院内感染预防与控制的Bundle策略.ppt

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。 Risk factors for the development of ventilator-associated pneumonia Severity of illness (APACHE score 16) Glasgow coma scale 9 Severe burns Chronic lung disease Acute or chronic respiratory conditions Supine body position Excessive sedation Mechanical ventilation for 7 days Mortality of VAP Longer length of stay, higher mortality with VAP vs control Principles of Antibiotic policiesin VAP 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。 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 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 Individualized Bundle Ventilator Care Bundle Elevation of the Head of the Bed Daily Sedation Vacations and Assessment of Readiness to Extubate Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis Prophylaxis? Elevation of the Head of the Bed 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, possibility of patient discomfort.? Elevation of the Head of the Bed Randomized trial Medical ICU/ RCU N=86 intubated and MV patients Cl