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【医学ppt课件】呼吸机相关性肺炎医院感染监测与控制

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医学ppt课件 呼吸机相关性肺炎医院感染控制 【医学ppt课件】呼吸机相关性肺炎医院感染监测与控制 呼吸机相关性肺炎 医院感染监测与控制 与呼吸机相关性肺炎 和呼吸机相关性肺炎 呼吸机相关性肺炎
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Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸机相关性肺炎 医院感染监测与控制 绵阳市中心医院 医院感染管理科 马春华 20112011年年1212月月2222日日 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 目标 ü掌握呼吸机相关性肺炎的诊断 ü掌握呼吸机相关性肺炎的监测方法 ü掌握呼吸机相关性肺炎的控制方法 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸机相关性肺炎定义 呼吸机相关性肺炎( VAP) 是指应用机械通 气≥48 h或撤停机械通气拔除人工气道导管 后48 h内发生的感染性肺炎, 这一类严重的医 院内感染[1] 。 参考文献:￿￿[1] 徐秀华. 临床医院感染学第2 版[M ] . 长沙: 湖南科 学技术出版社, 2005: 377~ 350. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. VAP病例诊断标准 患者应用机械通气 48 h后出现发热、气道 深部脓性分泌物、肺部湿罗音; WBC 总数 升高和嗜中性粒细胞比例升高; 影象学显示 肺部新的炎性侵润性病变和下呼吸道分泌 物培养2次分离到新的相同的细菌。 机械通气最初4 d内发生的为早发性VAP, ≥ 5 d者为晚发性VAP。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸机相关性肺炎监测 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 监测内容 基本资料 监测月份、住院号、科室 、床号、姓名、性别、年龄、疾病诊断、 疾病转归(治愈、好转、未愈、死亡、其 他) Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 监测内容 医院感染情况 感染日期及诊断、感 染与呼吸机使用的相关性、痰培养标本送 检日期、检出病原体名称、药物敏试结果 。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 监测内容 ICU患者日志 每日记录新住进患者数、 住在患者数、使用呼吸机人数、记录临床 病情分类等级及分值。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. ICU患者临床病情分类标准及分值 分类级别类级别 分值值 分类标类标 准 A级级 1分 需常规观规观 察,不需加强护护理和治疗疗(包括手术术后只 需观观察的患者)。患者常在48h内从ICU中转转出。 B级级 2分 病情稳稳定,但需预预防性观观察,不需加强护护理和治疗疗 的患者,如某些因需排除心肌炎、心肌梗死及因需服 药药而在ICU过过夜观观察的患者。 C级级 3分 病情稳稳定,但需加强护护理和/或监护监护 的患者,如昏迷 患者或出现现慢性肾肾衰的患者。 D级级 4分 病情不稳稳定,需加强护护理和治疗疗,需经经常评评价和调调 整治疗疗方案的患者。如心律不齐齐、糖尿病酮酮症酸中 毒(尚未出现现昏迷、休克、DIC)。 E级级 5分 病情不稳稳定,且处处在昏迷或休克状态态,需要心 肺复苏苏或需要加强护护理治疗疗,并需经经常评评价护护 理和治疗疗效果的患者。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 监测方法 宜采用主动监测(专职人员每日到ICU, 按照监测表 格中的内容进行观察、询问医生护士,查阅生命 体征\检测单、病程记录单、检查单等,收集资料, 逐项记录完整) ,也可专职人员监测与临床医务 人员报告相结合。 填写医院感染病例登记表。 每天填写ICU患者日志。 ICU患者各危险等级登记表。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. ICU患者日志 监测月份: 年 月 日期 新住进患者数a 住在患者数b使用呼吸机患者数e 1 2 3 …… …… …… …… a:指当日新住进ICU的患者。 b:包括新住进和已住进ICU的患者。 e:均指当日使用的患者数。 f:为ICU患者日志各项的累计。