PICC置管并发症的预防及护理研究进展

PICC目前在临床上主要用于为危重症患者提供中长期的静脉输液,尽管它为患者提供了相对安全的静脉通路,但受多种因素的影响,PICC置管后极易引发多种并发症。本文对PICC置管后常见并发症的发生原因进行了综述,并探讨了相应的预防与护理措施,以期提高我国护理人员对PICC置管并发症的认知与重视,预防并减少PICC置管后并发症的发生。     

PICC导管应用于3例新冠肺炎危重症患者的护理

本文回顾了三例危重症新冠肺炎患者,在重症监护隔离病房应用经外周置入中心静脉导管 (Peripherally inserted central catheter, PICC)的经验,包括重症患者应用PICC的指征、穿刺点的选择、穿刺的技巧、穿刺后的维护、抗凝状态下PICC的相关并发症。我们认为,包括新冠肺炎在内的、尤其是接受持续抗凝的重症患者,PICC可作为中心静脉通路的首选方案;术前详尽的超声血管评估和穿刺时正确的超声引导能够提高多重个人防护下的穿刺成功率;在不能停止抗凝的极端情况下,护理PICC相比CVC更加便捷,一旦出现穿刺点渗血等并发症,也能相对简单有效地进行处理。综上所述,我们推荐PICC在重症患者中有指征地应用,尤其是需要持续抗凝的患者中,充分发挥PICC的优势,有技巧地使用超声定位和引导,通过护理手段减少和处理PICC相关并发症。     

Peripherally inserted central catheters in the intensive care unit

We report the success rate and complications of peripherally inserted central catheters (PICCs) in patients hospitalized in an intensive care unit (ICU). We performed a cohort study in the ICU of a large tertiary care, university-affiliated community hospital. All ICU patients for whom their attending physicians requested a PICC service consultation were included. Main outcome measurements included (1) the success rate for initial PICC placement, (2) the placement complication rate, and (3) the overall success and complication rate. Of the 91 consecutive attempts at PICC placement, 89 (97.8%) were successful: of the 89 successful placements, 25 (28%) required cutdown procedures. There were 20 complications of initial placement and 8 delayed complications, which occurred in 19 PICCs. Complications included recatheterization after first attempt was unsuccessful (10), catheter malposition (7), palpitations or catheter clotting (3 each), heavy bleeding or mechanical phlebitis (2 each), and arterial puncture (1). The overall success rate for completion of therapy using the PICC was 74.7%. The most frequent reasons for failure to complete therapy were catheter dislodgment in 8 patients and "infection" in 9 patients. Of these 9 patients with "infections," 8 catheters were discontinued due to potential infection, and only 1 was removed due to confirmed infection. The confirmed infection rate was 6/10,000 patient days. The PICC appears to be a reasonable alternative to other approaches to peripheral and central venous access. The initial and overall success rates from this preliminary study justify further evaluation of the PICC in critically ill patients.     

44例PICC原发性上腔静脉内异位患者的护理

总结44例PICC置管患者原发性上腔静脉内异位的识别与处理经验。2020年1月—5月杭州市某三级甲等医院1 370例PICC置管患者中,44例发生原发性上腔静脉内异位,发生率为3.2%。结合腔内心电图P波形态、振幅改变以及B超影像综合分析、调整PICC尖端位置,43例复位成功,1例异位于奇静脉,复位成功率为97.7%。     

Complicaciones relacionadas con la inserción y el mantenimiento del catéter venoso central de acceso periférico

ObjectiveTo evaluate the rates and nature of the complications related to the Central Peripheral Access Catheter (CVCAP or PICC) from its insertion to its withdrawal.MethodsProspective observational study. All patients older than 14 years of age with a PICC inserted in the polyvalent intensive care unit (ICU) during the period between May 1, 2015 and April 30, 2016 were included. Data collected included: demographic data, insertion details, reason for insertion and removal, maintenance unit, total dwell time, incidence of complications and related factors and infection rate.Results144 PICCs were inserted, of which 94 corresponded to the ICU group (65.28%) and 50 (34.72%) to the non-ICU group. The most important complication was the suspicion of infection: 17.36% (rate of 15.2 per 1000 days of PICC). The total number of confirmed infections was 6.25% (5.5 per 1000 days of PICC), 1.39% (1.2 per 1000 days) being in the ICU group and 4.86% (4.2 per 1000 days) in the non-ICU group. There were 5 bacteraemias, all in the non-ICU group (3 per 1000 days). The most frequent germ was Staphylococcus epidermidis (6 cases). Phlebitis had an incidence of 9.03% (7.9 per 1000 days of PICC).ConclusionsPICC, effective device for central venous access due to the minimal incidence of risks in implantation and to its advantages with regard to the classic central venous catheters, is a further nursing technique.     

