老年肠外营养相关中心静脉导管微生物定植及危险因素分析

目的:研究老年病人肠外营养(PN)相关中心静脉导管(CVC)微生物定植(MC)的发生率和危险因素。方法:回顾性分析我院老年(≥60岁)住院病人。病人均禁食,通过CVC接受PN,拔管后进行导管尖端培养。采集病史资料、导管相关资料(放置部位、留置时间和培养结果)和PN相关指标(使用时间、输注液量、每天提供热量和PN液能量密度)。结果:204例老年病人入选本研究。总置管时间为2 983 d。MC发生率为20.6%(42/204),千导管日发生率为14次/千导管日(42/2 983 d)。Logistic回归分析显示,血清肌酐和前清蛋白水平、PN液能量密度、其他部位存在感染等是PN相关MC的危险因素。最常见的CVC定植微生物为革兰阳性球菌(50.0%),其次为革兰阴性杆菌(33.3%)和真菌(6株,14.3%)。机会致病菌占总微生物数的23.8%(共10株)。结论:血清肌酐水平降低以及输注能量密度较高的PN液,易导致老年病人发生MC。     

多中心超声定位下深静脉置管降低医院导管相关性感染的价值

目的探讨多中心超声定位下深静脉置管在降低医院导管相关性感染的应用价值。方法选取在本院行多中心超声定位下深静脉置管的120例患者为研究组,选取同期传统体位标定下行深静脉置管的50例患者为对照组。比较深静脉置管相关指标(提前拔管率、一次置管成功率、机械损伤率);导管相关感染类型(导管细菌定植、出口部位感染、导管相关性血流感染);检测病原菌感染分布情况。结果研究组患者提前拔管和机械损伤比例(15.83%、4.17%)均明显低于对照组(28.00%、24.00%),一次置管成功率(90.00%)明显高于对照组(64.00%),差异均有统计学意义(均P0.05)。研究组患者导管相关感染发生率明显低于对照组,其中导管细菌定植、出口部位感染、导管相关性血流感染发生率均明显低于对照组,差异有统计学意义(均P0.05)。两组病原菌感染中革兰阳性菌比例明显高于革兰阴性菌,差异有统计学意义(P0.05);革兰阳性菌中以金黄色葡萄球菌感染比例最高,革兰阴性菌中以鲍氏不动杆菌和大肠埃希菌为主。结论多中心超声定位下深静脉置管可有效降低置管时间,增加导管留置时间,降低导管相关性感染的发生率。     

ICU导管相关性感染及危险因素分析

目的 探讨ICU住院患者导管相关性感染(CRI)的病原学特征以及可能的影响因素.方法 对2008年1月-2009年6月医院综合ICU住院的268例患者进行观察,统计和分析这时期ICU患者的CRI发生率、病原学特征以及可能相关危险因素.结果 共收集深静脉留置管,气管插管、导尿管、胸腔引流管、腹腔引流管等556根,导管检出病原菌阳性率为38.12%,CRI发生率为34.70%,每日每1000根导管发生CRI 19.3次;CRI主要病原菌依次为革兰阳性球菌(50.50%)、革兰阴性杆菌(30.30%)和真菌(19.20%);非条件Logistic回归分析提示,重复置管、股静脉置管、使用多腔导管、长期留置导管和长期使用抗菌药物为CRI独立危险因素.结论 ICU住院患者CRI的主要病原菌为革兰阳性球菌;应加强控制CRI危险因素,预防医院感染的发生.     

急性白血病患者PICC导管感染的病原学特点及影响因素研究

目的分析经外周静脉置入中心静脉导管(peripherally inserted central catheter,PICC)在急性白血病患者发生导管相关感染(catheter-related infection,CRI)的病原学特点及危险因素,为进一步改善急性白血病患者的CRI提供理论依据。方法回顾性选择2015年1月-2017年11月进行PICC置管的169例急性白血病患者的临床资料,统计患者发生CRI发生率,统计分析患者的性别、年龄、病程时长、PICC置管时间、PICC穿刺次数、化疗次数、是否发生导管相关感染、感染培养及药敏结果等资料,单因素及多因素Logistic回归分析CRI发生的影响因素。结果 169例急性白血病患者置管后有27例发生CRI,感染率为15.98%。共分离培养出57株病原菌,其中革兰阴性菌37株占64.91%,革兰阳性菌18株占31.58%;多因素Logistic回归分析显示,年龄≥60岁、置管时间≥8个月、化疗次数≥7次、PICC穿刺≥3次是导致急性白血病患者进行PICC置管发生CRI的危险因素(P<0.05)。结论急性白血病患者进行PICC置管后发生CRI主要是以感染革兰阴性菌为主,发生CRI的影响因素较多,可以通过针对性预防措施降低医院感染的发生率,对提高临床效果及医疗质量等具有重要意义。     

