中心静脉导管相关性发热处理体会

目的分析中心静脉导管相关性发热的主要因素,以指导临床治疗及预防。方法选取我科2002年12月至2008年12月500例行中心静脉插管患者中30例留置导管期间出现发热,常规拔管后发热消退者的临床资料进行回顾性分析。结果发热多发生置管后3~10 d,导管尖端可检出革兰阳性球菌(17/30)、真菌(8/30)及革兰氏阴性杆菌(5/30);30例中66.7%的病例发生在胃肠道功能不全需静脉营养的病人;76.7%病例在普通病房行中心静脉穿刺操作,23.3%病例在手术室行该操作。结论导管相关性发热致病菌主要为革兰阳性球菌和真菌,尽量缩短导管留置时间,尽早建立肠内营养,尽可能选择无菌环境行插管操作对防治导管相关性发热有一定意义。     

重症急性胰腺炎病人中心静脉导管感染的特点

目的　分析重症急性胰腺炎 (SAP)病人中心静脉导管感染的特点。方法　回顾性分析1998年 1月至 2 0 0 2年 12月在肠外营养过程中发生中心静脉导管感染的SAP病人。结果　 189次中心静脉插管中有 5 1次导管尖端培养阳性 (2 6 9% ) ,共培养出致病菌 6 9株 ,其中革兰阴性菌 35株 ,占5 1% ;革兰阳性菌 2 8株 ,占 4 0 % ;真菌 6株 ,占 9%。多重导管感染 7例 ,占 13 7% ,多重导管感染病人的住院时间显著延长 [(2 8 9± 12 3)dvs (2 0 4± 10 6 )d ,P <0 0 5 ]。根据临床表现和药敏结果调整抗生素 ,5例加用抗真菌药物。治愈 4 8例 ,死亡 3例。结论　SAP病人中心静脉导管感染以革兰阴性菌最常见 ,需减少肠源性感染 ,合理使用预防性抗生素。     

中心静脉插管相关性感染因素分析及护理

目的对中心静脉插管相关性感染因素进行原困分析,并提出护理对策。方法对我科28例行48次中心静脉导管穿刺患者进行中心静脉导管尖培养结果进行回顾性分析。结果培养阳性5例,其中表皮葡萄球菌2例,肺炎克雷伯杆菌1例,鲍蔓不动杆菌1例,铅黄球菌1例,白假丝酵母菌1例,感染率10.3%(5/48)。结论留置导管时间过长,忽略插管部位的监测和护理,无菌操作不严格,高渗静脉液等是引起中心静脉导管相关感染的主要原因,加强基础性疾病的治疗及抗生素技术的应用等可减少中心静脉导管穿刺相关感染的发生。     

消化道手术患者中心静脉导管感染的特点及预防

目的探讨消化道手术患者中心静脉导管感染的特点及防护措施。方法回顾性分析2004年3月—2009年3月145例中心静脉置管的消化道手术患者的临床资料。结果145次中心静脉插管中有40次导管尖端培养阳性(27.6%),共培养出致病菌56株,其中革兰氏阴性菌(G-)28株,占50.0%;革兰氏阳性(G+)22株,占39.3%;真菌6株,占10.7%。多重导管感染6例,占15.0%。治愈39例,死亡1例。结论消化道手术患者中心静脉导管感染以革兰氏阴性菌最常见。全程规范静脉输液操作与护理,减少肠源性感染,合理使用抗菌素是防治关键。     

