中心導管組合式照護措施之探討

Evaluation of Central Venous Catheterization Care Bundle

中心導管置入已經成為現代臨床醫學最重要的治療方法之一，置入過程中若未採取嚴謹的無菌防護措施，可能增加導管相關血流感染的機率，而執行導管置入者之經驗和技巧、導管置入方式、過程以及部位，也會影響感染的發生，目前多數指引建議避免於股靜脈置放中心導管，但是現今臨床醫師對此觀念仍持保留態度、認同度並不高，認為並不會因為置放於股靜脈而增加感染率，有作者以系統性回顧相關文獻，使用整合分析（meta-analysis）對於導管置放於頸靜脈、股靜脈及鎖骨下靜脈等部位之感染風險進行分析比較，雖然結果並不因置放股靜脈而有較高之感染率，但還需要更多相關的研究才有更明確的建議。然而另一方面，現在很多國家都在推行中心導管組合式照護，主要的項目包含：手部衛生、最大無菌面防護、使用含2% chlorhexidine gluconate消毒置入部位、避免置放股靜脈、放置時使用查檢表監督操作過程及每日執行照護評估，並及早移除中心導管，此類組合式照護對於預防中心導管　關血流感染確實有顯著的效果。

Central venous catheterization (CVC) is the most important treatment in clinical medicine. However, the incidence of catheter-related bloodstream infections (CRBSI) might increase if strict sterile precautions are not followed. Moreover, the skills and experience of the physician, the choice of insertion site, and the processes during catheterization may influence the incidence of CRBSI. Although many guidelines suggest that placement at the femoral site should be avoided because of the possible higher risk of CRBSI, many physicians consider differently. Hence, we performed a systematic review of the literature and a meta-analysis, and compared the rate of CRBSI at the femoral, subclavian, and/or internal jugular sites. We concluded that placement at the femoral site did not result in a higher infection rate than placement at the other two sites. However, more studies should be performed to determine a more specific suggestion. Many healthcare institutions worldwide are implementing a CVC care bundle that includes hand hygiene, maximal barrier during insertion, chlorhexidine skin antisepsis, optimal catheter site selection that avoids the femoral site, a bundle checklist during catheterization, daily line care, and removal of the line when it is no longer needed. These bundle interventions have proved to be effective in significantly reducing the incidence of CRBSI.