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.     

长期留置深静脉血液透析导管真菌感染的治疗

我们用氟康唑导管内滴注加氟康唑稀释尿激酶封管的方法治疗1例长期留置深静脉血液透析导管真菌感染,获得成功.     

应用氟康唑预防重症急性胰腺炎真菌感染

目的探讨用氟康唑预防重症急性胰腺炎（SAP）合并真菌感染的效果。方法将1998年7月至2004年6月收治的SAP并存真菌感染易感因素79例患者随机分预防组和对照组。预防组在常规治疗的基础上加每日静脉点滴氟康唑200mg，对照组仅给予常规治疗；观察两组患者的真菌感染的发生率、发生时间、抗真菌治疗后的真菌清除率和因真菌感染的死亡率，两组患者的住院时间。结果预防组的真菌感染率（5．3％：27．5％，P〈0．05）。因真菌感染的死亡率（5．1％：12．5％。P〈0．05），住院时间（38．3：57．4，P〈0．05）均明显低于对照组。但预防组发生真菌感染后抗真菌治疗的真菌清除率低（33％：72．7％，P〈0．05）。结论氟康唑能有效降低SAP合并真菌易感因素患者的真菌感染发生率和死亡率。缩短住院时间。     

血液透析非永久性深静脉留置导管相关性感染临床观察

目的分析血液透析患者非永久性深静脉留置导管相关性感染的相关因素、常见致病菌,并探讨其预防措施。方法分析327例血液透析患者导管留置时间、置管部位、年龄、有无合并糖尿病与感染的关系以及感染的常见致病菌和耐药情况。结果非永久性深静脉留置导管相关性感染率与导管留置时间有关,股静脉置管的感染率高于颈内静脉置管,老年、合并糖尿病患者的感染率明显高于非老年、未合并糖尿病患者。感染常见致病菌为革兰氏阳性球菌,对替考拉宁、万古霉素耐药率最低,革兰氏阴性杆菌对亚胺培南耐药率最低。结论血液透析非永久性深静脉留置导管相关性感染与置管时间、置管部位、年龄、是否合并糖尿病有关,需要早期发现,选用敏感抗生素并及时治疗。     

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。     

长期性留置带涤纶套双腔导管在血液透析中的使用及护理

目的:探讨慢性肾功能衰竭(CRF)患者长期性留置带涤纶套双腔导管行血液透析(HD)的并发症及护理.方法:对2006年7月～2010年10月6例使用长期性留置带涤纶套双腔导管的患者血液透析例情况和护理做一小结,介绍留置导管的适应证、置管方法、导管的护理操作、导管使用不当的因素以及常见并发症.结果:6例患者共2976次治疗期间,其中1例全身感染,经抗感染治疗无效而把拔管,其余5例全部在维持血透,并发局部感染1次,血流不畅2例共11次,微血栓形成73次,无一例因导管功能失效而拔管.与使用动静脉内瘘患者相比,血液透析充分性无显著差异.结论:使用长期性留置带涤纶套双腔导管行血液透析,医护人员严格的无菌操作、正确的使用导管和封管、对患者针对预防并发症的健康宣教是保证患者延长导管使用寿命的关键.     

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。     

精细化管理在血液透析患者深静脉留置导管维护中的作用

目的探讨精细化管理在血液透析患者深静脉留置导管维护中的作用。方法选取我院2013年5月至2016年3月血液透析深静脉留置导管患者203例,随机分为观察组及对照组,观察组109例,对照组94例。观察组在常规护理的基础上采用精细化管理方法,包括精细化的环境管理、围手术期护理、深静脉置管操作维护、患者健康教育、患者心理护理多方面进行干预和管理。对照组采取常规护理方法,主要为一般健康指导,常规环境管理和常规置管术前、术后护理。观察2组患者深静脉留置导管脱管发生率、出血发生率、栓塞发生率、导管感染发生率以及患者治疗依从性,并对上述观察指标进行统计学分析。结果观察组脱管率3%,出血率14%,感染发生率6%,栓塞的发生率6%;对照组脱管率17%,出血率29%,感染发生率17%,栓塞的发生率6%。观察组脱管率、出血率、感染发生率均低于对照组,差异具有统计学意义(P0.05)。2组患者栓塞发生率差异无统计学意义(P0.05)。观察组患者治疗依从性高于对照组,差异具有统计学意义(P0.05)。结论在血液透析患者深静脉留置导管的维护中落实精细化管理措施可减少血液透析患者深静脉留置导管管路脱落、出血、感染并发症的发生,能显著提高患者治疗依从性,为血液透析患者进行血液净化治疗提供有效的血管通路,保证血液净化治疗的有效实施,提高了患者生存质量;同时也提高了护理人员的护理效率和护理质量,和谐了医患关系。     

透析导管相关血流感染的危险因素及风险预测模型

目的:探讨留置带隧道和涤纶套的透析导管（tunnel-cuffed catheter,TCC）的血液透析（hemodialysis,HD）患者发生导管相关血流感染（catheter-related bloodstream infection,CRBSI）的危险因素,构建感染风险预测模型。方法:本研究为回顾性研究,选择2...     

