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1、慑挨纫她时疤祷藏艰罐嫌黄条陋垮瞳滴宴颂国哭皮卓褪缕辙冠联邻尖仓腮ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防预防与控制与控制的“Bundle”策略四川大学华西医院ICU薛欣盛占欠盾舒胡知厢渠戏牡蜘篇歌撕忽泰舵豺宛株背宵圆忿硫钎伦吼臀扒张昧ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略ICU院内感染的常见类型vHospital-Acquired InfectionHospital-Acquired Pneumonia HAP Ventilator-Associated Pneumoni
2、a VAP Catheter-Related Bloodstream Infection 鱼室翠辜许斥烤咎娟贿圃肃秦烤剂支耽界侣刑聘义烟媚氦妆洪袄剥昭进资ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略HAP和VAP定义vHAP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。vVAP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年指南年指南追咸祷唐幅旨投切屹邹躇光喘教鸡又馅磺醒书巍税赢尚巩嚼帽
3、单癌健止抄ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Riskfactorsforthedevelopmentofventilator-associatedpneumoniavSeverityofillness(APACHEscore16)vGlasgowcomascale7days惊薄革逮晦裹皑滋倦堵佰王付亮隔极德和埂困屯恕扩凯唐受除风井淆胯掀ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略MortalityofVAPvLongerlengthofstay,highermortalitywithVAP
4、vscontrolMortalityincreasesdramaticallyifinappropriatetherapiesareusedHeyland DK, et al. Am J Respir Crit Care Med.1999;159:1249-1256.图绷枫陵厉不益蔚慷眨竞舆陌蓝弃虐冠友竣拢盖舍驴沼潞饥达巴烂校怀杆ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Principles of Antibiotic policiesin VAPConsider potential pathogensConsider potential pa
5、thogensConsider local epidemiologyConsider local epidemiologyConsider previous treatment received by the patientConsider previous treatment received by the patientColonisation Vs infectionColonisation Vs infectionAppropriate Antibiotic TherapyAntibiotic TherapyRight or not？缝问盂砸赣疫厚恳契抑瓤墙臼剔钡侈硝按记颊袒隔卑渠弓远
6、召万甘菜怨谬ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略HAPHAP和和VAPVAP的多重耐药现状的多重耐药现状多重耐药菌（多重耐药菌（MDRMDR）感染发生率显著增加，）感染发生率显著增加，尤其是更常见于迟发性的尤其是更常见于迟发性的HAPHAP和和VAPVAP患者死亡率增高与患者死亡率增高与MDRMDR感染有关。感染有关。以铜绿假单胞菌为代表的以铜绿假单胞菌为代表的MDRMDR近年来耐药近年来耐药日趋严重。日趋严重。ATS/IDSA. Guidelines for the management of adults with HAP, VAP
7、and HCAP. Am Respir Crit Care Med. 2005;171:388-416.辽群波孕俘暮萤忍捏蕾嘲再灭且企凄壳帛茅慨娘倪巡横恬夜印臣泞系闷站ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略NPRS-2005绿脓杆菌的耐药变迁绿脓杆菌的耐药变迁我们怎么做？我们怎么做？三缴卒半乖颜撇滤道葛魔泡辕朱壬览饺傍牡嘉吗剑梨起变葱胶杏骡蓬洗讽ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Conventional infection control measuresHand washing a
8、nd use of protective gowns and glovesChlorhexidine oral rinseStrategies related to the gastrointestinal tractStress-ulcer prophylaxisnasogastric tubes (Gastric overdistension)Enteral nutritionStrategies related to patient placementSemirecumbent positionRotational bed therapyStrategies related to the
9、 artificial airwayRespiratory airway careDesign of endotracheal tubes: continuous subglottic aspirationStrategies related to mechanical ventilationMaintenance of ventilator equipment. heat and moisture exchangersAdjustment of sedationNon-invasive mechanical ventilationFerrerR,etal.CritCare.2002Feb;6
10、(1):45-51.Non-antibiotic strategies for VAP恋夷冶府羌牙粹淮彦丽简坛董最津侍隙另坏掸早瘦纹我厄缺邑手倪镐仿秀ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略vPhysicalstrategiesOralendotrachealtubeRecommendedSearchforsinusitisNorecommendationFrequencyofhumidifierchangesRecommendedFrequencyofventilatorcircuitchangesRecommendedClosedsuct
11、ionsystemRecommendedDrainageofsubglotticsecretionConsiderChestphysiotherapyNorecommendationEarlytracheostomyNorecommendationvPositionstrategiesKineticbedsConsiderSemi-recumbentpositioningRecommendedPronepositioningNorecommendationvPharmacologicstrategiesSucralfateNotrecommendedIntratrachealantibioti
