메르스 (MERS) 거점의료기관 실무대응지침 2015. 6. 11. 18:00 국립중앙의료원 National Medical Center
순 서 Ⅰ. 메르스중앙 지역거점의료기관개요 1. 거점의료기관배경및목적 2 2. 거점의료기관주요역할 5 3. 거점의료기관운영체계 10 4. 거점의료기관진료절차 12 Ⅱ. 선별진료소운영 1. 선별진료소운영 16 2. 거점의료기관지정후동선관리 25 Ⅲ. 입원수속및원내이송 1. 병실배정 29 2. 환자이송 33 3. 격리병동과이송로출입통제 36 Ⅳ. 메르스환자진료 1. 감염및직원관리 41 2. 메르스환자진료 (CPG/CP) 49
순 서 Ⅴ. 메르스환자퇴원 1. 퇴원환자관리 107 2. 사망자관리 112 부록 1. 메르스격리병상현황 ('15. 6. 7) 2. 메르스거점의료기관연락처 ('15. 6. 11)
본가이드라인은중동호흡기증후군 (Mid-East Respiratory Syndrom, 이하 메르스 ) 에대응하기위해중앙거점의료기관으로서국립중앙의료원이수행했던활동과사례를정리하였음 ' 메르스 (MERS) 거점의료기관실무대응지침 (ver1.0)' 을배포하여지역의 거점의료기관 과의진료공조체계를확립하고해당병원의메르스관리역량을향상시켜환자의건강증진을도모하는데목적이있음
메르스중앙 지역거점의료기관개요 1. 거점의료기관배경및목적 2 2. 거점의료기관주요역할 5 3. 거점의료기관운영체계 10 4. 거점의료기관진료절차 12
거점의료기관배경및목적 15. 5. 20 2, 3,
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메르스거점의료기관진료절차
선별진료소운영 1. 선별진료소운영 16 2. 거점의료기관지정후동선관리 25
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동선 2. 지역거점의료기관 ( 메르스치료병원 ) 동선 3. 지역거점의료기관 ( 노출자진료병원 )
입원수속및원내이송 1. 병실배정 29 2. 환자이송 33 3. 격리병동과이송로출입통제 36
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메르스환자진료 1. 감염및직원관리 41 2. 메르스환자진료 (CPG/CP) 49
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5. 3 (shedding). 8) 1). 2) 1 (,, N95, ). 2. 3. 8) 대한감염학회 MERS-CoV 감염관리지침 (version 1.0) ( 15.6.8)
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.. - ribavirin + interferon α2a + lopinavir/ritonavir ( 1). Lopinavir/ritonavir ribavirin + interferon α2a. Ribavirin, ribavirin interferon α2a + lopinavir/ritonavir. - SARS ribavirin 60% hemolytic anemia (Hb >2 g/dl ). Bradycardia (<55/min), hypomagnesemia, hypocalcemia. - (,, ).. -,
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(O2) (SpO2<90%),. 5L/min SpO2 90% ( 92-95%). (severe pneumonia and acute repiratory distress syndrome) 10),. 10) 참고문헌 : - Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.Bird D et al. - Putensen C, Theuerkauf N, Zinserling J, et al. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med 2009; 151:566. - Petrucci N, De Feo C. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; 2:CD003844. - 대한감염학회 MERS-CoV 감염관리지침 (version 1.0) ( 15.6.8) - Boles J-M, Bion J, Connors a, et al. Weaning from mechanical ventilation. The European Respiratory Journal. 2007;29(5):1033 56. - El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Critical Care. 2008;12(4):221.
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. - permissive hypercapnia, Open Lung Ventilation, High PEEP, Recruitment Maneuvers, ECMO rescue therapy. 그림. 급성호흡부전증후군초기관리흐름도
4) (weaning and extubation).,.,. 1 -.
2 2 -.,,,, 50%. (septic shock) 11) 11) 참고문헌 : - Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer s
( < 90mmHg). 1) crystalloid. lactated Ringer s solution (: 1L over 30 minutes ). (fluid loading), ( X- ). starch. 2) acetate in severe sepsis. The New England Journal of Medicine 2012;367:124 34. - Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. The New England Journal of Medicine 2012;367:1901 11.
. Norepinephrine epinephrine, dopamine (: > 90 mmhg) 3) hydrocortisone prednisolone. 4). input/ output, X-,.
