一针皮下隧道法预防导管相关并发症的效果观察

目的探讨一针皮下隧道法预防中心静脉导管相关并发症的效果。方法对500 例患者采用皮下隧道(长度6~7 cm)锁骨下静脉置管(皮下隧道组),155例患者采用传统锁骨下静脉置管(锁骨下静脉组),置管期间加强感染监测和护理。比较两组一次穿刺成功率和导管相关性并发症发生率及置管时间。结果两组一次穿刺成功率比较,差异无显著性意义(P>0 05); 并发症发生率及其感染发生率比较,差异有显著性意义(均P<0.01);两组置管时间比较,差异无显著性意义(P>0 05)。结论皮下隧道锁骨下静脉穿刺置管法操作容易,成功率高,并发症少,在预防中心静脉导管相关性感染中有一定作用。     

带涤纶套血液透析导管在透析中的应用

目的:观察带涤纶套血液透析导管的血液透析患者使用及并发症情况.方法:以我院2006年1月至2009年3月留置带涤纶套血液透析导管经左侧锁骨下静脉置管的35例患者为研究对象,收集其临床资料,分析置管后血栓形成和导管相关性感染的发生情况.结果:35例经左锁骨下静脉置管全部成功,导管置入后X线下复查全部位于上腔静脉与右心房交界处,置管成功率为100%.血流量均大于200ml/min,导管连续使用12月以上10例,6月以上18例,超过3月7例.共发生导管内血栓形成9例(占25.7%),其中合并其它部位血栓形成3例(占8.5%),左锁骨下静脉内血栓形成3例,其中1例同时合并上腔静脉内血栓形成和左颈内静脉内血栓形成.导管相关性感染2例(5.7%).结论:带涤纶套血液透析导管的置入可解决许多不适合进行造瘘手术且外周血管条件差的患者的血管通路问题.锁骨下静脉置管同样安全和方便.     

血液透析的临时通路：锁骨下静脉三腔导管的护理

血液透析的临时通路──锁骨下静脉三腔导管的护理北京协和医院王晓英，陈季贤我科应用经皮锁骨下静脉三腔导管置管，迅速建立暂时性血管通路进行维持血液透析，取得满意效果，报告如下：１，临床资料１９９２年６月至１９９３年１１月共行４６例，均１次置管成功。留置时...     

160例中心静脉留置导管在血液透析中的应用

目的:探讨血液透析患者暂时和永久性中心静脉留置导管在慢性肾衰竭血液透析治疗中的应用.方法:2001年1月～2003年10月,我科行单针双腔导管留置行血液透析160例,其中暂时中心静脉导管148例,颈内静脉122例,锁骨下静脉8例,股静脉置管18例;永久性中心静脉置管12例,颈内静脉1例,锁骨下静脉11例.分析不同置管方法其临床并发症的发生率及处理方法.结果:暂时中心静脉置管与永久性置管相比,各种并发症发生率高.颈内静脉置管与锁骨下静脉置管相比,各种并发症发生率无明显差别,但颈内因操作相对安全,在临床应用更广泛.结论:暂时中心静脉置管对紧急血液透析患者,因操作简便,并发症低,并能提供稳定血流量,为临床造瘘提供了时间,从而广泛使用.永久性中心静脉置管留置时间长,并发症低,对血管条件差,无法行动静脉瘘、血管移植术或人造血管植入术,或手术失败,预计存活时间在2～3年内的老年体弱患者,为一理想的选择.     

中心静脉置管行血液净化治疗临床应用分析

目的：分析血液净化治疗患者中心静脉置管的并发症及其处理,探讨其临床意义。方法：回顾分析234例血液净化治疗患者的中心静脉置管,其中颈内静脉168例（右157例,左11例）,锁骨下静脉41例（右38例,左3例）,股静脉17例（右16例,左1例）,永久性颈内静脉置管8例。结果：置管术中的常见并发症有：误穿动脉5例,皮下血肿8例,穿刺部位渗血4例。置管术常见远期并发症有：导管栓塞11例,导管相关感染10例,导管意外脱落4例,血流量不足（血流〈180 ml/min）20例。带管时间8～283 d。右颈内静脉置管的导管感染发生率及导管栓塞发生率较锁骨下静脉置管明显低（P〈0.01）,以尿激酶封管治疗导管栓塞发生率下降明显。结论：中心静脉留置导管是建立血液净化治疗临时血管通路的一种方便快捷方法,操作技术简便,并发症低,并能提供稳定血流量,是建立血液净化治疗临时性血液通路的理想选择。     