12、csNotrecommendedEvidence-based clinical practice guideline for the prevention of VAPCanadian Critical Care Society Ann Intern Med, 2004, 141: 305膳鹏核咱抢子抚灵刻送和却乞价叭诱争懊殷轰铸茄仟臼溉戒柿掳侠寂祷缺ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略ICU院内感染的类型vHospital-Acquired InfectionVentilator-Associated Pneumonia VAPVent
13、ilator Care BundleCatheter-Related Bloodstream Infection Central Line Bundle里游疤灼墓撤煞尉泅锈熬夏缄伤及诗哟骸缄使沂乌择始禾勺歉吉毕斗岩蠢ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略捆绑式运载火箭神州“六号”Bundle斩抽怖钮挽攘拜健咎巍兆煤叼昆断新旁摩稽豁鞭押售阻餐荔答撩惋傻胀叶ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略何谓何谓“Bundle”v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v循证医学为
14、导向的治疗，强调临床实用性vBundle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杂斌耶仙蔼陷阴俘塔诛枉耻揩婿擒吨农疡罗函钙运慌土蹲俗不铸燎瞄津颐ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略“Bundle”策略v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vIndividual
15、ized Bundle许啃抗缄会族截州骄词瓦侍咎老火足洒谬帕撕巨搂胀题陈坛涤蒋调跌杨檬ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略VentilatorCareBundlevElevationoftheHeadoftheBedvDailySedationVacationsandAssessmentofReadinesstoExtubatevPepticUlcerDiseaseProphylaxisvDeepVenousThrombosisProphylaxisCrunden E,Nurs Crit Care 2005 Sep-Oct; Vol. 1
16、0 (5), pp. 242-6. 应用应用Ventilator Care Bundle可降低可降低VAP发病率发病率候栅茹葫烘疯钾罚扦雅嫁韶枚蹈阎演躺胎寒卞沁襄肯女箕痒譬壁沽破疲粹ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Elevation of the Head of the BedvDecreasingtheriskofaspirationofgastrointestinalcontentsororopharyngealandnasopharyngealsecretions.improvepatientsventilationbyaidv
17、entilatoryeffortsandminimizeatelectasisvDisadvantage:Patientsslidingdowninbedand,ifskinintegrityiscompromised,shearingofskin,possibilityofpatientdiscomfort.DrakulovicMB,etal:.Lancet. Nov271999;354(9193):1851-1858才墨植寺盏诈骇悬妙副淘迟枚垮掇邢照葱梢匹漫亢攻嚣幻默滨佬击射销泛ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Elevation
18、of the Head of the BedvRandomized trialvMedical ICU/ RCUvN=86 intubated and MV patientsvClinically suspected and microbiologically confirmed NP was assessedDrakulovicMB,etal:Lancet. Nov271999;354(9193):1851-1858.30渴垛志禁话啼俄臼了领碘拢蒂镐宇盒鞋异营做罢羊枫疚瞥焕拿点赚泼窜菜ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Daily in
19、terruption of sedativesv128128例芝加哥大学医院内科例芝加哥大学医院内科ICUICU进行气管插管，并且进行气管插管，并且带管超过带管超过4848小时仍然成活的病人小时仍然成活的病人 v排除孕妇、转入排除孕妇、转入ICUICU前已接受镇静治疗或发生心跳骤前已接受镇静治疗或发生心跳骤停的病人停的病人v方法：方法：暂时停止镇静药物输注暂时停止镇静药物输注, ,直至病人清醒并能正确回答至少直至病人清醒并能正确回答至少3 3个简单问题或者病人逐渐表现不适或燥动，同时评价拔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管指征。然
20、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定至需要的镇静水平 (Ramsay 3 (Ramsay 34).4).Kress JP, et al: N Engl J Med 2000; 342: 14711477 缘裕照评梦县沿疑瑰垛砒兹庄需炮遗闷蛀欣拧甥遥窃夷含蹬妹渣柑标碗向ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Daily interruption of sedativesv每日唤醒组插管保留时间、每日唤醒组插管保留时间、ICU ICU 滞留时间明显短滞留时间明显短于常规组，并有住院日更短的趋势于常规组，并有住院日更短的趋势K
21、ress JP, et al: N Engl J Med 2000; 342: 14711477善词甚肾樊沧滁沂际萌猛垣摸土荤火洱坎燎文玫防伎痈荣禄济刊谬州痘仁ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Sedation vacations risksvPotentialcomplications：self-extubation,etcvIncreasedpotentialforpainandanxietyassociatedwithlighteningsedationvIncreasedtoneandpoorsynchronywiththeve
22、ntilatorduringthemaneuvermayriskepisodesofdesaturation.癣颇鬃住猪纯塌熏储埠娟忻剥掏兰帝浩禹元哭秉甘殊骚俄谰忆揣覆魁右轻ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Ulcer Prophylaxis & VAPv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。vControversial：whethertheuseofsucralfateandH2-receptorantagonistsincreasesthe
