1、ICU院内感染的常见类型,Hospital-Acquired InfectionHospital-Acquired Pneumonia HAP Ventilator-Associated Pneumonia VAP Catheter-Related Bloodstream Infection,HAP 和VAP定义,HAP是指住院48小时后发生的感染，但入院时并不处在感染的潜伏期，可在普通病房接受治疗，仅当病情加重时转ICU治疗。VAP是指气管内插管4872小时以上发生的肺炎。病情转严重需接受气管内插管的HAP病人虽然不属于VAP的范畴，但治疗方案与VAP 相同。,ATS 2005年指南,Ris
2、k factors for the development of ventilator-associated pneumonia,Severity of illness (APACHE score 16) Glasgow coma scale 7 days,Mortality of VAP,Longer length of stay, higher mortality with VAP vs control,Mortality increases dramatically if inappropriate therapies are used,Heyland DK, et al. Am J R
3、espir Crit Care Med.1999;159:1249-1256.,Principles of Antibiotic policiesin VAP,Consider potential pathogens,Consider local epidemiology,Consider previous treatment received by the patient,Colonisation Vs infection,Appropriate Antibiotic Therapy,Right or not？,HAP和VAP的多重耐药现状,多重耐药菌（MDR）感染发生率显著增加，尤其是更常
4、见于迟发性的HAP和VAP患者死亡率增高与MDR感染有关。以铜绿假单胞菌为代表的MDR近年来耐药日趋严重。,ATS/IDSA. Guidelines for the management of adults with HAP, VAP and HCAP. Am Respir Crit Care Med. 2005;171:388-416.,NPRS-2005,绿脓杆菌的耐药变迁,我们怎么做？,Ferrer R, et al. Crit Care. 2002 Feb;6(1):45-51.,Non-antibiotic strategies for VAP,Physical strategies
5、 Oral endotracheal tube Recommended Search for sinusitis No recommendation Frequency of humidifier changes Recommended Frequency of ventilator circuit changes Recommended Closed suction system Recommended Drainage of subglottic secretion Consider Chest physiotherapy No recommendation Early tracheost
6、omy No recommendationPosition strategies Kinetic beds Consider Semi-recumbent positioning Recommended Prone positioning No recommendationPharmacologic strategies Sucralfate Not recommended Intratracheal antibiotics Not recommended,Evidence-based clinical practice guideline for the prevention of VAP,
7、Canadian Critical Care Society Ann Intern Med, 2004, 141: 305,ICU院内感染的类型,Hospital-Acquired InfectionVentilator-Associated Pneumonia VAP Ventilator Care BundleCatheter-Related Bloodstream Infection Central Line Bundle,捆绑式运载火箭,神州“六号”,Bundle,何谓“Bundle”,一个组合治疗计划，当同时实施时能比单一方案产生更好的临床效果 循证医学为导向的治疗，强调临床实用性
8、Bundle的产生需有几个前提:1. 组成必需有确定的临床疗效且适用于临床治疗2. 所有的组成治疗必需在同一个场所及时间內完成3. 每一项的组成完成与否可用”yes”或”no”回答4. Bundle的完成与否可用”yes”或”no”回答5. Bundle应用的疾病要常见,而且效果能时常监测,“Bundle”策略,捆绑是有或无的概念，要么不用，要么全用。应用以取得治疗成功来判断，每个病人、每个措施都要落实Individualized Bundle,Ventilator Care Bundle,Elevation of the Head of the Bed Daily Sedation Vaca