深静脉置管感染因素分析

目的通过研究经皮穿刺深静脉置管术与感染的关系，分析深静脉置管导管相关性感染的发病率以及影响深静脉置管感染的相关因素以采取有效的防控措施降低感染的发生。方法采用回顾性调查方法，将2005年1月至2012年12月我院收治的60例深静脉置管患者按置管部位分为颈内静脉组26例和股静脉组34例，出现发热者采集导管内血培养及导管培养，对感染发生率、感染发生的时间、感染发生的部位、患者的血流量和不同病因患者感染发生率进行了统计。结果深静脉置管放置时间越长，导管相关性感染发生越多。股静脉穿刺组感染发生时间为（26．5±9．6）d，颈内静脉穿刺组感染发生时间为（35．4±6．8）d。本研究深静脉置管导管相关性感染发生率为21．67％，其中股静脉置管的感染发生率为32．3％，颈内静脉置管的感染发生率为7．6％，股静脉置管感染发生率远高于颈内静脉置管（P〈0．01）。在病因方面，糖尿病肾脏疾病组感染率为所有组别中最高（33．3％），与其他组比较存在显著差异（P〈O．05）。慢性肾小球肾炎组（16．7％），高血压肾动脉硬化组（16．7％），多囊肾病（14．2％）、狼疮肾炎（20％）之间无明显差异。患者血流量在200ml／min以上时，导管相关性感染的发生率较低，为9．5％；血流量〈200ml／min时，感染的发生率为28．2％，二者比较，存在显著差异（P〈0．05）。细菌培养病原体以革兰阳性球菌为主（53．85％），其中金黄色葡萄球菌占30．76％，表皮葡萄球菌占23．08％。结论为减少感染发生，颈内静脉置管应作为中心静脉置管的首选部位，导管留置时间应尽可能缩短。对有易感因素的患者，如原发病为糖尿病时血流量较低，应加强无菌操作，一旦发生感染，应立即治疗。     

中心静脉导管定植病原体及药敏分析

目的:了解中心静脉导管定植病原体及药敏情况。方法:对疑似中心静脉导管感染的成年病人进行回顾性研究。采集病人临床资料、置管时间、部位和目的,导管培养结果及药敏情况。结果:651例病人纳入本研究,中位年龄为63(18～97)岁,累计置管762例次,中位置管时间为11(2～122)d。中心静脉导管病原体定植率为16.0%(122/762),共培养出134株病原体。肠外营养病人导管病原体定植率明显高于非肠外营养病人(18.8%比13.1%,χ2=4.662,P=0.032)。在导管定植病原体中,革兰阳性球菌占70株(52.2%),以溶血性葡萄球菌最常见;革兰阴性杆菌45株(33.6%),真菌19株(14.2%)。革兰阳性球菌主要对万古霉素和替考拉宁敏感,革兰阴性杆菌主要对β-内酰胺类抗生素联合β-内酰胺酶抑制剂及碳青霉烯类抗生素敏感。结论:革兰阳性球菌是最常见的中心静脉导管定植菌,对万古霉素和替考拉宁敏感。全肠外营养病人更易发生中心静脉导管病原体定植。     

输液接头微生物检测结果分析及护理对策

目的了解一次性输液接头使用过程中存在的感染风险,寻求防控导管相关性血流感染的干预措施。方法选择ICU 4个时间段56例住院患者的抗生素、输液接头使用及输注营养液体情况进行调查,并采集留置时间≥24h的所有使用中的输液接头进行微生物检测。结果ICU患者抗生素使用率为75.00%,静脉高营养使用率达到67.85%。检测一次性输液接头59套,其中6套检出致病菌,阳性检出率10.17%。检出多重耐药鲍曼不动杆菌3株,表皮葡萄球菌1株,真菌(近平滑假丝酵母菌、白色假丝酵母菌)2株。结论一次性输液接头存在严重的感染风险,应综合循证医学证据督导临床加强深静脉留置管路的更换及充分冲管,特别是输注血液、血浆等营养液体后管路的冲洗、更换,以降低导管相关性血流感染发生。     