216例涤纶套深静脉留置导管应用回顾性分析

目的：探讨涤纶套深静脉留置导管血液透析的使用和退出原因。方法：分析置管方法与血流通畅情况,随访留置导管的使用和并发症,记录导管使用终点。结果：实施深静脉留置长期带涤纶套导管术216例,右颈内静脉置管209例,成功率96.8%,左侧颈内置管5例,2例经股静脉;导管使用期限：平均（15±13）个月,使用留置导管时间分别为：〉36月56例,〉24月75例,〉12月45例,〉6月25例,〈6个月15例（大部分在继续使用）,28例失访。观察导管使用终点105例,约占49.5%,导管退出时使用时间2～28月,平均（10±5）个月;退出原因：死亡52例,其余为感染拔管、血流不畅和肾移植。在导管使用终点,90.5%（95/105）的导管功能良好;导管透析充分性：151例患者的透析后尿素下降率平均70%,平均Kt/V达到1.45;与内瘘透析患者Kt/V=（1.51±0.30）比较,二者差异无统计学意义（P〈0.05）。左侧颈内静脉置管血流不畅发生率高;感染25例,治疗有效23例,无效拔管2例。结论：长期导管可以达到充分透析;长期导管使用人群主要是老年人、等待肾移植和多次内瘘失败者,良好的导管留置技术提高导管的有效使用,尽量采用右侧颈内静脉置管,良好的护理显著降低导管感染率。     

Citrate lock versus heparin lock for the prevention of catheter related infections in hemodialysis patients with tunneled catheters: a Meta-analysis of randomized controlled trials

ObjectiveTo study whether citrate lock is superior to heparin lock in the prevention of catheter related infections, bleeding complications and catheter malfunctions among hemodialysis patients with tunneled catheters. MethodsBy searching in Pubmed, the Cochrane Library, EMBASE, Ovid, WanFang, VIP, CNKI and CBM databases as well as related journals, qualified randomized controlled trials were included in a Meta - analysis using Revman 5.0 and STATA 10.0 software. The endpoints included catheter related infection, bleeding complication, thrombolytic treatment, catheter removal for malfunction, catheter thrombosis and all - cause death. ResultsFifteen randomized controlled trials were included with 1621 patients involved. Eight studies compared citrate alone with heparin lock, while 7 trials focused on citrate in combination with other antimicrobials. Pooled analysis demonstrated that incidence of catheter related infections in patients receiving citrate lock decreased by 47% compared with those on heparin (RR=0.53, 95%CI 0.36-0.77, P＜0.01). Subgroup analysis by types of citrate lock indicated that all combined lock solutions of citrate and other antimicrobials (citrate + gentamicin, citrate + taurolidine, citrate + methylene blue + methylparaben + propylparaben) were superior to heparin lock in preventing catheter-related infections (P＝0.01, 0.04, 0.01, respectively); citrate alone seemed to reduce catheter-related infection risk (RR＝0.68), but no statistically significant difference was observed (95%CI 0.38-1.21, P＝0.19). There were fewer patients with bleeding complications in citrate group (RR＝0.53, 95%CI 0.34-0.84, P＜0.01), while citrate showed no advantage over heparin lock in terms of thrombolytic treatment (P＝0.93), catheter removal for malfunction (P＝0.35), catheter thrombosis (P＝0.64) and all - cause death (P＝0.35). ConclusionsFor hemodialysis patients with tunneled catheters, combined lock solutions of citrate and other antimicrobials, rather than citrate alone, are superior to heparin in preventing catheter related infections. Citrate locks are associated with less bleeding complications, and are comparable to heparin in the maintenance of catheter patency.     

Prevention of hemodialysis subclavian vein catheter infections by topical povidone-iodine.