PICC在耳鼻咽喉肿瘤患者应用中并发症的预防及护理

目的探讨耳鼻咽喉肿瘤患者使用外周中心静脉置管（PICC）的并发症及其预防、护理对策。方法对142例使用PICC的耳鼻咽喉肿瘤患者进行观察,分析并探讨并发症的预防和应对措施。结果成功置管138例,置管成功率为97．18％。发生并发症14例（10．14％）,其中穿刺口渗血2例（1．45％）,导管异位6例（4．35％）,机械性静脉炎5例（3．62％）,上肢深静脉血栓形成1例（0．72％）。预防性应用抗凝药物和加强置管前、置管中、置管后的护理可以减少并发症的发生。结论增强PICC相关并发症和相关风险的防范意识,严格把握PICC置管的适应证,规范PICC置管的护理和相关并发症的预防措施,可以提高使用PICC的安全性。     

血液肿瘤患者经外周置入中心静脉导管的并发症及其护理

目的探讨血液肿瘤患者外周导入中心静脉置管(peripherally inserted central catheter,PICC)术后并发症的原因及其防治策略。方法回顾性总结109例血液肿瘤患者植入PICC导管后并发症的发生及处理情况。结果本组患者一次穿刺成功率为97.3%。主要并发症有穿刺点渗血、穿刺点感染、导管堵塞、静脉炎、导管脱出、血栓形成。结论严密观察,规范无菌操作选择适宜导管、正压封管,有效固定等措施能有效减少PICC置管后并发症的发生。     

家庭健康教育在PICC置管远期并发症预防中的应用

目的探讨家庭健康教育在PICC置管远期并发症的应用效果。方法以100例PICC置管患者为研究对象,在传统换药的基础上,采用讲解、答疑、现场演示、发放小册子、与患者互动等方式,针对PICC置管远期出现的穿刺部位的皮肤过敏感染、导管堵塞、静脉炎、导管脱出及移位等并发症及拔管的注意事项、应对措施等实施家庭健康教育。结果 100例患者置管期间,8例患者出现轻度皮肤过敏感染,占8%,未出现穿刺点化脓及留置管道溢脓现象;5例出现导管堵塞,及时处理后通畅;5例出现静脉炎,无深静脉血栓形成,无导管脱出及移位发生;治疗期间导管耐受情况良好,无1例因并发症而拔出导管,导管达到预期留置时间。结论家庭健康教育在减少PICC置管患者远期并发症的发生上具有重要意义。     

Community management of peripherally inserted central catheters

Peripherally inserted central catheters (PICCs) are increasingly being used in the UK to allow patients requiring medium-to-long term venous access for a range of therapies, including ambulatory chemotherapy, to receive their treatment at home, away from the hospital setting. This article provides information for community nurses on the background of PICC lines in the UK, and practical advice on how to clinically maintain and manage these lines. Complications relating to PICCs are discussed, including how to recognize and deal with these complications in the community, and when to refer back to the specialist centre. The author leads at a nurse-managed PICC insertion service at a major cancer centre in Wales. The ongoing success of this service relies heavily on the skill and expertise of the community nurses who support the service.     

PICC超声引导下肘上置管的穿刺置管效果及并发症的系统评价

目的 系统评价PICC超声引导下肘上置管对穿刺置管成功率、并发症发生率的影响.方法 计算机检索The Cochrane Library(2012年第3期)、JBI循证护理中心图书馆、MEDLINE、EMbase、CBM、VIP、CNKI和WanFang Data,收集所有关于PICC超声引导下肘上置管和常规肘下置管对穿刺置管成功率、并发症发生率影响的随机对照试验、临床对照试验和队列研究.检索时限均为从建库至2012年3月.由2名研究员按照纳入和排除标准筛选文献、提取资料、评价质量,然后采用RevMan 5.1软件进行Meta分析或仅行描述性分析.结果 共纳入11个随机对照试验、5个临床对照试验、4个队列研究,4 052例患者.Meta分析结果显示:超声引导下结合改良赛丁格技术肘上置管的一次穿刺成功率、置管成功率均较常规肘下置管高,其差异均有统计学意义[OR=4.71,95％CI(1.97,11.28),P=0.000 5;OR=8.63,95％CI(1.92,38.82),P=0.005].常规肘下置管的静脉炎发生率较超声引导下肘上置管高,其差异有统计学意义[OR=0.13,95％CI (0.08,0.21),P＜0.000 01].结论 PICC超声引导下结合改良赛丁格技术肘上置管较常规肘下置管在提高穿刺置管成功率和降低并发症发生率方面具有明显优势.     

