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证据:如何预防中心静脉导管相关血流感染?

2019-06-10 复旦循证护理中心 复旦循证护理中心

临床问题如何预防中心静脉导管相关血流感染?临床问题一些慢性疾病患者因治疗所需,将长期放置中心静脉导管。如果发生中心静脉导管(CVCs)相关的血流感染(BSI)将导致患者死亡率、患病率增加,并增加治疗成本,因此,预防中心静脉导管相关血流感染意义重大,现将有关证据汇总如下。证据描述●一项meta分析表明,使用葡萄糖酸氯己定(CHG)溶液进行局部消毒比使用聚维酮碘(PI)溶液减少约49%的住院患者导

临床问题

如何预防中心静脉导管相关血流感染

临床问题

一些慢性疾病患者因治疗所需,将长期放置中心静脉导管。如果发生中心静脉导管(CVCs)相关的血流感染(BSI)将导致患者死亡率、患病率增加,并增加治疗成本,因此,预防中心静脉导管相关血流感染意义重大,现将有关证据汇总如下。

证据描述

●一项meta分析表明,使用葡萄糖酸氯己定(CHG)溶液进行局部消毒比使用聚维酮碘(PI)溶液减少约49%的住院患者导管相关性血流感染(CRBSI)的风险1。(Level I)

●没有证据显示口服或肠外使用抗生素或抗真菌药物可减少成人CRBSI的发病率1。(Level I)

●一篇随机对照试验的meta分析评价了肝素对导管通畅时间的影响和对预防静脉和动脉导管相关并发症的效果,认为10U/ml肝素间歇冲洗并不比用生理盐水冲洗更有利1。(Level I)

●三项随机对照试验结果显示,不低于每72小时更换一次CVC 敷料的频率是安全的且符合成本效益。当输注的液体可能促进微生物生长时(如:脂肪乳剂、血制品),需要加快敷料更换频率,因为这些物质是CRBSI的独立危险因素1。(Level I)

●一篇系统评价发现锁骨下中心静脉通路优于股静脉通路,因为无论长期还是短期置管,其发生感染、血栓等并发症的风险较低2,3。(Level I)

●此外,锁骨下动脉和颈内静脉长时间置管,发生导管相关血流感染的风险是相似的3。(Level I)

●推荐在CVC插入前用酒精或2%葡萄糖酸氯己定清洁皮肤4。(Level I)

●一篇针对如何减少小儿CVC感染的系统评价推荐用2%葡萄糖酸氯己定(洗必泰)做皮肤准备,可以减少CVC定植菌和血液感染。使用洗必泰敷料可以降低导管相关血流感染的发生率5。(Level I)

实践推荐

● 中心静脉导管护理过程中接触导管系统时必须使用无菌技术。(Grade B)

● 接触或更换中心静脉导管敷料前,必须用抗菌皂液和清水洗手,或用酒精搓手。若手上有可见污物或被灰尘、有机物污染,在用酒精搓手前必须用肥皂和水清洗。 (Grade A)

● 手消毒以后,戴用无菌手套更换插管部位的敷料。 (Grade B)

● 最好用无菌、透明、半渗透性聚氨酯敷料敷盖导管插入点。(Grade A)

● 如果患者出汗过多,或插入部位有出血或渗血,最好采用透明、半渗透性敷料。纱布敷料应尽早更换为透明辅料。(Grade B)

● 更换敷料时需要用酒精溶液或葡萄糖酸氯己定清洁导管穿刺点,并保持干燥。 (Grade A)

● 最好用0.9%无菌氯化钠注射液冲洗和封腔。(Grade B)

● 正常情况,连续使用CVC时的装置更换频率不必高于每72小时更换一次,除非导管断开或怀疑或证实有导管相关性感染 。(Grade A)

● 通过CVC输注血液和血制品的装置应为每12小时更换一次,或根据制造商的建议。(Grade B)

● 用于全肠外营养(TPN)输注的装置一般应为每24小时更换一次。如果溶液只包含葡萄糖和氨基酸,在连续使用时更换频率不高于每72小时一次。(Grade B)

● 不推荐通过定期更换短期导管以降低感染率 。(Grade B)

● CVC插入24小时后需更换敷料,然后每周换一次,除非有特殊需更换的指征(如有渗出)。(Grade B)

● 若非紧急情况应避免插入股静脉。(Grade A)

● 常规使用生理盐水冲洗CVC 。(Grade A)

适用性说明

本证据来自于国内外循证资源,在应用该证据时,应考虑具体的临床情境、专业判断和患者意愿,做出最佳决策。若需获取更加详细的信息,请与作者联系。

参考文献

1. National Institute for Clinical Excellence (NICE). Infection control: prevention of healthcare-associated infection in primary and community care: full guideline. NICE, 2003; (2).

2. Hamilton HC, Foxcroft D. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Sys Rev. 2007 (3). (Level I)

3. Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev. 2012; 3. (Level I)

4. Bishop L, Dougherty L, Bodenham A, Mansi J, Crowe P, Kibbler C, Shannon M, Treleavan J. Guidelines on the insertion and management of central venous access devices in adults. Int J  Lab Hematol. 2007; 29; 261–278. (Level IV)

5. Huang EY, Chen C, Abdullah F, Aspelund G, Barnhart DC, Calkins CM, Cowles RA, Downard CD, Goldin AB, Lee SL, St Peter SD, Arca MJ. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2011; 46 (10):2000-11. (Level I)

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    2019-09-07 fusion
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    2019-06-16 okgirl621_28169748

    我们医院还是习惯用肝素钠加生理盐水封管

    0

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