覃铁和：感染控制-抗生素之外的话题

感染控制 --- 抗生素之外的话题覃铁和 [email_address] 广东省人民医院重症医学科（ ICU ）

感染的趋势 08/21/11 覃铁和 QIN TIEHE N Eng J Med, 2003, 348:1546-1554

风险无处不在 08/21/11 覃铁和 QIN TIEHE ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

细菌≠感染感染的发生取决于病原体局部屏障全身状况与器官功能 08/21/11 覃铁和 QIN TIEHE

何为感染诊断感染需满足的条件致病微生物：病毒、细菌 … … 侵入机体并产生炎症反应局部反应全身反应器官功能改变 … … 08/21/11 覃铁和 QIN TIEHE

Infection 菌血症真菌血症寄生虫血症病毒血症其他 Sepsis SIRS 创伤烧伤胰腺炎其他感染、 Sepsis 和 SIRS 的内在关系

感染判断指标一般临床症状、体征器官功能指标：氧合指标、血流动力学炎症标志物细胞因子 08/21/11 覃铁和 QIN TIEHE

可能忽略的问题神经专科医生引起全身感染的因素吞咽功能的评估返流 --- 人工气道建立的时机呼吸道的评估声门 --- 人工气道建立的时机营养支持返流误吸的潜在因素各种导管管理 08/21/11 覃铁和 QIN TIEHE

可能忽略的问题神经专科医生感染的全面管理用药预防用药的不恰当急性手术指征的把握患者所处感染的阶段发热的处理不能充分评估炎症反应忽略局部引发全身的因素分析 08/21/11 覃铁和 QIN TIEHE

可能忽略的问题神经专科用药对全身的影响脱水药物 : 甘露醇，利尿剂，白蛋白器官功能的影响：心、肾内环境影响镇静、抗癫痫治疗呼吸抑制和排痰能力评估不够激素感染危险因素的评估全身性感染的综合救治 08/21/11 覃铁和 QIN TIEHE

可能忽略的问题重症专科医师神经重症患者的气道评估未能及时建立人工气道抗感染药物对神经系统的影响碳青霉烯类喹诺酮类不理解意识状态变化的内涵：满足于专科意见脑灌注基本条件的认识不足脑缺氧状态和后果的评估不到位神经系统治疗时机把握不当 08/21/11 覃铁和 QIN TIEHE

可能忽略的问题 08/21/11 覃铁和 QIN TIEHE JPEN J Parenter Enteral Nutr. 2010;34:64-69 营养问题

可能忽略的问题 08/21/11 覃铁和 QIN TIEHE JPEN J Parenter Enteral Nutr. 2010;34:64-69

08/21/11 覃铁和 QIN TIEHE Clinical Nutrition (2006) 25, 37–44

各种神经系统疾病抽搐、意识障碍卧床、吞咽障碍、返流坠积、返流性肺炎全身炎症反应脱水血容量与内环境变化 MODS 相关器官功能变化镇静、抗癫痫抗生素使用各种有创操作相关感染免疫力下降死亡营养障碍

《指南》 --- 越指越明，还是越指越难？ 08/21/11 覃铁和 QIN TIEHE

I. MANAGEMENT OF SEVERE SEPSIS Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Inotropic Therapy Corticosteroids Recombinant Human Activated Protein C Blood Product Administration 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

II. SUPPORTIVE THERAPY OF SEVERE SEPSIS Mechanical Ventilation of Sepsis-Induced Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS) Sedation, Analgesia, and Neuromuscular Blockade in Sepsis Glucose Control Bicarbonate Therapy Renal Replacement F. Deep Vein Thrombosis Prophylaxis G. Stress Ulcer Prophylaxis H. Selective Digestive Tract Decontamination (SDD) I. Consideration for Limitation of Support 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

I. MANAGEMENT OF SEVERE SEPSIS A. Initial resuscitation (first 6 hrs) Begin resuscitation immediately patients with hypotension or elevated serum lactate 4 mmol/L; do not delay pending ICU admission (1C) Resuscitation goals (1C) CVP 8–12 mm Hg Mean arterial pressure 65 mm Hg Urine output 0.5 mL/kg/hr Central venous (superior vena cava) oxygen saturation 70% or mixed venous 65% If venous oxygen saturation target is not achieved (2C) Consider further fluid Transfuse packed red blood cells if required to hematocrit of 30% and/or Start dobutamine infusion, maximum 20ug/kg/min 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

