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1、ICU院内感染预防与控制的 “Bundle”策略,ICU院内感染的常见类型,Hospital-Acquired Infection Hospital-Acquired Pneumonia HAP Ventilator-Associated Pneumonia VAPCatheter-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
2、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 therapies are used,
3、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 not？,HAP和VAP的多重耐药现状
4、,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-antibiotic strategies
5、 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 ConsiderChest physiotherapy No rec
6、ommendation Early tracheostomy No recommendation Position strategiesKinetic beds ConsiderSemi-recumbent positioning Recommended Prone positioning No recommendation Pharmacologic strategiesSucralfate Not recommendedIntratracheal antibiotics Not recommended,Evidence-based clinical practice guidelinefo
7、r 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 VAPVentilator Care Bundle Catheter-Related Bloodstream InfectionCentral 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
8、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 Bundle,Elevation of the Head of
9、 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 Bed,Decreasing the risk of asp
10、iration 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, possibility of patient discomfort.,
11、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;354(9193):1851-1858.,Daily
12、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 sedatives,每日唤醒组插管保留时间、ICU 滞留时间明
13、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 during the maneuver may risk epi
14、sodes 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 pneumonia in the ranitidine gro
15、up 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),