그림. 패혈성쇼크관리흐름도
(continuous renal replacement therapy: CRRT),, / -.,. 그림. 지속적신대체요법기계의예
1) CRRT 1 (anuria) for 6 hr 2 (oliguria) ( <200/12hrs) 3 BUN >80mg/dl >3mg/dl 4 K > 6.5mEq/l 5 6 - BUN. 2) CRRT 1 (vascular access) - uncuffed catheter. 2 (modality) -
. 3) CRRT 1 -,.,, -,. - 20-25 ml/kg/hour. (hypercatabolic) (individualized treatment). 2 CRRT -. - ( > 12 ml/min)
- (: ) -,,, CRRT. -.,.. ( MERS-CoV (version 1.0) ( 15.6.4))
(extracorporeal membrane oxygenation: ECMO) 12) ECMO,.,, ECMO. ECMO, 12) 참고문헌 : - UpToDate: extracorporeal membrane oxygenation: last updated: 15.5.5 - Extracorporeal life support organization (ELSO)
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- ECMO. 2) ECMO,. 1 ECMO - -. - -: vena cava.,. - -:.. 2 ECMO - ECMO
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). 3) ECMO 1 ECMO circuit,,. - : - > 90%, - > 75% - : - 70-80% -, 2 /,.,,. 3 ECMO
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4) ECMO X-, ECMO. (pulsatility) ECMO. 5) 1 : ECMO 30-40%,. /, > 100,000 /mm3, ACT/ aptt. 2 : circuit,. - ECMO, ACT/ aptt, circuit
. /, circuit. 3 :,,.. 4 :, ACT/ aptt argatroban. 5 - ECMO, /.
13) 13) Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. The New England Journal of Medicine 2006;355:2725 32.
(Cardiac compression or defibrillation), ECMO, (critical care team),. () 14) (severe acute respiratory syndrome: SARS), 14) 참고문헌 : - Wei W, Tuen H, Ng R, Lam L. Safe tracheostomy for patients with severe acute respiratory syndrome. Laryngoscope 2003; 113: 1777-1779 - Kwan A, Fok WG, Law KI, Lam SH. Tracheostomy in a patient with severe acute respiratory syndrome. Br J Anesth 2004; 92(2): 280-282 - Peiris JSM, Chu CM, Cheng VCC, Chan KS, Hung IF, Poon LL, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361: 1767-1772 - Cooper A, Joglekar A, Adhikari N. A practical approach to airway management in patients with SARS. CMAJ 2003; 169(8): 785-787 - Tien HC, Chughtai T, Jogeklar A, Cooper AB, Brenneman F. Can J Surg 2005;48(1): 71-74 - 대한감염학회 MERS-CoV 감염관리지침 (version 1.0) ( 15.6.8)
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메르스환자퇴원 1. 퇴원환자관리 107 2. 사망자관리 112
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-. -. -. () -,. -. -.( ) - ( ). -. (, ) -. -.
사망자관리 15)16)17)18)19),. 15) http://cdc.go.kr 질병관리본부 16) 질병관리본부국가입원치료 ( 격리 ) 병상운영과관리. 2011 17) 감염병의예방및관리에관한법률 18) 장사등에관한법률시행령 19) 국립중앙의료원감염관리지침. 2014
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1. 메르스격리병상현황 ('15. 6. 7) 2. 메르스거점의료기관연락처 ('15. 6. 11)
메르스격리병상현황 ('15.6.7) 20) : 225 (67)= 1(45) +(12) - - () 20) (2015. 6. 7( 일 ) 20:00 기준, 중앙응급의료센터 )
-
('15.6.7)
메르스거점의료기관연락처 ('15.6.11)
발행일 : 2015 년 6 월 11 일 발행본 : version 1.0 발행처 : 국립중앙의료원 발행인 : 원장안명옥 공동편저자 : 신장내과차란희공공보건의료지원센터곽미영 집필자공공보건의료지원센터이태호간호교육행정팀박복희감염관리실장윤영감염내과신형식, 김가연, 김연재호흡기내과조준성, 정인아, 이지연흉부외과신용철, 김우식 연락처국립중앙의료원메르스비상대책본부상황실 02-2276-2112 공공보건의료지원센터 02-2260-7039