I. MANAGEMENT OF SEVERE SEPSIS B. Diagnosis Obtain appropriate cultures before starting antibiotics provided this does not significantly delay antimicrobial administration (1C) Obtain two or more BCs One or more BCs should be percutaneous One BC from each vascular access device in place 48 hrs Culture other sites as clinically indicated Perform imaging studies promptly to confirm and sample any source of infection, if safe to do so (1C) C. Antibiotic Therapy 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

I. MANAGEMENT OF SEVERE SEPSIS D. Source identification and control A specific anatomic site of infection should be established as rapidly as possible (1C) and within first 6 hrs of presentation (1D) Formally evaluate patient for a focus of infection amenable to source control measures (e.g. abscess drainage, tissue debridement) (1C) Implement source control measures as soon as possible following successful initial resuscitation (1C) (exception: infected pancreatic necrosis, where surgical intervention is best delayed) (2B) Choose source control measure with maximum efficacy and minimal physiologic upset (1D) Remove intravascular access devices if potentially infected (1C) 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

I. MANAGEMENT OF SEVERE SEPSIS E. Fluid Therapy Administration of either crystalloid or colloid fluid resuscitation (1B) fluid challenge to restore mean circulating filling pressure (1C) reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D) F. Vasopressor Vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure >65 mm Hg (1C) G. Inotropic Therapy Dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C) 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

I. MANAGEMENT OF SEVERE SEPSIS H. Corticosteroids Stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C) I. Recombinant Human Activated Protein C Recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients ) J. Blood Product Administration In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage,target a hemoglobin of 7–9 g/dL (1B) 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

II. SUPPORTIVE THERAPY OF SEVERE SEPSIS A . Mechanical Ventilation of Sepsis-Induced ALI /ARDS A low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for ALI /ARDS Application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C) Head of bed elevation in mechanically ventilated patients unless contraindicated (1B) Avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); To decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); Protocols for weaning and sedation/analgesia (1B); 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

II. SUPPORTIVE THERAPY OF SEVERE SEPSIS B. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis Using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B) Avoidance of neuromuscular blockers, if at all possible (1B) C. Glucose Control Institution of glycemic control (1B) Targeting a blood glucose <150 mg/dL after initial stabilization (2C) D. Renal Replacement Equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B) 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

CRRT 的应用时机 08/21/11 覃铁和 QIN TIEHE

II. SUPPORTIVE THERAPY OF SEVERE SEPSIS F.Deep Vein Thrombosis Prophylaxis Prophylaxis for deep vein thrombosis (1A) G.Stress Ulcer Prophylaxis Use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B) 08/21/11 覃铁和 QIN TIEHE 指南告诉我们什么以“ Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” 为例

感染控制的内涵整体的管理策略抗生素策略清除病原体非抗生素策略避免新的器官功能损伤恢复相关器官功能 08/21/11 覃铁和 QIN TIEHE

病情评估的重要性 08/21/11 覃铁和 QIN TIEHE

08/21/11 覃铁和 QIN TIEHE 感染的管理重要步骤：感染的严重程度的评估的执行方法

感染控制的非药物措施 08/21/11 覃铁和 QIN TIEHE

宏观措施病房设计：尽可能达到相关规范的要求空间要求：按照空间设定床位，避免为床位数牺牲空间病房分区：工作区与辅助区分开，隔离区与非隔离区分开医疗流程：符合感染与非感染流程的需要污物处理：专门的区域，确保污物不向洁净区域流动通风与空气净化工作制度人员管理：上岗前的培训物品管理：从放置到使用感染监测：重点病人、重要部位、重要区域的监控预警机制：警惕一切可能发生的流行 08/21/11 覃铁和 QIN TIEHE

个体化措施适当的体位防止反流、误吸引流体位的应用翻身与拍背伤口的引流与护理关注病人的营养状况严格管理抗生素：并非所有病人都必须使用 08/21/11 覃铁和 QIN TIEHE

个体化措施气道管理口腔护理非人工气道管理：解痉与排痰人工气道管理口、鼻插管与气管切开的管理策略非机械通气：湿化与排痰机械通气：通气管道与管道的加温、湿化、积水管理导管气囊的管理：监测气囊压 08/21/11 覃铁和 QIN TIEHE