猪全肠外营养模型

白色杂种猪 19只 ,体重 2 2 .3± 2 .4 kg,经皮颈总静脉穿刺前腔静脉置管 ,其中 14只动物完成 2 8d全肠外营养 ( TPN)。 14只动物 ,共施行置管 2 9次 (平均 1.31± 0 .86次 ) ,成功率为10 0 %。再次置管的原因为导管脱出 ( 7/ 2 9)和导管栓塞 ( 2 / 2 9) ,本研究还对与腔静脉置管相关静脉进行了解剖     

重症监护室中心静脉导管相关性感染分析

目的了解某院综合重症监护室（ICU）患者中心静脉导管相关性感染（CRI）发生情况,分析其感染特点,为预防感染提供对策。方法对该院综合ICU 2008年10月-2011年10月留置中心静脉导管的209例患者病历资料进行回顾性调查。结果209例患者共留置中心静脉导管256例次,发生CRI 60例次(23.44%),其中导管相关血流感染率为18.75%（48例次）,导管出口部位感染率为4.69%（12例次）。发生CRI的中位时间为8.9（2～49）d。置管时间≤2周、＞2周的CRI 发生率分别为16.09%、39.02%,两者比较,差异有统计学意义(χ2=16.334,P=0.000）;股静脉、颈内静脉、锁骨下静脉3种置管方式CRI发生率分别为40.00%、21.53%、18.06%,差异有统计学意义（χ2=7.570,P=0.023）。血及导管尖端培养病原菌48株,以革兰阴性杆菌为主（47.92%）,其次为革兰阳性球菌(37.50%)和真菌(14.58%)。结论置管部位和导管留置时间是发生CRI的危险因素,应针对相关危险因素,采取有效措施,防范CRI的发生。     

持续性质量改进对肝癌患者中心静脉置管相关感染的影响

目的评估医院感染管理持续性质量改进对肝癌行颈内中心静脉置管患者相关感染因素,为有效预防控制感染提供依据。方法选取2010年1月-2014年12月243例住院治疗并行颈内静脉置管的肝癌患者为研究对象,根据实施医院管理持续性改进的时间分为对照组145例(改进前)和干预组98例(改进后),观察并比较两组患者颈内中心静脉置管相关感染的发生率。结果干预组98例患者中6例发生中心静脉置管相关感染,发生率为6.12%,其中导管细菌定植3例、导管局部感染1例、导管相关性血流感染2例;对照组患者中有31例发生中心静脉置管相关感染,发生率为21.38%,其中导管细菌定植14例、导管局部感染10例、导管相关性血流感染7例,干预组中心静脉置管相关感染发生率显著低于对照组(P<0.05)。结论医院感染管理持续性质量改进可以明显降低肝癌患者颈内中心静脉置管相关感染的发生率。     

降低导管相关性感染超声定位深静脉置管的临床研究

目的探讨医院多中心超声定位下深静脉置管,以降低医院导管相关性感染(CRI)的临床研究。方法随机选取医院2012年12月-2013年12月进行多中心超声定位下深静脉置管患者138例为观察组;另选取同时期在传统体位标定下进行深静脉置管患者100例为对照组,分析两组患者深静脉置管时间、感染类型及病原菌种类。结果观察组患者置管时间、留置导管时间及一次置管成功率、机械损伤率分别为(31.3±10.9)s、(15.2±4.9)d及90.5%、4.3%,对照组分别为(67.5±20.1)s、(67.5±20.1)d及24.0%、27.0%,两组相比差异有统计学意义(P<0.05);两组患者感染类型主要为导管细菌定植、出口部位感染及导管相关性血流感染,观察组患者发生感染8例,感染率为5.8%,对照组患者发生感染19例,感染率为19.0%,两组相比差异有统计学意义(P<0.05);两组患者感染病原菌分布差异有统计学意义(P<0.05)。结论医院多中心超声定位下深静脉置管CRI发生率显著低于传统体表定位,能减少置管时间,增加留置时间,减小创伤并提高置管成功率,因此临床可以广泛应用。     