PICC在乳腺癌患者化疗中的应用及护理

目的探讨乳腺癌术后化疗患者行经外周插管的中心静脉导管（peripherally inserted central catheter,PICC）置管后并发症的发生情况．并总结并发症的预防和护理措施。方法采用方便取样法,选择2004年12月-2007年12月乳腺癌术后经PICC置管进行化学治疗的218例患者,置管后给予及时有效的护理。结果218例患者一次穿刺成功率贵要静脉组最高,为97．5％,而正中静脉组和头静脉组分别为89．3％和72．7％。置管后总并发症发生率为25．7％,其中一般并发症20．6％,较重并发症5．1％,元严重并发症发生,化疗过程均顺利。结论乳腺癌术后对需化疗的患者行PICC置管,可以更好地保护血管以及周围组织,减少静脉炎及避免化疗药物渗漏引起的严重并发症,而正确有效的护理是PICC留置成功的关键。     

Focus on peripherally inserted central catheters in critically ill patients

Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks associated with each type of CVAD (CICCs or PICCs). Second, an inappropriate CVAD choice and, particularly, an inadequate insertion technique are relevant-and often not recognized-potential risk factors for complications in critically ill patients. We strongly believe that all healthcare professionals involved in the choice, insertion or management of CVADs in critically ill patients should know all potential risk factors of complications. This knowledge may minimize complications and guarantee longevity to the CVAD optimizing the risk/benefit ratio of CVAD insertion and use. Proper management of CVADs in critical care saves lines and lives. Much evidence from the medical literature and from the clinical practice supports our belief that, compared to CICCs, the so-called power-injectable peripherally inserted central catheters are a good alternative choice in critical care.     

血液病患者应用PICC的管理

目的：探讨血液病患者经外周插管的中心静脉导管(peripherally inserted central catheters，PICC)置管期间的维护管理。方法：对32例采用PICC置管治疗的患者在置管期间严格管道管理，尤其注意并发症的预防和观察护理。结果：32例病例均成功进行PICC置管，置管期间无1例因导管并发症而拔管。结论：血液病患者应用PICC置管．护理方便，无禁忌证；而有效的、正确的导管维护管理．则是PICC置管成功的关键。     

早产儿PICC的危险因素及护理管理对策

文章归纳了早产儿经外周中心静脉置管术的危险因素,包括导管相关性血流感染、导管异位、导管移位、导管破损或断裂、导管堵塞、血栓形成、静脉炎及误穿动脉等,并提出了相应的护理管理对策.在此基础上,对国内经外周中心静脉置管术在早产儿中的应用及护理进行了展望.     

超声导引结合改良塞丁格技术行上臂PICC置入与盲穿置管的比较

目的 比较超声导引结合改良塞丁格技术进行上臂PICC置入与传统PICC置入的效果差异.方法 采用多中心随机对照研究,共5家三级甲等肿瘤专科医院的150例患者参与本次研究,按照随机数字表法分为观察组和对照组,各75例.分别在置管过程中、置管第2天、中间回访和置管第7天,比较两组患者置管成功率、穿刺点渗血、机械性静脉炎发生情况及置管手臂舒适度等指标的差别.结果 两组患者置管成功率均为100%,出血量、导管末端位置的差异无统计学意义(P＞0.05);置管第2天及中间回访时,两组患者穿刺点渗血、穿刺点情况、手指肿胀的差异亦无统计学意义(P＞0.05),但观察组机械性静脉炎发生情况好于对照组,差异有统计学意义(P＜0.05);第7天回访时,观察组穿刺点渗血、手指肿胀、机械性静脉炎发生情况、置管手臂的舒适度均优于对照组,差异有统计学意义(P＜0.05或P＜0.01).结论 超声导引结合改良塞丁格技术进行上臂PICC置入能明显改善穿刺点渗血、手指肿胀、机械性静脉炎和置管手臂舒适度.     