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. ICU患者各危险等级登记 表 临临床病情等 级级 分值值 第1周 第2周 第3周 第4周 A 1 B 2 C 3 D 4 E 5 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 监测资料分析 呼吸机相关肺炎感染发病率= 使用呼吸机患者中肺炎人数 患者使用呼吸机总日数 ×1000‰ Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 总结和反馈 结合历史同期资料进行总结分析,提出监 测中发现的问题,报告医院感染管理委员 会,并向临床科室反馈监测结果和分析建 议,制定控制方案,减少导致感染的危险 因素。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸机相关性肺炎的预防 üICU环境 ü医务人员的手消毒 ü物品的消毒、灭菌(呼吸机管路及吸氧相关器具的管 理) ü加强口腔、鼻胃管的护理 ü呼吸道的管理 ü加强营养,提高机体抵抗力 ü心理护理 无菌操作,减少或缩短呼吸机使用时间 轮换或替换应用抗生素,并建立细菌耐药监测系统 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. ICU环境 清洁、相对独立区,其建筑材料不产尘、不积尘,防腐蚀 、防潮防雾;易清洁、消毒 明确分区:清洁区、半清洁区、污染区 ICU特殊流程(人流、物流)工作人员、病人及家属、物 品(包括污物),各行其道 限制进入ICU人员 床位有足够空间,避免床位排列过密,病人之间交叉感染 良好的通风系统,足够的辅助用房以更衣、放置清洁物品 及污物处置 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 落实WHO关于手卫生的六个指征 1. 接触病人前后 2. 摘除手套后 3. 进行侵入性操作前 4. 接触病人体液、排泄物、粘膜、破损的皮肤或者 伤口敷料后 5. 从病人身体的感染部位到干净的部位 6. 直接接触接近病人的物品(包括医疗器械)后 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. ICU物品消毒 普通的医疗用品:血压计、听诊器、简易R 器、体温表等 抹布、拖把、扫把 及时清理污物 终末清理 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸机清洗消毒 建立清洗消毒基地,呼吸机统一清洗消毒 制定可操作性强的清洗消毒制度和流程 落实规章制度与合理的清洗消毒流程,确 保清洗消毒质量到位 严格消毒溶剂的配比 严格的监控检测手段及工作人员专业知识 提升 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸机管路方面的管理 l呼吸机管路的消毒及监测 l呼吸机管路的更换 l冷凝水的处理 参考文献:程红缨.气管内吸引合并症的发生原因及其预防措施[J].中华护理杂志 ,2002,37(7):536-538. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 加强多重耐药菌(multiple resistant bacteria) 的监测和病例管理 •鲍曼不动杆菌(A. baumanii) •耐甲氧西林金黄色葡萄球菌 (methicillin- resistant Staphylococcus aureus) •耐万古霉素肠球菌(VRE) •铜绿假单胞菌(p.aeruginosa) Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 口腔护理 正常人上呼吸道正常菌群维持相互平衡状态,而下 呼吸道是无菌的 口咽部菌群常发生改变,最突出的是革兰氏阴性杆 菌定植比例明显增加,与病情严重程度及住院时间 呈正比 口咽部分泌物是进入下呼吸道的重要感染源 0.01ml口腔分泌物含有106-108个细菌 参考文献:苏鸿熙.重症加强监护学[M].北京:人民出版社,1996:345. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 鼻胃管的护理 l选择肠内营养的时机 l体位 l胃内容物的观察 l鼻饲的注意事项 参考文献:曹林英.鼻饲在气管切开患者肺部感染中的关系探讨[J].护士进修杂志 ,2002,17(3):218. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呼吸道的管理 吸入气体的加温、加湿管理 肺部感染率随气道湿化程度的降低而升高 呼吸道分泌物的清除 吸痰的管理 2005年的研究证明气道内滴入生理盐水对痰液的粘稠度没有影响,起不 到稀释痰液的作用,反而容易引发呼吸机相关性肺炎(VAP) 气囊的管理 目前认为气囊不必常规放气,因为放气后1小时内气囊压迫过的黏膜毛细 血管血流也难以恢复。只需非常规放气或调整气囊的压力。气囊放气时 最好两人操作,边放边吸渗漏的分泌物 参考文献:王宝华.全麻气管插管后与下呼吸道感染关系探讨[J].中华医院感染学杂志 ,2002,12(4):286. 蓝惠兰,李雪球,覃铁和,等.机械通气患者吸痰前气管内滴入生理盐水 湿化的比较研究[J].中华护理杂志,2005,40(8):567-569. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 人工气道的管理 及时吸痰 做好气囊管理 气道湿化 口腔护理 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 吸痰的管理 评估评估 观察:视、听观察:视、听 适时吸痰适时吸痰 气道阻力气道阻力 肺部听诊肺部听诊 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 吸痰的管理 选择合适的吸痰管型号选择合适的吸痰管型号 调节合适的负压吸引压力调节合适的负压吸引压力 成人: - 100 ~ -120 mmHg- 100 ~ -120 mmHg 儿童: - 80 ~ -100 mmHg- 80 ~ -100 mmHg 幼儿: - 60 ~ -80 mmHg- 60 ~ -80 mmHg Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 吸痰的管理 吸痰的步骤及注意事项吸痰的步骤及注意事项 解释解释 预充氧预充氧 时间时间 小于小于1515秒秒 次数次数 不超过不超过3 3次次 监测生命体征监测生命体征 预防并发症预防并发症 低氧血症低氧血症 气道损伤气道损伤 感染感染 气道阻塞气道阻塞 右支气管吸引右支气管吸引 肺不张肺不张 气气 管痉挛等管痉挛等 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 气囊的管理 气囊的充气方法气囊的充气方法 最小闭合容量技术最小闭合容量技术 ((1 1)将听诊器放于气管处,向套囊内)将听诊器放于气管处,向套囊内注气注气,直,直 到到听不到漏气声听不到漏气声 ((2 2)然后)然后抽出抽出0.5ml0.5ml气体,可闻少量的漏气量气体,可闻少量的漏气量 ((3 3))再注气再注气,直到吸气时听不到漏气声为止,直到吸气时听不到漏气声为止 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 气囊的管理 气囊的压力要求气囊的压力要求 一般在一般在15-20mmHg(15-20mmHg(20-20- 27cmH27cmH 2 2 OO) ) 每每8 8小时测压一次小时测压一次 大容量低压气囊能承受大容量低压气囊能承受30mmHg30mmHg 的囊内压的囊内压 气管的毛细血管压力达气管的毛细血管压力达30mmHg30mmHg以以 上时可对气管血流具有损伤作用上时可对气管血流具有损伤作用 在在37mmHg37mmHg时可完全阻断血流时可完全阻断血流 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 气囊的管理 气囊放气(大容量低压气囊)大容量低压气囊) 大多数医师认为,如果没有指征,并没有必要常 规套囊放气。因为套囊放气并没有明显影响气管 壁的压力,相反却增加分泌物吸入和诱发低氧血 症的危险。而且在重新充气时,有可能套囊充气 过多而致压力过高,或因频繁的使用致使充气接 头的单向活瓣损坏 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 气囊的管理 清除气囊上滞留物的方法清除气囊上滞留物的方法( (传统传统)) 使患者取头低脚高位或平卧位使患者取头低脚高位或平卧位 充分吸引气管内、口、鼻腔内分泌物充分吸引气管内、口、鼻腔内分泌物 简易呼吸器与气管插管相接,简易呼吸器与气管插管相接,吸气末呼气初吸气末呼气初用力挤用力挤 压呼吸器,同时助手放气囊、充气囊压呼吸器,同时助手放气囊、充气囊 再一次吸引口鼻腔内分泌物,反复操作再一次吸引口鼻腔内分泌物,反复操作2 ~ 32 ~ 3次,次, 吸净气囊上的分泌物吸净气囊上的分泌物 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 根据循症医学建立的预防VAP行动指南 Canadian Critical Care Society 经口气管插管建议 人工鼻过滤器建议 定期更换呼吸机管路不建议 封闭吸痰管建议 声门下吸引 建议 胸部理疗考虑 早期的气管切开不建议 动力翻身床考虑 半卧位建议 俯卧位不建议 气道内应用抗生素不建议 Ann Intern Med, 2004, 141: 305 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 气管插管/气管切开之后 分泌物在声门下间隙潴留 声门下气道及口鼻咽腔细菌定植 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 声门下分泌物持续吸引(CASS) Evac气管导管/气切套管进行声门 下间隙分泌物持续吸引,可使长期机 械通气病人医院获得性肺炎的发生 率降低 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. Hi-Lo® Evac气管导管和气切导管的操作方法 1. 10ml注射器 每小时抽吸一次 最简单 2. 持续吸引 24小时/天,连接吸引 使用EVAC吸引泵 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 封闭式吸痰好处 37 •保证通气支持的连续性 •防止交叉感染 •减少了时间/物
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