Intravascular Catheter-related Infections.Ann Intern Med 2000;13
35、2:391-402中心静脉插管相关性感染中心静脉插管相关性感染:治疗治疗不符合IDSA治疗指南的比例第一阶段n34%(24/71)n普通病房(23/52 44%)明显高于ICU(1/19 5%)(p .01)第二阶段n44%(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 Socie
36、ty 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 Wij
37、ngaerden 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如何改进依从性如何改进依从性Rijnders BJA,V
38、andecasteele 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 Treatment of Intravascular Catheter-Related Infection:A Before-After Study.Clinical Infectious Diseases 2003;37:9803中心静脉插
39、管相关感染中心静脉插管相关感染:宣教宣教201112051015202530干预前干预后随访CRBSI(/1,000导管日)Lobo RD,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 Braz
40、il.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预防策略: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;29:1287-94Lancet 2000;356:1307-1312最严格的隔离措施最严格的隔离措施(maximal barrier precauti
41、ons)对于医生而言n手部清洁n非无菌帽子和口罩u帽子应覆盖所有头发u口罩应当罩紧口鼻n无菌手套和隔离衣对于患者而言n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最严格的隔离措施(maximal barrier precautions)最严格的隔离措施最严格的隔离措施(MBP):文献回顾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)Raad 1994前瞻随机CVC3.3(p=0.03)Am J Med 1991;91(3B):197S-205SInfect Control Hosp Epidemiol 1994;15:2
42、31-8皮肤消毒皮肤消毒:洗必太洗必太Ann Intern Med.2002;136:792-801皮肤消毒皮肤消毒:洗必太洗必太Ann Intern Med.2002;136:792-801选择哪个部位进行插管选择哪个部位进行插管ICU股静脉和锁骨下静脉插管的RCTn145名患者股静脉插管/144名患者锁骨下静脉插管预后n股静脉插管组感染并发症更高:19.8%vs 4.5%(p .001)n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%n机械并发症发生率相似:17.3%vs 18.8%(p=NS)JAMA 2001,286:700-7ICU
43、医生的依从性医生的依从性为期2周的观察期n对医生设盲26根导管n8(31%)根新置入中心静脉插管n18(69%)根通过导丝更换的导管n没有紧急插管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.2
44、004 Oct;32(10):2014-20.ICU医生的依从性医生的依从性62%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.消除消除CRBSI
45、医务人员的宣教nVAD政策以及网络教育项目nwww.hopkins-heic.org/prevention/vad.html避免烦琐的准备过程:插管车反复检查n每日询问导管是否可以拔除n清单观察到医生违反操作规程时,护士有权终止其操作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 infection
46、s in the intensive care unit.Crit Care Med.2004 Oct;32(10):2014-20.CRBSI清单清单操作前,医生是否:n洗手n消毒操作部位n在无菌情况下铺巾覆盖患者全身操作过程中,医生是否:n使用无菌手套,口罩和无菌隔离衣n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.Elimin
47、ating catheter-related bloodstream infections in the intensive care unit.Crit Care Med.2004 Oct;32(10):2014-20.CRBSIBerenholtz 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
48、 in the intensive care unit.Crit Care Med.2004 Oct;32(10):2014-20.CSICU CRBSI:20028.509.805.581.582.90024681012第一季度第二季度第三季度第四季度CRBSI(/1000导管日导管日)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
49、catheter-related bloodstream infections in the intensive care unit.Crit Care Med.2004 Oct;32(10):2014-20.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
50、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n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n立即拔除不必要的导管Central Line Bundle授权护士强调使用中心静脉清单,以确保与留置中心静脉插管有关的所有措施的正确实施将上述各项措施作为留置中心静脉插