血液透析患者三种深静脉置管临床效果比较及护理体会

目的比较颈内静脉、股静脉、锁骨下静脉置管在血液透析患者临时置管中的疗效。方法 90例慢性肾功能衰竭行血液透析患者,随机分为三组,每组30例,分别行颈内静脉、股静脉、锁骨下静脉置管。结果颈内静脉、股静脉、锁骨下静脉一针穿刺成功率分别为90.0%(27/30),96.7%(29/30)及86.7%(26/30),组间比较无显著差异(P0.05)。三组置管使用天数分别为(35.5±16.5)d,(38.6±20.3)d,(58.9±22.5)d,使用次数分别为(12.3±5.0)次,(15.6±6.3)次,(23.7±8.7)次,静脉回流不畅发生率为26.7%,33.3%和6.7%,锁骨下静脉组优于其他两组(P0.05)。结论锁骨下静脉置管更适于作为慢性肾功能不全患者血液透析的临时通道。     

PICC与锁骨下静脉置管在肿瘤患者化疗中的应用效果比较

目的 探讨PICC与锁骨下静脉置管在肿瘤化疗患者中的应用效果,为临床护理工作提供依据.方法 将80例肿瘤化疗患者根据所选择导管类型分成PICC组和锁骨下静脉置管组各40例,比较两组置管成功率、导管留置时间、并发症发生率.结果 两组一次穿刺置管成功率、导管留置时间比较,PICC组显著优于锁骨下静脉置管组(均P＜0.01);两组并发症发生率比较,差异无显著性意义(P＞0.05),但锁骨下静脉置管组发生严重感染2例、血气胸1例、动脉损伤2例,PICC组无严重并发症发生.结论 PICC一次穿刺置管成功率高、留置时间长,无严重并发症发生,可作为肿瘤患者长期化疗的首选.     

PICC与锁骨下静脉置管在肿瘤患者化疗中的应用效果比较

目的 探讨PICC与锁骨下静脉置管在肿瘤化疗患者中的应用效果,为临床护理工作提供依据。方法 将80例肿瘤化疗患者根据所选择导管类型分成PICC组和锁骨下静脉置管组各40倒,比较两组置管成功率、导管留置时问、并发症发生率。结果 两组一次穿刺置管成功率、导管留置时间比较,PICC组显著优于锁骨下静脉置管组（均P〈0．01）;两组并发症发生率比较,差异无显著性意义（P〉0．05）,但锁骨下静脉置管组发生严重感染2例、血气胸1例、动脉损伤2例,PICC组无严重并发症发生。结论 PICC一次穿刺置管成功率高、留置时间长,无严重并发症发生,可作为肿瘤患者长期化疗的首选。     

不同入路深静脉置管的临床护理回顾性分析

目的 探索四种入路中心静脉置管在临床应用的效果。方法 通过对四种入路中心静脉置管在置管过程和留置导管期间并发症、留置时间进行回顾性分析。结果 ①在置管过程中穿刺失败,锁骨下静脉入路发生率最高,为10.64%;②送管困难及导管头端异位、局部血肿,PICC发生率最高;③气胸、误入动脉,锁骨下静脉入路发生率最高;④留置导管期间并发症,脱管、导管感染、非计划拔管颈内静脉、锁骨下静脉入路发生率最高;⑤导管断裂或导管漏液、机械静脉炎PICC发生率高。结论 四种入路中心静脉置管在不同期间都有其并发症,但PICC在置管过程、留置期间并发症处理效果满意,留置时间长、患者无不适感及严重并发症。     

锁骨下静脉穿刺置管在小儿造血干细胞移植中的应用

目的评价锁骨下静脉穿刺置管在小儿造血干细胞移植中的可行性。方法对16例接受造血干细胞移植手术的患儿行锁骨下静脉穿刺置管,观察置管的成功率、时间以及并发症。结果一次穿刺置管成功率93.75%,导管放置时间20～67天,平均42.0±17.40天。一例伤口轻微感染,二例导管阻塞,溶栓后复通。结论小儿锁骨下静脉穿刺置管可为造血干细胞移植患儿建立良好的静脉通路,减轻患儿的痛苦,保证化疗计划及静脉高营养的实施,值得临床推广和应用。     