9、tions and Assessment of Readiness to Extubate Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis Prophylaxis,Crunden E,Nurs Crit Care 2005 Sep-Oct; Vol. 10 (5), pp. 242-6.,应用Ventilator Care Bundle可降低VAP发病率,Elevation of the Head of the Bed,Decreasing the risk of aspiration of gastrointestinal co
10、ntents or oropharyngeal and nasopharyngeal secretions.improve patients ventilation by aid ventilatory efforts and minimize atelectasis Disadvantage: Patients sliding down in bed and, if skin integrity is compromised, shearing of skin, possibility of patient discomfort.,Drakulovic MB , et al:. Lancet
11、. Nov 27 1999;354(9193):1851-1858,Elevation of the Head of the Bed,Randomized trialMedical ICU/ RCUN=86 intubated and MV patientsClinically suspected and microbiologically confirmed NP was assessed,Drakulovic MB, et al: Lancet. Nov 27 1999;354(9193):1851-1858.,Daily interruption of sedatives,128例芝加哥
12、大学医院内科ICU进行气管插管，并且带管超过48小时仍然成活的病人 排除孕妇、转入ICU前已接受镇静治疗或发生心跳骤停的病人方法：暂时停止镇静药物输注,直至病人清醒并能正确回答至少3个简单问题或者病人逐渐表现不适或燥动，同时评价拔管指征。然后以原来剂量的一半开始给药重新镇静并滴定至需要的镇静水平 (Ramsay 34).,Kress JP, et al: N Engl J Med 2000; 342: 14711477,Daily interruption of sedatives,每日唤醒组插管保留时间、ICU 滞留时间明显短于常规组，并有住院日更短的趋势,Kress JP, et al:
13、N Engl J Med 2000; 342: 14711477,Sedation vacations risks,Potential complications：self-extubation,etcIncreased potential for pain and anxiety associated with lightening sedation Increased tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation.,Ulcer Prophyl
14、axis & VAP,可能的是:：当使用制酸剂使胃液PH上升 4时, 胃可成为细菌尤其是肠道细菌的贮存场所,逐步增殖并可能通过胃- 肺途径引起细菌上呼吸道定植。 Controversial ：whether the use of sucralfate and H2-receptor antagonists increases the probability of developing VAP?NO identify an increased rate for pneumonia in the ranitidine group than the sucralfate group,Cook DJ,
15、 et al. N Engl J Med 1998, 338:791-797.,Peptic Ulcer Disease Prophylaxis,ASHP应激性溃疡预防指南：ICU高危患者应适时应用H2受体阻滞剂、抗酸剂或PPI，以减少SU的发生具有以下一项危险因素以上的患者应采取预防措施: 呼吸衰竭(机械通气超过48h) ；凝血机制障碍,1 年内有消化道溃疡病史或上消化道出血史。GCS评分10；烧伤面积 30 %。器官移植。多发伤(创伤程度积分16) 。肝肾功能不全。脊髓损伤。具有以下2 项的以上危险因素的患者应采取预防措施：败血症,ICU 住院时间1周,潜血持续天数6,应用大剂量皮质醇(氢
16、化可的松 250mgPd),Peptic Ulcer Disease Prophylaxis,H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents. Proton pump inhibitors have not been assessed in a direct comparison with H2 receptor antagonists and, therefore, their relative efficacy is unknown. They do demon
17、strate equivalency in ability to increase gastric pH,Dellinger RP, et al. Crit Care Med. Mar 2004;32(3):858-873.,Deep Venous Thrombosis Prophylaxis,Recommends prophylaxis for patients undergoing surgery, trauma patients, acutely ill medical patients, and patients admitted to the intensive care unit.