个体化措施气道管理注意气道与全身状况的联系水肿、营养、感染、内环境之间的关系吸痰的技术与技巧（医生、护士都应该掌握的技术）吸痰前的评估：肺部体征、气道状况与氧储备不主张吸痰前常规气管内注水主张按需、随时吸痰，而不是按时吸痰 08/21/11 覃铁和 QIN TIEHE

个体化措施消化道管理胃管、肠内营养管与造瘘管的管理肛周处理：尤其腹泻病人泌尿道管理导尿管的管理尿液性状的监测全身其他容易导致感染部位的处理穿刺部位水肿受压部位口腔与皱褶部位的护理 08/21/11 覃铁和 QIN TIEHE

抗生素决策的另一面 08/21/11 覃铁和 QIN TIEHE

用药前评估入科前状况及处理基础疾病、器官功能状态存在感染？用药情况入科后状况器官功能评估入室主要问题评估感染相关问题评估 08/21/11 覃铁和 QIN TIEHE

感染控制相关问题感染病灶的处理用药的技巧药物选择、给药途径、疗程作用与副作用观察联合用药问题：单药？何时联合？如何联合？病人的体质：单器官与 MODS 、营养、免疫力医院的制度：感染控制制度相关科室的合作：细菌室、影像学、药理 08/21/11 覃铁和 QIN TIEHE

辨别致病菌 08/21/11 覃铁和 QIN TIEHE 致病菌寄植菌

确定致病菌很难 08/21/11 覃铁和 QIN TIEHE

似是而非 08/21/11 覃铁和 QIN TIEHE

影响选药的因素基础病史与既往用药史感染的原发部位可能的病原体能够保证药物到达并维持有效浓度吗？病人的器官功能状况直接影响抗生素代谢的器官间接影响抗生素代谢的器官预后判断 08/21/11 覃铁和 QIN TIEHE

影响选药的因素抗生素的特性抗菌谱能否覆盖可能或者潜在的病原体药代动力学能否保证适当的有效浓度潜在副作用常规条件下的副作用 MODS 状态下的副作用各种治疗手段之间的相互影响药物之间的相互作用血液净化 08/21/11 覃铁和 QIN TIEHE

理解药物特性药物的作用与副作用都是治疗成败的关键药物的特性不同，其效应也不同目标器官的药物浓度不同药物作用的起效时间与半衰期不同副作用的类型与强度不同指导抗生素的选择不同器官感染的常见病原体不同仅仅按照细菌的种类选择抗生素可能导致治疗失败 08/21/11 覃铁和 QIN TIEHE

药物的剂量调整肾功能损害情况下的剂量调整透析病人的用药争议药物能透过去吗？多少？普通血透与持续血液净化（ CBP ）某些技巧病情总是动态变化，最好能够随时监测血药浓度靶器官药物浓度主要副作用器官的功能状态 08/21/11 覃铁和 QIN TIEHE

药物与 CRRT 08/21/11 覃铁和 QIN TIEHE 抗生素的组织渗透与结合力抗生素的蛋白结合力药物进入体内与血浆蛋白结合游离分子量增大分子量不变不易被 CRRT 清除更易被 CRRT 清除抗生素渗入组织并与组织结合分布容积增大 CRRT 对其清除降低

选药的压力病原体的确认 MODS 对选药的限制器官功能的影响细菌不断变迁、似是而非经济的影响病人和 / 或家属的期望值选择的空间总是非常有限！ 08/21/11 覃铁和 QIN TIEHE

我们的目标正确判断感染病灶和致病微生物清除病原体与改善器官功能一样重要兼顾各种治疗措施和各脏器功能，关注感染对脏器功能的影响，及时发现和处理影响抗感染效果的因素专科之间应该经常互相学习充分利用科室以及全院的医疗资源，尽可能通过监测指导治疗，尽可能取得准确的病原学资料，而不是单凭经验判断 08/21/11 覃铁和 QIN TIEHE

08/21/11 覃铁和 QIN TIEHE 谢谢！

覃铁和：感染控制-抗生素之外的话题

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覃铁和：感染控制-抗生素之外的话题