Ultrasound-guided peripherally inserted central catheters (PICC) in cancer patients: success of the insertion, survival and complications

ObjectiveTo evaluate the results of peripherally inserted central catheters (PICC) inserted by nurses using an ultrasound-guided technique at bed-side.MethodsAn observational and prospective study was conducted on all the PICC inserted at bed-side by an ultrasound-guided technique at the Araba University Hospital. The technique was introduced in June 2010, and the data collection period ended in November 2011. The main study variables were successful insertion, duration of PICC, incidences related to the catheter, devices reaching end of treatment and reasons for withdrawal. Patient sociodemographic data and PICC technical features were also registered.ResultsA total of 165 PICC were inserted, 73 are still in use, with 95.2% inserted in patients from oncology or haematology departments. Insertion was successful in the 89.7% (95% CI: 85.1%-94.3%) of the cases. The study included 16,234 catheter days, with a median dwell time of 92 days by PICC. The most frequent incidence was accidental removal in 0.986 per 1000 catheter days (95% CI=0.970-1.001). The thrombosis rate was 0.308 per 1,000 days (95% CI= 0.299-0.317), and the catheter-associated bloodstream infection rate was 0.062 per 1,000 catheter days (95% CI=0.058-0.065).ConclusionUltrasound-guided PICC insertion can be performed at bedside by trained nurses with a high probability of success. PICC, because of its low complication rate and long indwelling catheter survival, is a suitable central venous device for long-term treatment in oncology and haematology patients.     

PICC带管期间皮炎患者的质性研究

目的 探讨PICC带管期间皮炎患者受到皮炎的影响和改变,为临床个性化护理提供参考依据,以期提高护理质量。方法 采用目的抽样法,选取11例发生皮炎的PICC带管患者进行半结构化式访谈,资料通过Colaizzi法分析法得出主题。结果 通过对访谈资料的归类与剖析可归纳为4个主题:皮炎对患者日常生活的影响;焦虑与担忧;对PICC专科护士的认可增加;患者迫切需要便捷的医疗资源。结论 医护人员应发挥对政策信息掌握及自身专业技术优势,加强对患者的健康指导,预防皮炎发生,对皮炎患者及时评估,尽早进行综合性的护理干预和心理疏导,提高患者生活质量。     

外周中心静脉导管体内破损或断裂的原因分析与护理对策

我院2010年9月至2012年11月行外周中心静脉置管的1357例患者,其中5例患者发生导管体内破损或断裂,分析原因可能有:穿刺时未使用导针器、穿刺时肢体外旋、穿刺的血管位置深、肘关节长期反复伸屈、导管批号、输入药液刺激性大。经临床观察总结,提出提高置管的规范操作、保证后期的规范维护及使用、加强对患者及家属的指导和教育、提高防范意识及应急能力等护理对策。     

以护理结局为导向的专案管理模式在极低出生体质量儿PICC导管维护中的应用

目的探讨以护理结局为导向的专案管理模式在极低出生体质量儿经外周静脉穿刺中心静脉置管(PICC)导管维护中的应用效果。方法选取2019年8月至2020年8月苏州市立医院收治的极低出生体质量儿86例,随机分为两组,各43例。对照组实施常规护理干预模式,观察组实施以护理结局为导向的专案管理模式,比较两组一次性穿刺成功率与依从性、导管留置时间、新生儿重症监护病房(NICU)住院时间及并发症发生率。结果观察组干预后一次性穿刺成功率与依从性均高于对照组,导管留置时间长于对照组,NICU住院时间短于对照组,总并发症发生率低于对照组(均P<0.05)。结论以护理结局为导向的专案管理模式应用于极低出生体质量儿中可有效提高一次性穿刺成功率与新生儿的依从性,延长置管时间和缩短NICU住院时间,并显著降低并发症发生率。     

An experience in nursing an acute lymphocytic leukemia patient with Peripherally Inserted Central Catheter

The Peripherally Inserted Central Catheter (PICC) is still in its infancy in Taiwan. It has many advantages, including safety, simplicity, and few complications during the insertion process. It is suitable for patients who need long-term parenteral administration of medication or chemotherapy. However, the duration of PICC implantation is around six months, or even up to one year. As a result, it is very important to educate patients to take care of themselves throughout the implantation period in order to prevent complications. This report describes the experience of nursing a forty-four-year old male patient who suffered from acute lymphocytic leukemia and received a PICC implantation while undergoing chemotherapy treatment. As a PICC case manager, the author utilized self-efficacy theory and devoted herself to nursing care, interviews and phone calls to collect valuable information. During the process of PICC implantation, the author analyzed the characteristics of this case and assisted the patient and his primary care giver in choosing a suitable catheter and self-care techniques to achieve minimal complications during implantation. It is hoped that, by sharing in her experience, nursing staff may enhance their ability to assist patients with PICC and to help them to maintain their quality of life.