心脏外科术后中心静脉导管相关性感染的危险因素分析

目的 研究心脏外科术后中心静脉导管(CVC)相关性感染(CRI)、导管相关性菌血症(CRB)的发生率及高危因素,为临床预防CRI的发生提供对策.方法 将200例危重患者术中随机分为锁骨下静脉置管组及颈内静脉置管组,每组各100例.术后对留置的CVC尖端进行细菌培养,同时进行血培养.结果 200例CVC检出CRI 31例,发生率15.5%;CRB 4例,发生率2.0%.其中,锁骨下静脉置管组检出CRI 13例(13.0%),CRB 1例(1.0%);颈内静脉置管组检出CRI 18例(18.0%),CRB 3例(3.0%),两组比较差异均有统计学意义(P＜0.05).CVC留置时间≥6d感染率明显增加.结论 危重心脏外科手术患者放置CVC是重要的病原菌感染途径,经锁骨下静脉穿刺置管CRI、CRB的发生率比经颈内静脉穿刺置管低.CVC留置时间应尽量＜6d,以减少CRI、CRB的发生.     

改良无针接头维护方法预防导管相关性感染

目的通过改进外周中心静脉导管(PICC)无针接头的消毒方法,提高消毒效果,减少导管相关性感染的发生率。方法 510例行PICC置管的肿瘤患者,随机分为研究组和对照组,研究组采用改良的消毒方法消毒无针接头,对照组采用传统的消毒方法。结果研究组静脉炎发生率1.9%,对照组静脉发生率19.2%,两组比较差异有统计学意义(P<0.01);研究组导管细菌定植率0.4%,对照组为6.0%,两组导管细菌定植比较,差异有统计学意义(P<0.01)。结论改良无针接头维护方法可明显降低导管相关性感染的发生率。     

Implication of a distant septic focus in parenteral nutrition catheter colonization

During a 4-year period, 244 surgical patients receiving total parenteral nutrition (TPN) were studied with emphasis on the relationship between TPN catheter colonization and a preexisting distant septic focus (DSF). A colonized catheter was defined as a catheter with a positive semiquantitative culture of the catheter tip (greater than or equal to 15 colonies on the plate). Catheter-related sepsis (CRS) was defined as a catheter with either the same organisms cultured from the catheter tip and from blood or with defervescence following catheter removal. Two hundred sixty-nine catheters were inserted for TPN for a total of 4433 patient days, with a mean length of stay of 16.5 days. Forty-two of the 269 catheters (15.6%) were colonized and more than half (57.1%) of the organisms cultured were Gram-negative bacilli or enterococci. Nineteen of the 42 colonized catheters were associated with CRS with a CRS rate of 7.1% among the 269 catheters. A DSF was present in 165 of the 244 patients or in 188 of the 269 catheters (69.9%). The colonization rate of 19.1% (36/188) in those catheters with DSF was significantly higher than that of 7.4% (6/81) in those without DSF (p less than 0.05). Those patients with DSF or with a colonized catheter were associated with a high mortality (p less than 0.001). Sepsis was responsible for 33 of the 48 patients (68.8%) who died. The data stress the important contribution of DSF to the colonization of TPN catheters and to the mortality of these critically ill surgical patients.     

ICU中心静脉导管相关性感染的危险因素分析

目的探讨老年ICU中心静脉导管相关性感染(CRI)的发生率及其相关危险因素。方法回顾性分析行中心静脉插管的66例患者CRI的发生率,同时对患者CRI可能相关的25个因素进行多因素logistic回归分析,寻找与CRI相关的危险因素。结果 66例患者插管143次,共发生CRI 46例次,CRI发生率为32.17%、千导管日感染率为28.57‰;丧失自理能力、置入三腔导管为发生老年内科ICU患者CRI的危险因素(OR值分别为3.066、1.778)。结论老年内科ICU患者CRI的发生率高,而丧失自理能力、置入三腔导管者更易于发生CRI,尽量避免不必要的三腔静脉导管的留置、严格无菌操作和加强护理是降低该人群CRI发生率的关键。     

A prospective, randomized study in critically ill patients using the Oligon Vantex catheter