体外循环手术患者中心静脉留置管道感染的分析

目的观察不同心脏疾病在体外循环手术后中心静脉留置管道感染的情况。方法将我科监护室近2年来收治的所有心脏手术后患者,心功能衰竭或心律失常抢救患者及心脏外伤患者按病种分类,对明确的和可疑的中心静脉留置管道感染患者,均留取外周血和导管标本进行培养。结果心脏移植术后中心静脉留置管道感染率最高,为25％;其次是动脉瘤手术,感染率为21．8％;第三是一些急诊抢救患者,感染率为15．1％;而中心静脉留置管道感染的致病菌以革氏阳性菌为主。结论体外循环手术后中心静脉留置管道感染的发生率与患者原发病、基础疾病的严重程度、术后心功能及其他脏器功能状况、以及术后所用药物均有很大的相关性。     

危重病患者中心静脉插管相关性感染的前瞻性研究

作者对加强医疗病房收治的危重病患者留置的中心静脉插管相关性感染（ＣＲＳ）进行了研究,以了解其患病率及危险因素。研究结果显示,总共１５１根中心静脉插管中,１３根（８．６％）伴有ＣＲＳ;危重病患者ＣＲＳ的发生率为每天１６．７次／１０００导管。插管时患者存在其它感染灶、插管穿刺部位、插管留置时间、拔管后２４小时内体温下降程度均与明确的ＣＲＳ相关;插管操作时间、拔管时体温、拔管后２４小时内患者体温下降程度均与没有ＣＲＳ呈显著相关。作者认为,危重病患者ＣＲＳ的发生率较高,导管穿刺和留置过程中仔细操作和护理是降低ＣＲＳ发生率的关键。     

PICC无针输液系统在ICU病人中的应用

对100例ICU病人采用经外周静脉置入中心静脉导管(PICC)无针输液系统进行置管给药。结果置管成功率为99．0％；操作时间平均13．0min；留置导管时间平均95．0d，无并发症发生。提示PICC无针输液系统安全、省时，应用效果肯定。     

带涤纶套隧道血液透析导管相关感染临床分析

目的回顾性分析带涤纶套隧道血液透析导管相关感染资料,探讨感染发生时间及细菌种类,导管感染发生率,抗生素治疗效果等,为有效防治导管相关感染提供理论依据。方法选择符合导管相关感染诊断标准的患者74例（85例次）,进行抗生素肝素盐水封管及静脉滴注抗生素,有出口感染及隧道感染的还进行局部换药。结果颈内静脉导管相关感染83例次,其中81例次为导管相关血流感染,2例次为皮肤出口及隧道感染;股静脉导管相关感染2例,均为导管相关血流感染。总的导管相关感染发生天数的中位数为368导管日,四分位间距为975导管日。金黄色葡萄球菌占检出细菌总数的32.94%。导管相关感染发生率在1年内为6.5例次/1000导管日,总的导管相关感染发生率为1.29例次/1000导管日。2例患者因基础疾病死亡,其余均临床治愈。结论带涤纶套隧道血液透析导管相关感染的患者,可使用敏感抗生素导管封管及静脉滴注抗生素治疗2-3周,无效者可拔管。检出细菌种类以金黄色葡萄球菌最常见。铜绿假单胞菌较其他菌种抗生素使用时间较长,导管相关感染发生率在1年内最高,带涤纶套隧道血液透析导管相关感染重在预防。     

Outpatient percutaneous central venous access in cancer patients

A 1-year experience of percutaneous subclavian catheterization in outpatients with cancer was reviewed to document reliability, safety, and cost. There were 763 catheter insertions attempted with prospective documentation of complications in 664 consecutive patients. Catheter insertion was successful in 722 attempts (95%). There were only 13 pneumothoraces (2%). Thirty catheters required repositioning (4%). The average catheter duration was 191 days (range: 0 to 892 days). Fifty-six catheters (8%) were removed because of suspected infection. Documented catheter sepsis occurred in 21 patients (3%); catheter site infection occurred in 8 patients (1%). Thus, only 0.22 infections per catheter year occurred during this 382 catheter-year experience. The estimated cost of catheter insertion was $562, which is one-third the estimated cost for tunneled catheters ($1,403) and for reservoir devices ($1,738). In our experience, percutaneous subclavian catheterization is a reliable, cost-effective method compared with tunneled or reservoir devices, with an equivalent incidence of catheter-related infections. The cornerstone of our success with this program is a staff dedicated to catheter care and intensive patient education. In centers where a large number of patients require central venous access, percutaneous catheterization should be the technique of choice.     