深静脉置管术在腹腔大出血患者抢救中的临床应用

目的研究锁骨下静脉、股静脉两种置管术在抢救急性腹腔大出血患者的临床应用价值。方法将120例急诊腹腔大出血患者,随机分为观察组和对照组,各60例。观察组行锁骨下静脉穿刺置管术,对照组行股静脉穿刺置管术。观察2组穿刺成功率、插管完成时间,误穿动脉率、穿刺口感染率。结果观察组首次穿刺成功率较对照组高,插管完成速度快,误穿动脉率、切口感染率低,并发症少,效果好。结论锁骨下深静脉穿刺置管术能够很好进行腹腔大出血患者的抢救治疗,优点多,适合在基层医院广泛应用。     

380例次长期深静脉留置导管临床应用的生存分析

目的提高对长期静脉留职导管的置管、使用、护理的认识，延长其使用寿命。方法随访本院血液净化中心患者380例次深静脉置管并长期留置的情况和并发症，记录导管使用终点。应用Kaplan-Meier法绘制导管使用寿命的生存曲线，计算中位生存时间。log-rank检验比较导管使用寿命的差异。分析评价置管方法、感染发生率、导管退出原因及透析充分性。结果导管静脉入路途径包括颈内、颈外、锁骨下及股静脉。3种静脉入路中位生存时间分别为颈内（31．0±2．8）月，颈外（30．0±4．0）月，锁骨下（19．0±2．9）月。log-rank生存曲线检验结果显示，颈内与锁骨下进路比较差异有统计学意义（P〈0．05）。导管使用终点113例次，其中患者死亡60例（53．1％），感染14例（12．4％），导管功能不良13例（11．5％），肾移植13例（11．5％），内瘘2例（1．8％），导管意外拉脱7例（6．2％），导管破损4例（3．5％）。导管内感染61例次，隧道感染2例次。结论长期留置导管首选颈内静脉入路，其次为颈外静脉入路。导管终点以患者死亡、感染及导管功能不良占绝大多数。     

纳米银消毒凝胶防治血液透析患者导管相关性感染的前瞻性研究

目的观察纳米银消毒凝胶作为血液透析深静脉置管外用抗菌剂的疗效及安全性。方法将我院使用深静脉置管的62例维持性血液透析患者随机分为3组，对照组20例，深静脉置管处不使用药物；莫匹罗星组21例，深静脉置管处使用莫匹罗星软膏；纳米银消毒凝胶组（纳米银组）21例，深静脉置管处使用纳米银消毒凝胶。比较3组深静脉置管穿刺部位及导管内细菌培养阳性率，并观察纳米银组治疗开始时及观察终点肝功能的变化。结果（1）本组62例，16例穿刺部位或导管内细菌感染，感染率为25．8％，其中置管6周后感染12例（占75％）；（2）3组深静脉置管穿刺部位细菌培养阳性率分别为40．O％、14．3％和9．5％，莫匹罗星组与纳米银组较对照组明显降低，差异有统计学意义（P〈0．05），莫匹罗星组与纳米银组间无统计学差异（P〉0．05）；（3）导管内细菌培养阳性率分别为10．0％、4．8％和4．8N，3组间无统计学差异（P〉0．05）；（4）纳米银组开始时及观察终点肝功能无统计学差异（P〉0．05）。结论纳米银消毒凝胶可有效降低透析用深静脉置管相关性感染发生率，是透析用深静脉置管外用抗菌剂的良好选择。     

Ultrasound-guided cannulation and endocavitary electrocardiography placement of internal jugular vein catheters in uremic patients: the importance of routine chest X-ray evaluation