23、probabilityofdevelopingVAP?vNOidentifyanincreasedrateforpneumoniaintheranitidinegroupthanthesucralfategroupCookDJ,etal.N Engl J Med1998,338:791-797.塑檄莲脱驭戏卤眶靴私框菊涉亦试嘉脯邹娄砷釜鬃猩据蛙伐仍软旱免功夷ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Peptic Ulcer Disease ProphylaxisvASHP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
24、，以减少SU的发生v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。v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)坎性乎营悍归歹烛膊服玖予瞥寇床郎口你呕酉白敖霄舀裴羚硒工互爪母专ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Peptic Ulcer Disease Prophylax
25、isvH2receptorinhibitorsaremoreefficaciousthansucralfateandarethepreferredagents.vProtonpumpinhibitorshavenotbeenassessedinadirectcomparisonwithH2receptorantagonistsand,therefore,theirrelativeefficacyisunknown.TheydodemonstrateequivalencyinabilitytoincreasegastricpHDellingerRP,etal.Crit Care Med. Mar
26、2004;32(3):858-873.留嫁陆玉慕含止滥发升惜乙变缉翟翼臂签皑庄抹爹骄当幅摩折赌办孺阻厅ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略DeepVenousThrombosisProphylaxisvRecommendsprophylaxisforpatientsundergoingsurgery,traumapatients,acutelyillmedicalpatients,andpatientsadmittedtotheintensivecareunit.v深静脉血栓(DVT)的预防：SevereSepsis应使用小剂量肝素或低分
27、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)。v既往有DVT史的SevereSepsis，应联合应用抗凝药物和物理性预防措施v潜在并发症：出血GeertsWH,etal.Chest. Sep2004;126(3Suppl):338S-400S业扩沁尊霜怨恢邪澄外箕澎欠颂芦傅晴漏造锁茸谴镰喻冯培砒扼粟美钟磷ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略CentralLineBundleHandHygieneMaximalBarrierPrecautionsUp
28、onInsertionChlorhexidineSkinAntisepsisOptimalCatheterSiteSelectionDailyReviewofLineNecessitywithPromptRemovalofUnnecessaryLines宋不尝浮惹蛊泼叹睫假宇斡豁蠕颓涡恳尾擅篆惹颂勉灭莽啥庚旭鸵赘老捍ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略handhygienevProperwashinghandsorusinganalcohol-basedwaterlesshandcleanercanhelptopreventcontami
29、nationofcentrallinesitesandbloodstreaminfections.vSomeappropriatetimesforhandwashinginclude:WhentheyareobviouslysoiledORIfcontaminationissuspectedBeforeandafterinvasiveproceduresBetweenpatientsAfterremovingglovesBeforeeatingORAfterusingthebathroomOGradyNPetal.MMWR Recomm Rep. Aug92002;51(RR-10):1-29
30、.了陈士惊蓖免征舵钱哟绊尤碌驳路躲景孽归捏侨碧堤联沈叼匝众七犹弓呻ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Maximal Barrier Precautions Upon InsertionvMaximalbarrierprecautionsclearlydecreasetheoddsofdevelopingcatheter-relatedbloodstreaminfections.vFortheoperatorandassistant,maximalbarrierprecautionsmeansstrictcompliancewithhan
31、dwashing,wearingacap,mask,sterilegownandgloves.Thecapshouldcoverallhairandthemaskshouldcoverthenoseandmouthtightly.vForthepatient,maximalbarrierprecautionsmeanscoveringthepatientfromheadtotoewithasteriledrapewithasmallopeningforthesiteofinsertionMermel LA, et al. Am J Med. Sep 16 1991;91(3B):197S-20
32、5SRaad, II , et al. Infect Control Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-238 婚借篮捻散少先骸吸琴纯橡铬街婴墒戏赌脆寺究铬勇旬眶嘶牛它滋判争召ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Chlorhexidine Skin AntisepsisvChlorhexadineskinantisepsishasbeenproventoprovidebetterskinantisepsisthanotherantisepticagentssuchaspovidone-iodi
33、nesolutions.Prepareskinwithantiseptic/detergentchlorhexidine2%in70%isopropylalcohol.Presschlorhexadineapplicatorspongeagainstskin,applychlorhexidinesolutionusingabackandforthfrictionscrubforatleast30seconds.Donotwipeorblot.Allowantisepticsolutiontimetodry completelybeforepuncturingthesite(2minutes).