Subclavian catheter (SCC) related infections are a major cause of morbidity in hemodialysis patients, the vast majority due to staphylococci species. Povidone-iodine (PI) has proven anti-staphylococcal activity. Therefore, a randomized controlled trial of topical PI ointment was undertaken to evaluate the impact of this prophylactic intervention on the incidence of SCC related infections in hemodialysis patients. The role of S. aureus nasal carrier state in the acquisition of infection was also evaluated. Patients requiring SCC for temporary hemodialysis access were randomized to receive the treatment (T; N = 63) or sterile gauze dressings alone (C; N = 66). Catheter duration ranged from 2 to 210 days in both groups, with a mean of 38.6 days in T and 36.2 days in C (NS). Exit site (ES) infections were significantly less in T (5%) versus C (18%) (P less than 0.02); tip colonization (TC) was 17% in T versus 36% in C (P less than 0.01), while the incidence of septicemia (S) was also significantly less in T (2%) versus C (17%; P less than 0.01). S. aureus nasal carriers were at a threefold higher risk of SCC related septicemia (0.009/day) than noncarriers (0.003/day; P less than 0.05). The beneficial effect of PI ointment was most evident in this high risk group of S. aureus carriers: ES = 0% T versus 24% C, TC = 12% T versus 42% C, S = 0% T versus 29% C, P less than 0.05. There were no adverse effects of the treatment. The routine application of topical PI ointment to temporary hemodialysis catheter exit sites is effective in reducing SCC related infections.     

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.     

Antibiotic Catheter Locks in the Treatment of Tunneled Hemodialysis Catheter‐Related Blood Stream Infection

We prospectively examined the efficacy of systemic antibiotics and antibiotic catheter locks for the treatment of tunneled hemodialysis catheter related blood stream infections (CRBSI). Patients with clinical signs of tunnel or metastatic infection were excluded. All patients with suspected CRBSI were treated empirically with systemic antibiotics at the onset of symptoms before final culture and susceptibility results were available. Once the organism was identified, antibiotics treatment was tailored and antibiotic catheter locks were instilled after each dialysis treatment. Clearance of infection was documented by negative surveillance cultures after completion of antibiotic course. Out of 46 episodes of CRBSI; 16 were due to gram positive organisms, 22 were due to gram negative organisms, and 8 were polymicrobial (≥2 organisms) infections. 19 cases required removal of dialysis catheter. Antibiotic lock protocol was successful for eradicating infection in 27 of 46 episodes (59%). The likelihood of a clinical cure was identical in both gram‐positive and gram‐negative infections (63% and 62% respectively). Antibiotic lock protocol remains an option in the treatment of clinically stable patients with CRBSI; however, success rate of this protocol in eradicating the infection is modest.     

中心静脉导管相关血流感染的诊疗及防治对策

目的 从临床实用角度探讨中心静脉导管引发的导管相关性血流感染(CRBSI)的诊疗及防治,为进一步降低导管相关性血流感染发病率提供依据.方法 采用近5年国内外相关文献回顾与北京友谊医院监测结果及临床实际相结合的综合分析方法.结果 (1)从临床角度看,CRBSI原发的病原菌经由穿刺点/导管接头而侵入血流;继发的病原菌从其他...     

Bacterial colonization in hemodialysis temporary dual lumen catheters: a prospective study

AIMS: The use of hemodialysis temporary dual-lumen catheters is often complicated by infections, which may be a significant cause of death among patients with end stage renal disease (ESRD). The aim of this study was to assess the incidence of bacteremia and bacterial colonization related to non-tunneled, non-cuffed, dual-lumen temporary catheters in patients with ESRD submitted to hemodialysis. METHODS: This study included 29 patients with ESRD. After catheter implantation, patients were monitored throughout the period of catheter permanence by means of blood samples collected weekly from a peripheral vein. Bacteria were isolated and identified according to CLSI recommendations. When catheters were removed for any reason, their tips were evaluated microbiologically. RESULTS: A total of 194 blood samples from the 29 patients implanted with 55 catheters were analyzed. Of these, 15.5% (30 samples) demonstrated bacterial growth, principally Staphylococcus epidermidis (64.5%). Twenty patients (68.9%) presented at least one positive blood culture during follow-up. The median time for catheter colonization was 18.5 days (95% CI: 16.8-30.3). Of the 55 catheters implanted, 28 (50.9%) showed bacterial colonization, corresponding to 23.4 episodes/1000 catheter/days and 9.2 episodes of bacteremia /1000 catheter/days. Fifteen of 28 catheter tips analyzed showed bacterial growth (53.5%). In 14 of these (93.3%), there was agreement between the isolates from the catheter tip and blood cultures. Of 24 episodes of positive blood cultures from 20 different patients in 17 episodes (70.8%), the patients showed no clinical signs or symptoms of bacteremia. CONCLUSIONS: The high incidence of catheter colonization, the correlation between blood and catheter tip cultures, and the occurrence of frequent cases of asymptomatic bacteremia justify the proposal of routine peripheral blood collections to monitor patients undergoing hemodialysis with temporary dual-lumen catheters.     