The NKF-DOQI guidelines recommend performing chest-X-ray(CXR) after subclavian and internal jugular vein insertion prior to catheter use. This is to exclude complications such as a pneumothorax before starting hemodialysis. Indication of a central venous dialysis catheter was based on the historic use of the subclavian vein for placement of these catheters and upon the reported incidence of pneumothorax after this approach of between 1% to 12.4%. In contrast, the incidence of these complications using the internal jugular vein (IJV) is much lower (< 1%). We report our experience in ultrasound-guided cannulation of the right IJV for dialysis vascular access in 527 uremic patients and central catheter placement by endocavitary electrocardiography (EC-ECG). Fluoroscopy was not utilized. In the first hundred cases, all patients underwent CXR. Subsequently, because of total absence of complications and catheter tip malpositioning, the CXR control was carried out only in selected cases (repeated cannulation of the jugular vein or absence of P wave). We believe that only in selected cases should a pCXR be performed before starting hemodialysis sessions, and that our method using the right IJV, ultrasound-guided puncture of the vessel, and catheter placement by EC-ECG is a safe and simple technique that avoids the need for CXR control.     

血液透析中心静脉置管出血性并发症的分析

目的回顾性分析血液透析患者临时中心静脉置管出血并发症发生的原因。方法回顾性分析471例接受临时中心静脉置管的血液透析患者资料，分析置管位置（颈内、锁骨下、股静脉）、置管后透析时机（即刻或隔日）、透析中抗凝方式（普通肝素、低分子量肝素和无肝素）与出血并发症的关系。结果①置管后即刻透析患者发生出血并发症的风险较隔日透析高（16．4％ vs 4．2％，P〈0．01）；②低分子量肝素抗凝较普通肝素抗凝出血少（5．2％ vs 13．8％，P〈0．01）。结论恰当的安排透析时机、选用合适的抗凝技术以可有效减少中心静脉置管患者出血并发症的发生。     

Transverse cervical artery pseudoaneurysm: a rare complication of internal jugular vein cannulation

Internal jugular vein cannulation has become the preferred approach for temporary hemodialysis catheter placement following reports of an increased incidence of subclavian vein stenosis due to subclavian vein catheterization. Internal jugular vein catheterization is associated with a high rate of successful catheter placement. However, significant complications such as internal carotid artery (ICA) puncture, pneumothorax, vessel erosion, thrombosis, airway obstruction and infection can occur. The most common complication is ICA puncture. More recently a few cases of thyrocervical trunk pseudoaneurysm and fistula following internal jugular vein and subclavian vein catheterization attempts have been reported. Patients with renal failure who are on hemodialysis may have to undergo multiple catheter placements and vascular access interventions. This, along with their comorbid conditions, increases the risk of such complications. Here we report a patient on hemodialysis who developed transverse cervical artery pseudoaneurysm following an attempted right internal jugular vein catheterization. We report this case because of its rarity, to raise awareness of such a complication and to discuss different treatment options, in particular endovascular coil occlusion. A review of relevant literature is also presented.     

Complications related to subclavian catheters for hemodialysis. Report and review

Personal experience with subclavian vein cannulations for hemodialysis are given, and the pertinent literature on the subject is reviewed. Two hundred subclavian dialysis catheters were placed in 148 patients who kept them in place for a total of 2,798 days. Immediate complications were two pneumothoraxes and two hemothoraxes due to subclavian artery puncture. Seventeen cases of bacteremia were related to subclavian catheter infections. In 1 case, a complication of sepsis was a vertebral osteomyelitis. Clinical evidences of subclavian vein thrombosis occurred in 5 cases. Life-threatening complications were met in 2 cases: 1 with pericardial tamponade due to right atrium perforation and 1 with mediastinal hematoma and right hemothorax due to superior vena cava perforation. Review of the literature indicates that pneumothoraxes and/or hemothoraxes occurred in 1.7% of the catheter insertions and that sepsis related to subclavian dialysis catheters occurred in 8.9% of the patients. As systematically investigated subclavian vein thrombosis involved at least 50% of the patients. Our 2 personal cases of life-threatening complications and 14 similar cases of the literature were analyzed: left subclavian catheters were associated with superior vena cava perforation with right hemothorax or mediastinal hematoma, while right subclavian catheters gave atrial perforation with pericardial tamponade. Death occurred in 3 of 16 cases, and emergency surgery was required in 5 of 16 cases. Taking into account all these complications, recommendations are made for the use of subclavian dialysis catheters.     