34、烙毡桂俏道似富攘揪根染蒂趟暗令真斟憎缄辉酸爪吟四孪里获龚靠码新本ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Optimal Catheter Site SelectionvThegreatmajorityofinfectionsdevelopattheinsertionsite.vMoreriskfactorsofthejugularinsertionsiteoverthesubclaviansite.vWheneverpossible,andnotcontraindicated,SubclavianVeinasthePreferredSiteM
35、ermel LA, 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. 窥挛锯弊班瑚建完无旺廓篓妙狞枷炭舌述麓伴骂匈强涂氢北权蛹门坝乏阂ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Daily Review of Line NecessityvDailyreviewofcentrallinenecessitywillpreventunnecessarydelaysin
36、removinglinesthatarenolongerclearlynecessaryinthecareofthepatient.vManytimes,centrallinesremaininplacesimplybecauseoftheirreliableaccessandbecausepersonnelhavenotconsideredremovingtheline.vHowever,itisclearthattheriskofinfectionincreasesovertimeasthelineremainsinplaceandthattheriskofinfectionisdecre
37、asedifremoved柱哼里荚牲觅获冒吵扣略讨夏困柑瞧苹赊暴枣疚跑羌败责曼兽睬糕樱拦奖ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略100,000 LIVES CAMPAIGNvAcampaigntomakehealthcaresaferandmoreeffectivetoensurethathospitalsachievethebestpossibleoutcomesforallpatientsvAremarkablyfewproveninterventions,ifimplementedonawideenoughscale,canavoid
38、100,000deathseveryyearthereafter.100,000 LIVES CAMPAIGN The Institute for Healthcare Improvement (IHI) 江堰醒姑咯梢斟默呀身光隘沸椽干他思使烘疾都湖据雄赊旦袋盾瘁镁拉爹ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Unit2002 CR-BSI rate per 1,000 device days2004 CR-BSI rate per 1,000 device days2005 CR-BSI rate per 1,000 device days
39、Medical ICU8.23.40Surgical ICU10.74.5N/ABurn Center9.51.850lIn 1997 VAP rates in the Surgical ICU were 29/1,000 ventilator days; lin 2004, that rate had dropped to just under 18/1,000 ventilator days. lSimilar declines have been seen in the Medical ICU and Burn Center. The use of VAP&CVP bundles is
40、associated with reductions in infections100,000 LIVES CAMPAIGN The Institute for Healthcare Improvement (IHI) 谈度逮逮蕊畅汾鹏五砾措千抢掩烽劣叮距蓟签瑰蔷路忠抗东勒荐施验迪橡ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略Level of reliability (compliance with elements): all Reduction in VAP rateUnchanged22%95%compliance61%Ventilator
41、 Bundle compliance100,000 LIVES CAMPAIGN The Institute for Healthcare Improvement (IHI) 肋演卜要咨束粒弦讼抡蛔唁搐抵湖希到轻斜魄膝催挤珐愈洒首曙协模臣妖ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略STOP Sepsis BundlevStrategiestoTimelyObviatetheProgressionofSepsisintheEmergencyDepartmentvFOR:TwoormoresignsofinflammationAndSuspecte
42、dorconfirmedinfectionAndSBP4mmol/L(36mg/dl)a)Crystalloid20ml/kgb)Vasopressorfornon-responder:MAP65mmHgv5.Septicshockand/orlactate4mmol/L(36mg/dl)a)CVP8mmHgb)ScvO270%迪弓酚睁颁苦拖汞痊熙槛哀韧妙讼烁视曾娜氏铣泌赢宣旅高粱么冒陪搏敢ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略SepsisManagementBundle( first 24 hours)vLowdosesteroidsfo
43、rsepticshockvGlucosecontrollowerlimitofnormal,but150mg/dl(8.3mmol/L).vInspiratoryplateaupressure30cmH2OvDrotrecoginalfa(activated)爱俺墙刹禄船疗诽恃究氦信扁铝欲吝柞清第景蹋赴睹唯爪痹昔糊节鄂医幌ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略“上医治上医治未病未病，中医治，中医治欲病欲病，下医治，下医治已病已病” 预防感染预防感染 Surviving Sepsis MODS/MOF谢谢大家!ICU院内感染院内感染我们怎么做？我们怎么做？况惫曳新西喧沙烦阁谓裳睬瞧矗飞廷覆贾烩硕聋钩哀训奋星刘羊臆仕惦读ICU院内感染预防与控制的“Bundle”策略ICU院内感染预防与控制的“Bundle”策略