Microbial colonization and the incidence of catheter-related bloodstream infections (CR-BSI) associated with Oligon Vantex silver central venous catheters (CVC) in critically ill patients were determined. A prospective, randomized, controlled 17-month trial was carried out in an intensive care unit (ICU). All patients requiring a triple-lumen CVC for four days or longer were enrolled. Patients were randomized to receive a standard polyurethane CVC or an Oligon Vantex silver CVC. Before removal of the catheter either due to discharge from the ICU or suspected infection, blood for cultures was taken via the CVC and a peripheral site. Skin and hub swabs and catheter-tips were also cultured. Two hundred and six catheters, 103 in both groups, were evaluated. In the control group (CG) 45/103 (44%) and in the silver group (SG) 30/103 (29%) were colonized or had a CR-BSI (P=0.04). The SG was less likely to be colonized than the CG when the catheter remained in situ for eight days or less (P=0.03) or over 15 days (P=0.01); a second or subsequent catheter was present in the same patient (P=0.002), or if the CVC was placed in the internal jugular vein (P=0.05). Multivariate logistic-regression showed predisposing factors for catheter colonization were jugular and femoral sites, second or subsequent catheter, and being a member of the CG. CR-BSI occurred in five cases (four in CG). Rates of CR-BSI per 1000 catheter-days in the CG were 2.8 and in the SG, 0.8 (P<0.001). The Oligon Vantex silver catheter reduced the incidence of catheter-colonization and may decrease the risk of CR-BSI.     

Prospective evaluation of single and triple lumen catheters in total parenteral nutrition

The recent introduction of triple lumen catheters has facilitated the care of seriously ill patients by providing multipurpose central venous access through a single percutaneous 7 French catheter. This prospective study was performed to examine the complications associated with the use of these catheters in patients receiving long-term total parenteral nutrition (TPN). Seventy-five patients undergoing catheterization were randomly separated into two groups: 36 patients underwent placement of a single lumen catheter (SLC), and 39 patients, a triple lumen catheter (TLC). The two groups were comparable with respect to concomitant infections, treatment with antibiotics, and need for intensive care. Patients in the SLC group received TPN for a mean of 9.7 days and in the TLC group, for a mean of 8.5 days (p = 0.427). However, after 5 days of catheterization, there was a marked increase in the number of TLC removed because of skin entry site infections. SLC were more likely to be used for the full duration of TPN administration (p = 0.025). Catheter tips were cultured by semiquantitative techniques. A higher incidence of catheter sepsis was seen with TLC, 12.8% vs 0% with SLC (p = 0.055). TLC used for TPN are associated with higher rates of catheter entry site infections and systemic sepsis. SLC should be used for TPN administration.     

丙氨酰胺谷氨酰胺对烫伤大鼠的作用

目的研究添加丙氨酰谷氨酰胺(Ala-Gln)全胃肠外营养对烫伤大鼠的蛋白质代谢、肠粘膜形态学、创面肉芽组织的影响。方法将22只30%TBSAⅢ度烫伤SD大鼠行颈外静脉插管后,随机分为传统TPN组(传统组)和添加二肽TPN组(二伏组),每组各11例,两组接受等热量(780kg     

Thrombosis of the superior vena cava due to a central catheter for total parenteral nutrition

Total parenteral nutrition (TPN) today is a fundamental procedure in the treatment of critically ill patients, especially if they have serious gastrointestinal diseases. However, use of the central venous catheter is connected with a very important morbidity. At the "Istituto di Patologia Chirurgica" and at the "Intensive Care Unit" of the University of Ferrara, we analyzed 59 cases of deaths from different diseases, on whom a postmortem examination had been performed. Twenty-seven patients had had no central venous catheter: none of them presented thrombosis of the central veins. Thirty-two patients had had a central venous catheter for TPN: five of them presented thrombosis of the central veins at the post-mortem examination. Except for one case who had thrombosis connected with a carcinoma of the right main bronchus, four cases (12.9%) presented thrombosis due to the central venous catheter. The subclavian vein seems to be more commonly connected with thrombosis than the jugular vein.     

Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters

BACKGROUND AND AIMS: Total parenteral nutrition (TPN) is typically delivered through catheters inserted into the superior vena cava (SVC) via a subclavian or internal jugular vein approach. A peripherally-inserted central venous catheter (PICC), utilizing a cephalic or basilic venous approach, may provide a safe alternative to the standard catheter approach and, because non-physician providers can insert the PICC, may introduce a potential cost-savings to health care institutions. We sought to determine if PICC lines are safer and more cost-effective than the standard central venous catheter approach for hospitalized patients who require TPN. METHODS: One hundred and two hospitalized patients (age range, 18-88 years) who required TPN were prospectively randomized to receive therapy via a centrally-inserted subclavian catheter (n=51) or a peripherally-inserted PICC line (n=51). The primary end-point was the development of a complication requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of each catheter was also studied. RESULTS: Complication-free delivery rate (without the need to remove or replace the catheter) was 67% for subclavian catheters and 46% for PICC lines (P<0.05). The overall infection rate was 4.9 per 1000 catheter days and was similar for each catheter type (P=0.68). PICC lines were associated with higher rates of clinically-evident thrombophlebitis (P<0.01), difficult insertion attempts (P<0.05), and malposition on insertion (P<0.05). No catheter complications resulted in significant long-term morbity or mortality. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P=0.18), dislodgement (P=0.12), or line occlusion (P=0.25). After standardizing costs for each hospital, the direct institutional costs for insertion and maintenance of PICC lines (US$22.32+/-2.74 per day) was greater than that for subclavian lines (US$16.20+/-2.96 per day;P<0.05). CONCLUSION: PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard subclavian approach for central venous access in hospitalized patients who require TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the catheter.     

Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit

This study was conducted to evaluate the impact of central venous catheters impregnated with chlorhexidine and silver sulphadiazine on the incidence of colonization and catheter-related bloodstream infection in critically ill patients. One hundred and thirty-three patients requiring central venous catheterization were chosen at random to receive either an antiseptic-impregnated triple-lumen catheter (N=64) or a standard triple-lumen catheter (N=69). The mean (SD) durations of catheterization for the antiseptic and standard catheters were 11.7 (5.8) days (median 10; range 3-29) and 8.9 (4.6) days (median 8.0; range 3-20), respectively (P=0.006). Fourteen (21.9%) of the antiseptic catheters and 14 (20.3%) of the standard catheters had been colonized at the time of removal (P=0.834). Four cases (6.3%) of catheter-related bloodstream infection were associated with antiseptic catheters and one case (1.4%) was associated with a standard catheter (P=0.195). The catheter colonization rates were 18.7/1000 catheter-days for the antiseptic catheter group and 22.6/1000 catheter-days for the standard catheter group (P=0.640). The catheter-related bloodstream infection rates were 5.3/1000 catheter-days for the antiseptic catheter group and 1.6/1000 catheter-days for the standard catheter group (P=0.452). In conclusion, our results indicate that the use of antiseptic-impregnated central venous catheters has no effect on the incidence of either catheter colonization or catheter-related bloodstream infection in critically ill patients.     

A comparative study of polyurethane and silicone cuffed-catheters in long-term home total parenteral nutrition patients.

AIM: The purpose of this study was to report our compared experience of long-term complications with polyurethane (LeaderCuff) and silicone (Lifevac) tunnelled, cuffed catheters in home adult TPN patients. METHODS: All catheters were inserted by a percutaneous technique under local anaesthesia. RESULTS: Forty silicone catheters were inserted in 31 patients and 13 polyurethane catheters were inserted in 11 patients totaling a total experience of 480 months and 175 months respectively. Mean catheter life span was 12 months (range: 0.25-47) and 13 months (range: 3-44) for Lifevac and LeaderCuff catheters, respectively. Complication rates (expressed as patient-year of TPN) were no significantly different for Lifevac and LeaderCuff catheters: sepsis (0.15 vs 0.14), obstruction (0.05 vs 0), dislodgement (0.13 vs 0.07) and thrombosis (0 vs 0.14). The fracture rate was 20 times lower for Lifevac than for LeaderCuff (P < 0.01): in all cases, this mechanical problem was due to the dysfunction of the detachable flow-control device. CONCLUSION: Both Lifevac and LeaderCuff catheters enable safe, long-term, venous access and prevent, in most cases, inadvertent catheter dislodgement. There is little evidence, from our study, to support the hypothesis that polyurethane catheters offer more security than silicone catheters in home TPN adult patients.     

Risk of infection accompanying the use of single-lumen vs double-lumen subclavian catheters: a prospective randomized study

A prospective study was undertaken to compare the risks of a multiple-lumen catheter to bilateral subclavian catheters in patients receiving total parenteral nutrition (TPN). All patients had one preexisting subclavian catheter. Patients were randomized into two groups: one group received a double-lumen catheter via a guidewire change of the preexisting single-lumen subclavian catheter. In the second group, a second single-lumen subclavian catheter was inserted and the preexisting single-lumen catheter was changed over a guidewire. Patients were followed by the Nutrition Support Service and were managed identically with regard to solutions given, catheter care, dressing changes, monitoring of mechanical complications, and evaluation of fever. Total infection rates in both groups were identical (22.7%). The difference in mechanical complication rates in the double-lumen catheter group (9%) and the group with bilateral single-lumen catheters (22.7%) was not significant by Fischer's exact test. The multiple-lumen catheter is superior in convenience and as safe as bilateral single-lumen catheters.