[每周一问]NO.23-Intravascular Catheter Related Infections
This week we are discussing intravascular catheter related infections. For the next three days, we'll discuss preventative therapies.
1. Does the site of insertion affect the incidence of catheter related infections?
2. Do sterile barrier precautions when placing catheters make a difference?
3. Do contamination-shielded pulmonary artery catheters prevent related infections?
1. 置管位置是否影响导管相关性感染的发生？
2. 置管时消毒屏障有区别吗（如仅戴手套和穿无菌手术衣时导致感染几率的区别）？
3. 隔离污染的肺动脉导管（个人理解为PAC外的塑料保护套）能否预防相关感染的发生?
参考答案
1.置管位置是否影响导管相关性感染的发生？
最近，有非随机研究比较了不同穿刺置管位置（锁骨下静脉、颈内静脉或股静脉）感染的发生率[1]。然而在多变量分析的观察研究中，锁骨下静脉与颈内静脉相比感染机率显著降低[2]。在另一个非隧腔（？？）中心静脉导管的观察性研究中，低位位置（股静脉）与高位位置相比，可观察到感染趋势增加[3]。这些研究表明，导管位置的不同影响感染率的发生，然而，在确定任一位置是否有优势前，必须充分评估感染的风险和特定位置的优点。
2.置管时消毒屏障有区别吗？
与只使用无菌手套和小单相比，完善的预防机制（即还使用长袖无菌手术衣、口罩、帽子及大的消毒手术单）证明可以降低导管相关血流感染的发生率[4]。因此，在中心静脉置管时应该采取完善的消毒隔离措施，对于其他动脉和静脉导管置入时要考虑采用更完善的预防措施。
3.隔离污染的肺动脉导管（个人理解为PAC外的塑料保护套）能否预防相关感染的发生？
导管通过一薄的塑料外套的包装以预防接触性污染，这被证明可有效减低导管相关血流感染的发生，即使使用消毒隔离预防也是如此，因此被推荐使用[5]。
Does the site of insertion affect the incidence of catheter related infections?
Currently, no randomized trials have compared the risks of infection for catheter insertions into the subclavian, internal jugular, or femoral veins (1). However, in observational studies using multivariate analysis, the risk for infection was significantly decreased when the subclavian versus the internal jugular vein was utilized (2). In another observational study of non-tunneled central venous catheters, a trend towards higher colonization in lower body (femoral vein) versus upper body locations was noted (3). These findings suggest that the location of the catheter site may make a difference in infectious risk, however, a complete evaluation of the risks and benefits of certain locations should be considered before declaring one site to be superior.
Do sterile barrier precautions when placing catheters make a difference?
In comparison to the use of only sterile gloves and a small drape, full barrier precautions (i.e. the addition of a long-sleeved sterile gown, mask, cap, and a large sterile sheet drape) have been demonstrated to reduce the incidence of catheter-related bloodstream infections (4). Thus full barrier precautions should be utilized with central venous catheter insertions, and greater barrier precautions should be considered with other arterial and venous catheterizations.
Do contamination-shielded pulmonary artery catheters prevent related infections?
Catheters packaged with a thin plastic sleeve to prevent touch contamination have been noted to reduce the incidence of catheter related blood stream infections, even when sterile barrier precautions are used, and have therefore been recommended (5).
References:
1. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402.
2. Heard SO, Wagle M, Vijayakumar E, McLean S, et al. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Arch Intern Med. 1998;158(1):81-7.
3. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol 1998;19(11):842-5.
4. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15(4 Pt 1):231-8.
5. Cohen Y, Fosse JP, Karoubi P, et al. The "hands-off" catheter and the prevention of systemic infections associated with pulmonary artery catheter: a prospective study. Am J Respir Crit Care Med. 1998;157(1):284-7.
Site Editor: Stephen B. Corn, M.D. and B. Scott Segal, M.D.
Department of Anesthesia, Harvard Medical School