Peritoneal dialysis catheter-related complications

The introduction of a double-cuff swan neck type catheter has reduced the frequency of peritonitis. The frequency of complications associated with insertion of this catheter has remained unknown. We evaluated these complications in patients aged < 20 years at the start of the chronic peritoneal dialysis using double-cuff swan neck catheters. SUBJECTS AND METHODS: The data from 221 double-cuff swan neck catheters of 126 patients inserted in our hospital between 1990 and 2001 were compared with 102 single-cuff straight catheters of 54 patients between 1982 and 1990. The frequency of catheter-related complications, such as dislocation, leakage with in/outflow malfunction and infection(exit-site/tunnel infection and peritonitis within a month after catheter insertion) were estimated. RESULTS: We observed 37 dislocations(17%), 37 leakages(17%) and 36 infections(16%) of all double-cuff swan neck catheters. Twenty-nine catheters were removed due to catheter-related complications: 18 dislocations(8%), 2 leakages(1%) and 9 infections(4%). Catheter removal due to dislocation occurred significantly more frequently in 12% of children who were > or = 6 years old than in 1% of children < 6 years old(p = 0.002). Eighty-three percent of dislocations could be returned by the whiplash method(alpha-replacer, JMS, Tokyo). Of all single-cuff straight catheters, 10 catheters were removed due to catheter-related complications: 4 dislocations(4%), 6 leakages(6%) and 12 infections(12%). CONCLUSION: A single-cuff straight type catheter was more frequently replaced because of leakage and infection than a double-cuff swan neck type catheter. A double-cuff swan neck catheter was more frequently replaced because of dislocation than a single-cuff straight catheter. When a double-cuff swan neck catheter is inserted particularly in older children, care should be taken to avoid dislocation.     

What really affects the incidence of central venous catheter-related infections for short-term catheterization?

Central venous catheterization is one of the important sepsis reasons in surgical patients. In this randomized controlled study, the effect of the frequency and type of catheter site care, as well as age, coexisting malignancy or diabetes mellitus, total parenteral nutrition administration and antibiotics use, on central venous catheter infection was investigated. Seventy-two single-lumen polyurethane catheters were included. In group I (n: 33), a transparent occlusive dressing was applied to the insertion site and not removed for 7 days unless there were signs of local infection. In group II (n: 39), daily site care was done with povidone-iodine 10% solution and a new sterile gauze was applied. Chi-square, linear correlation and multiple regression tests were used for statistical analysis. Mean duration of catheters was 8 +/- 4 days. There was no catheter-related sepsis. Ten (13.9%) patients had positive catheter tip cultures of whom three had site infection as well. The incidence of site and tip infections were not significantly different in group I and II (p > 0.05). Site infection and age younger than 60 years significantly increased the rate of tip infection (p: 0.004 and p: 0.02 respectively). Total parenteral nutrition administration was associated with higher rate of tip infection (p: 0.06). Coexisting malignancy or diabetes mellitus, duration of catheter and antibiotics use did not have any significant effect on the rate of central venous catheter infections (p > 0.05). In conclusion, we observed that the frequency of insertion site care and the type of dressing applied to the site had no significant effect on the rate of CVC infection. Insertion site infection was the most significant factor increasing the incidence of catheter tip infection. The use of the CVC for total parenteral nutrition facilitated tip infection as well.     

