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”策略四川大学华西医院ICU薛欣盛ICU院内感染的常见类型Hospital-AcquiredInfectionHospital-AcquiredPneumoniaHAPVentilator-AssociatedPneumoniaVAPCatheter-RelatedBloodstreamInfectionHAP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48－72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。ATS2005年指南Riskfactorsforthedevelopmentofventilator-associatedpneumoniaSeverityofillness(APACHEscore16)Glasgowcomascale9SevereburnsChroniclungdiseaseAcuteorchronicrespiratoryconditionsSupinebodypositionExcessivesedationMechanicalventilationfor7daysMortalityofVAPLongerlengthofstay,highermortalitywithVAPvscontrol33312060010203040506070EarlyOnsetLateOnsetApprRxInapprRxMortalityincreasesdramaticallyifinappropriatetherapiesareusedHeylandDK,etal.AmJRespirCritCareMed.1999;159:1249-1256.PrinciplesofAntibioticpoliciesinVAPConsiderpotentialpathogensConsiderlocalepidemiologyConsiderprevioustreatmentreceivedbythepatientColonisationVsinfectionAppropriateAntibioticTherapyRightornot？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.GuidelinesforthemanagementofadultswithHAP,VAPandHCAP.AmRespirCritCareMed.2005;171:388-416.4050607080901001994199519961998199920002001200220032004年份敏感率%亚胺培南头孢他啶头孢吡肟哌拉/他唑哌酮/舒巴坦阿米卡星环丙沙星NPRS-2005绿脓杆菌的耐药变迁我们怎么做？ConventionalinfectioncontrolmeasuresHandwashinganduseofprotectivegownsandglovesChlorhexidineoralrinseStrategiesrelatedtothegastrointestinaltractStress-ulcerprophylaxisnasogastrictubes(Gastricoverdistension)EnteralnutritionStrategiesrelatedtopatientplacementSemirecumbentpositionRotationalbedtherapyStrategiesrelatedtotheartificialairwayRespiratoryairwaycareDesignofendotrachealtubes:continuoussubglotticaspirationStrategiesrelatedtomechanicalventilationMaintenanceofventilatorequipment.heatandmoistureexchangersAdjustmentofsedationNon-invasivemechanicalventilationFerrerR,etal.CritCare.2002Feb;6(1):45-51.Non-antibioticstrategiesforVAPPhysicalstrategiesOralendotrachealtube√RecommendedSearchforsinusitisNorecommendationFrequencyofhumidifierchanges√RecommendedFrequencyofventilatorcircuitchanges√RecommendedClosedsuctionsystem√RecommendedDrainageofsubglotticsecretionConsiderChestphysiotherapyNorecommendationEarlytracheostomyNorecommendationPositionstrategiesKineticbedsConsiderSemi-recumbentpositioning√RecommendedPronepositioningNorecommendationPharmacologicstrategiesSucralfateNotrecommendedIntratrachealantibioticsNotrecommendedEvidence-basedclinicalpracticeguidelineforthepreventionofVAPCanadianCriticalCareSocietyAnnInternMed,2004,141:305ICU院内感染的类型Hospital-AcquiredInfectionVentilator-AssociatedPneumoniaVAPVentilatorCareBundleCatheter-RelatedBloodstreamInfectionCentralLineBundle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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IndividualizedBundleVentilatorCareBundleElevationoftheHeadoftheBedDailySedationVacationsandAssessmentofReadinesstoExtubatePepticUlcerDiseaseProphylaxisDeepVenousThrombosisProphylaxisCrundenE,NursCritCare2005Sep-Oct;Vol.10(5),pp.242-6.应用VentilatorCareBundle可降低VAP发病率ElevationoftheHeadoftheBedDecreasingtheriskofaspirationofgastrointestinalcontentsororopharyngealandnasopharyngealsecretions.improvepatients’ventilationbyaidventilatoryeffortsandminimizeatelectasisDisadvantage:Patientsslidingdowninbedand,ifskinintegrityiscompromised,shearingofskin,possibilityofpatientdiscomfort.DrakulovicMB,etal:.Lancet.Nov271999;354(9193):1851-1858ElevationoftheHeadoftheBedRandomizedtrialMedicalICU/RCUN=86intubatedandMVpatientsClinicallysuspectedandmicrobiologicallyconfirmedNPwasassessed8%5%34%23%0%10%20%30%40%50%Morbidity/%Semirecumbentn=47Supinen=39SuspectedNPMicrobiologicallyNPDrakulovicMB,etal:Lancet.Nov271999;354(9193):1851-1858.30°Dailyinterruptionofsedatives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(Ramsay3–4).KressJP,etal:NEnglJMed2000;342:1471–1477Dailyinterruptionofsedatives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4.97.36.49.912.215.90246810121416DaysintubatedDaysinICUDaysinHospitalDailyInterruptioncontrolKressJP,etal:NEnglJMed2000;342:1471–1477SedationvacationsrisksPotentialcomplications：self-extubation,etcIncreasedpotentialforpainandanxietyassociatedwithlighteningsedationIncreasedtoneandpoorsynchronywiththeventilatorduringthemaneuvermayriskepisodesofdesaturation.UlcerProphylaxis&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：whethertheuseofsucralfateandH2-receptorantagonistsincreasestheprobabilityofdevelopingVAP???NOidentifyanincreasedrateforpneumoniaintheranitidinegroupthanthesucralfategroupCookDJ,etal.NEnglJMed1998,338:791-797.PepticUlcerDiseaseProphylaxis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