深静脉置管感染因素分析

目的通过研究经皮穿刺深静脉置管术与感染的关系，分析深静脉置管导管相关性感染的发病率以及影响深静脉置管感染的相关因素以采取有效的防控措施降低感染的发生。方法采用回顾性调查方法，将2005年1月至2012年12月我院收治的60例深静脉置管患者按置管部位分为颈内静脉组26例和股静脉组34例，出现发热者采集导管内血培养及导管培养，对感染发生率、感染发生的时间、感染发生的部位、患者的血流量和不同病因患者感染发生率进行了统计。结果深静脉置管放置时间越长，导管相关性感染发生越多。股静脉穿刺组感染发生时间为（26．5±9．6）d，颈内静脉穿刺组感染发生时间为（35．4±6．8）d。本研究深静脉置管导管相关性感染发生率为21．67％，其中股静脉置管的感染发生率为32．3％，颈内静脉置管的感染发生率为7．6％，股静脉置管感染发生率远高于颈内静脉置管（P〈0．01）。在病因方面，糖尿病肾脏疾病组感染率为所有组别中最高（33．3％），与其他组比较存在显著差异（P〈O．05）。慢性肾小球肾炎组（16．7％），高血压肾动脉硬化组（16．7％），多囊肾病（14．2％）、狼疮肾炎（20％）之间无明显差异。患者血流量在200ml／min以上时，导管相关性感染的发生率较低，为9．5％；血流量〈200ml／min时，感染的发生率为28．2％，二者比较，存在显著差异（P〈0．05）。细菌培养病原体以革兰阳性球菌为主（53．85％），其中金黄色葡萄球菌占30．76％，表皮葡萄球菌占23．08％。结论为减少感染发生，颈内静脉置管应作为中心静脉置管的首选部位，导管留置时间应尽可能缩短。对有易感因素的患者，如原发病为糖尿病时血流量较低，应加强无菌操作，一旦发生感染，应立即治疗。     

Wie sollen Urologen ven?se subkutane Portsysteme implantieren?

Background

Since 1999 urologists at the University of Essen in Germany have performed subcutaneous implantation of venous port systems, controlled by intravasal ECG.

Methods

Between December 1999 and June 2011 implantation of venous port systems was performed in 241 male (69.5%) and 106 (30.5%) female patients. The port systems were implanted subcutaneously above the pectoralis major muscle under local anesthesia. If it was not possible to isolate the cephalic vein or safe catheter implantation was not feasible, puncture of the subclavian vein was performed.

Results

The median follow-up was 491.6 days (2?C2568), and 163.254 catheter days (mean 239 days, range 2?C2604) were documented. During the follow-up period 191 (55.1%) patients died. The mean surgical implantation and explantation time was 36.5 min (14?C85 min) and 25.4 min (10-46 min), respectively; 79.7% were implanted and controlled by ECG. Altogether, 390 devices were used in 379 surgical procedures, 355 implantations (91.1%) and 35 explantations (8.9%). Implanted vessels were the cephalic vein in 303 patients (85.6%) and the subclavian vein in 51 (14.4%) patients. Of 35 explanted devices, the explantation was necessary due to complications in 28 (8.0%) cases: infection n=6 (1.7%, 0.036 per 1,000 catheter days), occlusion n=8 (2.3%, 0.049 per 1,000 catheter days), dislocation n=7 (2.0%, 0.042 per 1,000 catheter days), deep vein thrombosis of the upper extremity n=6 (1.7%, 0.037 per 1,000 catheter days), and clotting n=1(0.3%, 0.006 per 1,000 catheter days). Premature catheter removal (<30?days post-op) was required in six cases (1.9%, 0.036 per 1,000 catheter days) due to complications: three catheter dislocations/malfunctions (0.9%, 0.019 per 1,000 catheter days), one port-related infection, one pocket port infection, and one deep vein thrombosis of the upper extremity (0.3%, 0.006 per 1,000 catheter days). Other problems described in the literature like pneumothorax, vein perforation, or pinch-off syndrome did not occur.

Conclusions

Implantation of port systems with ECG control of the catheter tip position is related to a few cases of adverse events and good surgical outcomes. Furthermore, it has also shown great advantages in offering immediate support and early therapy initiation with a fast learning curve for the training urologists. The results of the presented analysis are comparable to those of surgical or radiological departments reported in the literature and provide good evidence that this procedure should be extended to urological centers with a high volume of chemotherapy patients.