Hemodialysis infection prevention with polysporin ointment

Hemodialysis patients in whom permanent vascular access cannot be achieved are dependent on a central venous catheter. In such patients, catheter-related infections are a common and serious complication. This study was a randomized clinical trial to determine if topical Polysporin Triple antibiotic ointment applied to the central venous catheter insertion site could reduce the incidence of catheter-related infections. A total of 169 patients receiving hemodialysis through a central venous catheter were randomized to receive Polysporin Triple or placebo using a double-blind study design. In the 6-mo study period, infections were observed in more patients in the placebo group than in the Polysporin Triple group (34 versus 12%; relative risk, 0.35; 95% CI, 0.18 to 0.68; P = 0.0013). The number of infections per 1000 catheter days (4.10 versus 1.02; P < 0.0001) and the number of bacteremias per 1000 catheter days (2.48 versus 0.63; P = 0.0004) were also greater in the placebo group. Within the 6-mo study period, there were 13 deaths in the placebo group as compared with 3 deaths in the Polysporin Triple group (P = 0.0041). When all available follow-up information was included, the difference in survival remained significant (19 versus 9 deaths; P = 0.0027). Within the first 6 mo, infections were observed in 7 of the 13 placebo subjects who died (54%) as compared with no infections in the three Polysporin Triple subjects who died. The prophylactic application of topical Polysporin Triple antibiotic ointment to the central venous catheter insertion site reduced the rate of infections and was associated with improved survival in hemodialysis patients.     

Use of catheters with the AgION antimicrobial system in kidney transplant recipients to reduce infection risk

Microbial blood infection represents a high risk for immuno-suppressed patients. Of all catheter-related infections in the bloodstream, 90% result from the use of central venous catheters, the main cause being microbial colonization at the catheter's insertion point or the catheter hub. Between January 2003 and December 2004, 102 patients received a renal transplant including 57 who received a triple-lumen central venous catheter (CVC) during the procedure. Two catheters were used: a standard polyurethane catheter placed in the jugular veina or the subclavian veina for group I, and polyurethane catheters with the AgION antimicrobial system always placed in the subclavian veina for group II. Care and maintenance of the CVCs was standardized in both groups. After catheter removal, the tips were analyzed microbiologically. Of 57 (43.9%) CVCs, 25 were found to be contaminated. In the first group 24 out of 41 CVCs (58.5%) showed bacterial growth, whereas in group II only one catheter (6.6%) had a biofilm. The most common contaminant (18 out of 25, 72%) was Staphylococcus epidermidis. In group II, two patients had positive blood cultures yet a microbiologically sterile CVC. None of the catheters with the AgION antimicrobial system had to be removed owing to local infection or intolerance. The continuous release of silver ions increases the protection against bacteria and fungi during the entire time of catheterization. Use of catheters with the AgION antimicrobial system lead to a marked reduction in catheter-associated infections of the bloodstream.     

High incidence of severe twin hemodialysis catheter infections in elderly women. Possible roles of insufficient nutrition and social support

BACKGROUND: Cuffed-tunneled hemodialysis (HD) catheters are recommended as a bridging therapy until peripheral access is available, but their long-term use is controversial. AIM: To evaluate the complications and lifetime of twin-tunneled HD catheters and to identify parameters which could predict their outcome. METHODS: 29 chronic HD patients (19 female and 10 male) were inserted with twin hemodialysis catheters (28 Tesio, 1 Schon Duoflow), followed for up to 9 months or until catheter loss, and evaluated for severe catheter-related complications necessitating catheter removal. Since the most common severe complication was catheter-related infection, we retrospectively examined whether parameters such as age, gender, duration of end-stage renal disease, delivered dose of dialysis, nutrition, diabetes and indices of social support correlate with this outcome. RESULTS: Severe catheter infection requiring catheter removal occurred in 11 patients (10 female). Of these infected female patients, 9 were elderly (> or =67 years) and in 6 of those, catheter infection was fatal (54% of infected cases). At 9 months, severe catheter infection and related patient death rates were 38 and 21%, respectively. Severe catheter infection was significantly related to less social support (p < 0.005), older age, female gender, lower nPCR (all p < 0.05), and tended to be related to shorter end-stage renal disease duration prior to catheter insertion (p = 0.06). CONCLUSION: This study demonstrated that twin HD catheters are associated with a high incidence of severe catheter-related infections which was most significantly related to social-support as well as inadequate nutrition, older age and female gender. Therefore, we suggest early removal of the catheter, enhancement of social support and dietary counseling for the elderly and lonely HD patients using this type of catheter.     