18、深静脉血栓(DVT)的预防：Severe Sepsis应使用小剂量肝素或低分子肝素预防DVT。有肝素使用禁忌证(血小板减少、重度凝血病、活动性出血、近期脑出血)者，推荐使用物理性的预防措施(弹力袜、间歇压缩装置)。既往有DVT史的Severe Sepsis ，应联合应用抗凝药物和物理性预防措施潜在并发症：出血,Geerts WH, et al. Chest. Sep 2004;126(3 Suppl):338S-400S,Central Line Bundle,Hand Hygiene Maximal Barrier Precautions Upon Insertion Chlorhexidi
19、ne Skin Antisepsis Optimal Catheter Site SelectionDaily Review of Line Necessity with Prompt Removal of Unnecessary Lines,hand hygiene,Proper washing hands or using an alcohol-based waterless hand cleaner can help toprevent contamination of central line sites and bloodstream infections. Some appropr
20、iate times for handwashing include: When they are obviously soiled OR If contamination is suspectedBefore and after invasive procedures Between patients After removing gloves Before eating OR After using the bathroom,OGrady NP et al. MMWR Recomm Rep. Aug 9 2002;51(RR-10):1-29.,Maximal Barrier Precau
21、tions Upon Insertion,Maximal barrier precautions clearly decrease the odds of developing catheter-related bloodstream infections. For the operator and assistant, maximal barrier precautions means strict compliance with handwashing, wearing a cap, mask, sterile gown and gloves. The cap should cover a
22、ll hair and the mask should cover the nose and mouth tightly.For the patient, maximal barrier precautions means covering the patient from head to toe with a sterile drape with a small opening for the site of insertion,Mermel LA, et al. Am J Med. Sep 16 1991;91(3B):197S-205SRaad, II , et al. Infect C
23、ontrol Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-238,Chlorhexidine Skin Antisepsis,Chlorhexadine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions.Prepare skin with antiseptic/detergent chlorhexidine 2%in 70 %isopropyl alco
24、hol. Press chlorhexadine applicator sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site ( 2 minutes).,Optimal Catheter Site Selection,The grea
25、t majority of infections develop at the insertion site. More risk factors of the jugular insertion site over the subclavian site. Whenever possible, and not contraindicated, Subclavian Vein as the Preferred Site,Mermel LA, et al. Am J Med. Sep 16 1991;91(3B):197S-205S McCarthy MC, et al. J Parenter
26、Enteral Nutr. 1987 May-Jun;11(3):259-62.,Daily Review of Line Necessity,Daily review of central line necessity will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of the patient. Many times, central lines remain in place simply because of their reliable
27、 access and because personnel have not considered removing the line. However, it is clear that the risk of infection increases over time as the line remains in place and that the risk of infection is decreased if removed,100,000 LIVES CAMPAIGN,A campaign to make health care safer and more effectivet
28、o ensure that hospitals achieve the best possible outcomes for all patientsA remarkably few proven interventions, if implemented on a wide enough scale, can avoid 100,000 deaths every year thereafter.,100,000 LIVES CAMPAIGN The Institute for Healthcare Improvement (IHI),In 1997 VAP rates in the Surg
29、ical ICU were 29/1,000 ventilator days; in 2004, that rate had dropped to just under 18/1,000 ventilator days. Similar declines have been seen in the Medical ICU and Burn Center.,The use of VAP&CVP bundles is associated with reductions in infections,100,000 LIVES CAMPAIGN The Institute for Healthcar
30、e Improvement (IHI),Ventilator Bundle compliance,100,000 LIVES CAMPAIGN The Institute for Healthcare Improvement (IHI),STOP Sepsis Bundle,Strategies to Timely Obviate the Progression of Sepsis in the Emergency DepartmentFOR:Two or more signs of inflammation And Suspected or confirmed infectionAnd SB
31、P 4 mmol/L (36mg/dl)a) Crystalloid 20 ml/kgb) Vasopressor for non-responder: MAP 65 mmHg5. Septic shock and/or lactate 4mmol/L (36mg/dl)a) CVP 8 mmHgb) ScvO2 70 %,Sepsis Management Bundle( first 24 hours),Low dose steroids for septic shockGlucose control lower limit of normal, but 150 mg/dl (8.3 mmol/L).Inspiratory plateau pressure 30 cmH2ODrotrecogin alfa (activated),“上医治未病，中医治欲病，下医治已病”,预防感染,Surviving Sepsis,MODS/MOF,谢谢大家!,ICU院内感染我们怎么做？,