经皮置管引流治疗重症急性胰腺炎合并胰腺坏死组织感染34例分析

目的 分析经皮置管引流（percutaneous catheter drainage, PCD）治疗重症急性胰腺炎（severe acute pancreatitis,SAP）合并胰腺坏死组织感染的临床效果及影响因素。方法 回顾性分析2008年1月至2010年2月南京军区南京总医院普通外科应用PCD治疗34例胰腺坏死组织感染的临床资料。根据PCD治疗效果将34例SAP病人分为PCD治疗成功组和PCD治疗变更组,比较两组病人全身状况、局部病变以及PCD治疗过程的差异。 结果 19例经PCD治疗成功,成功率55.9%。两组病人胰腺坏死组织感染的CT密度平均值、CT分布范围值等方面比较差异有统计学意义（P<0.01）。结论 胰腺坏死组织感染的CT密度平均值和CT分布范围值均为PCD治疗胰腺坏死组织感染的影响因素,其值越大,失败的风险性越高,不适合行PCD治疗。反之则建议首选PCD治疗。     

103例肝移植术后细菌感染危险因素分析

目的分析肝移植病人术后各类细菌感染的发生率及其危险因素。方法回顾性分析四川大学华西医院2000~2003年施行的103例肝脏移植病人的临床资料。选取围手术期45个独立变量,经单变量分析及logistic回归分析,筛选与术后感染相关的危险因素。结果52例病人术后发生77次细菌感染,感染率为50·49%(52/103);G-需氧菌占67·8%(103/152),G 需氧菌占32·2%(49/152)。手术时间、呼吸机带机时间、TPN支持时间与术后早期细菌感染有关。结论肝移植术后易发生细菌感染,针对其危险因素积极采取预防措施是降低术后感染率的主要措施。     

血液透析患者中心静脉导管感染的危险因素

目的 探讨中心静脉导管(central venous catheter,CVC)相关感染的发病率和高危因素.方法 以历史性队列研究的方法进行调查.结果 患者感染率为18.83/1 000导管日.单因素相关分析显示,使用非隧道导管(non-tenneled catheter,NTC)导致的导管相关血流感染(catheter related blood stream infection,CRBSI)的危险因素有糖尿病、导管留置时间、白细胞计数、血红蛋白浓度及中性粒细胞计数;NTC外口感染的危险因素为年龄、糖尿病、中性粒细胞计数及血清白蛋白水平,而导管留置部位和时间都不是外口感染的危险因素.多因素相关分析表明,使用NTC的患者发生CRBSI的危险因素为糖尿病、导管留置时间和中性粒细胞计数;使用NTC的患者外口感染的危险因素是年龄、血清白蛋白水平及中性粒细胞计数.结论 应控制感染发生的危险因素,降低感染发生率.     

Prevention and Treatment of Hemodialysis‐Related Bloodstream Infections

Despite improvements in the delivery of care, the annual all‐cause mortality rate for end‐stage renal disease (ESRD) patients is still around 220 deaths per 1000 at risk patient‐years. Infection‐related causes are second only to cardiovascular events as a cause for mortality among ESRD patients. Almost two‐thirds of all ESRD patients will require hemodialysis and they are at the highest risk for bloodstream infections. An effective method for reducing bloodstream infections is increasing the use of fistula for dialysis access, but, for a significant number of patients, catheter access is inevitable. Several interventions have been studied that primarily involves the application of antimicrobials at the catheter exit site. Other interventions include the use of antibiotic lock solutions, which have resulted in the development of antibiotic resistance. Novel connecting devices may be of use in the future, but studies are still needed to show their efficacy at preventing catheter‐related bloodstream infections among hemodialysis patients. As insertion sites can be limited in hemodialysis patients, treatment of certain catheter‐related bloodstream infections can be amenable to catheter retention as long as both systemic antibiotic and antibiotic lock therapies are also initiated. Until more data are available, catheter removal followed by systemic therapy is preferred for infections involving Staphylococcus aureus, Pseudomonas species, Enterococcus species, and Candida species.