Persistent Sciatic Artery Aneurysm: a Case Report

Central venous catheterization is one of the important sepsis reasons in surgical patients. In this randomized controlled study, the effect of the frequency and type of catheter site care, as well as age, coexisting malignancy or diabetes mellitus, total parenteral nutrition administration and antibiotics use, on central venous catheter infection was investigated.

Seventy-two single-lumen polyurethane catheters were included. In group I (n: 33), a transparent occlusive dressing was applied to the insertion site and not removed for 7 days unless there were signs of local infection. In group II (n: 39), daily site care was done with povidone-iodine 10% solution and a new sterile gauze was applied. Chi-square, linear correlation and multiple regression tests were used for statistical analysis.

Mean duration of catheters was 8 ±4 days. There was no catheter-related sepsis. Ten (13.9%) patients had positive catheter tip cultures of whom three had site infection as well. The incidence of site and tip infections were not significantly different in group I and II (p > 0.05). Site infection and age younger than 60 years significantly increased the rate of tip infection (p: 0.004 and p: 0.02 respectively). Total parenteral nutrition administration was associated with higher rate of tip infection (p: 0.06). Coexisting malignancy or diabetes mellitus, duration of catheter and antibiotics use did not have any significant effect on the rate of central venous catheter infections (p > 0.05).

In conclusion, we observed that the frequency of insertion site care and the type of dressing applied to the site had no significant effect on the rate of CVC infection. Insertion site infection was the most significant factor increasing the incidence of catheter tip infection. The use of the CVC for total parenteral nutrition facilitated tip infection as well.     

深静脉置管血液透析患者真菌感染的易感因素及护理对策

目的探讨血液透析患者带涤纶环深静脉留置导管真菌感染的易感因素，为临床制订预防感染的护理措施提供理论依据。方法观察24例采用带涤纶环深静脉留置导管行维持性血液透析患者真菌感染发生率、临床表现、治疗转归，并分析易感因素。结果5例（20.83％）发生导管相关性真菌感染，感染真菌均为假丝酵母菌，药物敏感试验提示氟康唑敏感性最高；氟康唑导管内滴注治疗3例有效；导管相关性真菌感染与近期抗生素的应用、导管置入时间有关（均P〈0.05）。结论导管相关性真菌感染不可忽视，了解其临床特点、易感因素，采取针以性预防措施，对减少感染发生率、延长导管的使用寿命具有重要意义。     

An evaluation of triple-lumen catheter infections using a guidewire exchange technique

One hundred fifty-six triple-lumen central venous catheters placed into 65 different sites in 52 surgical or trauma patients were prospectively evaluated to determine the frequency of catheter-related infection and the efficacy of multiple guidewire exchanges. Thirty-four anatomic sites in 33 patients without clinical signs of sepsis were compared to 31 anatomic sites in 19 patients with a clinical diagnosis of sepsis based on clinical, microbiologic, and radiologic evaluation. Anatomic sites were used indefinitely unless a positive semiquantitative catheter culture (greater than or equal to 15 cfu) or catheter-associated bacteremia developed. Seven catheter-related infections developed in five septic patients (26.3%) while no infections developed in the nonseptic group (p = 0.004). Three of 31 anatomic sites (9.6%) were associated with bacteremia. The number of hospital days to initial catheter insertion and the length of catheter site use were considerably higher in the septic patients compared to the nonseptic group. We conclude that triple-lumen catheter-related infections are uncommon in patients with no evidence of infection and can be safely guidewire-exchanged to prolong site use. Catheter-related infections in septic patients are much more frequent and unpredictable. Although guidewire exchange has a role in septic patients, multiple exchanges cannot routinely be recommended.