《ICU院内感染预防与控制的“Bundle”策略.ppt》由会员分享，可在线阅读，更多相关《ICU院内感染预防与控制的“Bundle”策略.ppt（37页珍藏版）》请在三一文库上搜索。
1、ICU院内感染预防与控制的 “Bundle”策略,四川大学华西医院ICU 薛欣盛,ICU院内感染的常见类型,Hospital-Acquired Infection Hospital-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
2、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,Risk 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 t
3、herapies are used,Heyland DK, et al. Am J Respir Crit Care Med.1999;159:1249-1256.,Principles of Antibiotic policies in VAP,Consider potential pathogens,Consider local epidemiology,Consider previous treatment received by the patient,Colonisation Vs infection,Appropriate Antibiotic Therapy,Right or n
4、ot？,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-ant
5、ibiotic strategies for VAP,Physical strategies 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 p
6、hysiotherapy No recommendation Early tracheostomy No recommendation Position strategies Kinetic beds Consider Semi-recumbent positioning Recommended Prone positioning No recommendation Pharmacologic strategies Sucralfate Not recommended Intratracheal antibiotics Not recommended,Evidence-based clinic
7、al practice guideline for the prevention of VAP,Canadian Critical Care Society Ann Intern Med, 2004, 141: 305,ICU院内感染的类型,Hospital-Acquired Infection Ventilator-Associated Pneumonia VAP Ventilator Care Bundle Catheter-Related Bloodstream Infection Central Line Bundle,捆绑式运载火箭,神州“六号”,Bundle,何谓“Bundle”,
8、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 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 Bun
9、dle,Elevation of the Head of the Bed Daily “Sedation Vacations“ 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 Be
10、d,Decreasing the risk of aspiration of gastrointestinal contents 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, possibi
11、lity of patient discomfort.,Drakulovic MB , et al:. Lancet. Nov 27 1999;354(9193):1851-1858,Elevation of the Head of the Bed,Randomized trial Medical ICU/ RCU N=86 intubated and MV patients Clinically suspected and microbiologically confirmed NP was assessed,Drakulovic MB, et al: Lancet. Nov 27 1999
12、;354(9193):1851-1858.,Daily interruption of sedatives,128例芝加哥大学医院内科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 sed
13、atives,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: N Engl J Med 2000; 342: 14711477,Sedation vacations risks,Potential complications：self-extubation,etc Increased potential for pain and anxiety associated with lightening sedation Increased tone and poor synchrony with the ventilator duri
14、ng the maneuver may risk episodes of desaturation.,Ulcer Prophylaxis & 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 pne
15、umonia in the ranitidine group than the sucralfate group,Cook DJ, 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
16、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 antagonist
17、s and, therefore, their relative efficacy is unknown. They do demonstrate 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
18、medical patients, and patients admitted to the intensive care unit. 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 Bund
19、le,Hand Hygiene Maximal Barrier Precautions Upon Insertion Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection Daily 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 to prevent cont
20、amination of central line sites and bloodstream infections. Some appropriate times for handwashing include: When they are obviously soiled OR If contamination is suspected Before and after invasive procedures Between patients After removing gloves Before eating OR After using the bathroom,OGrady NP
21、et al. MMWR Recomm Rep. Aug 9 2002;51(RR-10):1-29.,Maximal Barrier Precautions 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 handwash
22、ing, wearing a cap, mask, sterile gown and gloves. The cap should cover all 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 L
23、A, et al. Am J Med. Sep 16 1991;91(3B):197S-205S Raad, II , et al. Infect Control 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.
24、Prepare skin with antiseptic/detergent chlorhexidine 2% in 70 % isopropyl alcohol. 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 bef
25、ore puncturing the site ( 2 minutes).,Optimal Catheter Site Selection,The great 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,
26、 et al. Am J Med. Sep 16 1991;91(3B):197S-205S McCarthy MC, et al. J Parenter 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 patie
27、nt. Many times, central lines remain in place simply because of their reliable 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,1
28、00,000 LIVES CAMPAIGN,A campaign to make health care safer and more effectiveto ensure that hospitals achieve the best possible outcomes for all patients A remarkably few proven interventions, if implemented on a wide enough scale, can avoid 100,000 deaths every year thereafter.,100,000 LIVES CAMPAI
29、GN The Institute for Healthcare Improvement (IHI),In 1997 VAP rates in the Surgical 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 w
30、ith reductions in infections,100,000 LIVES CAMPAIGN The Institute for Healthcare 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 Department
31、FOR: Two or more signs of inflammation And Suspected or confirmed infection And SBP 90 mmHg after 20 ml/kg fluid bolus or Lactate 4 mmol/L,H.Bryant Nguyen, MD, MS. et al. Department of Emergency Medicine Loma Linda University for the STOP Sepsis Working Group,Sepsis Resuscitation Bundle ( first 6 ho
32、urs),1. Check lactate 2. B/C prior to antibiotcs 3. Antibiotics within 4 hours 4. Hypotension and/or lactate 4 mmol/L (36mg/dl) a) Crystalloid 20 ml/kg b) Vasopressor for non-responder: MAP 65 mmHg 5. Septic shock and/or lactate 4mmol/L (36mg/dl) a) CVP 8 mmHg b) ScvO2 70 %,Sepsis Management Bundle ( first 24 hours),Low dose steroids for septic shock Glucose control lower limit of normal, but 150 mg/dl (8.3 mmol/L). Inspiratory plateau pressure 30 cmH2O Drotrecogin 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？,