3种途径深静脉置管在血液净化中的应用比较

目的 总结3个不同部位深静脉置管在血液净化中的应用,本文通过对不同部位深静脉置管出现的并发症、穿刺成功率、导管留置时间进行分析,以寻找最佳的深静脉置管的血管通路.方法 分析2005年3月至2007年3月我院血液净化室对90例需要行血液净化治疗病人先后采用锁骨下静脉置管30例,颈内静脉置管30例,股静脉置管60例.结果 导管留置时间:锁骨下静脉13-116(30±9)d,颈内静脉16-103(26±11)d,股静脉2-60(15±8)d;穿刺成功率:锁骨下静脉90%,颈内静脉93%,股静脉98%;感染的发生率:锁骨下静脉10%,颈内静脉6.7%,股静脉16.7%.结论 深静脉置管有快捷、方便、安全的优点,导管留置时间锁骨下和颈内静脉差异无显著性,但比股静脉明显延长;穿刺成功率股静脉优于颈内静脉及锁骨下静脉;感染率股静脉高于颈内静脉及锁骨下静脉.     

中心静脉留置导管不同置管方式在血液透析中的应用及护理

目的 探讨中心静脉留置导管(CVT)不同置管方式在血液透析中的应用及护理.方法 回顾性分析2005年7月至2009年12月我院血液净化中心1810例CVT情况.结果 CVT留置时间分别为:临时性股静脉导管3～30 d,临时性颈内静脉导管7～120 d,半永久性颈内静脉导管6～38个月.临时性颈内静脉导管的使用寿命明显长于股静脉导管,CVT主要并发症为导管功能不良和感染,以股静脉导管发生率较高,其余两种置管方式的并发症少且相近.结论 CVT是有效的血液透析血管通路,应根据病情选择合理的置管方式,严格无菌操作,正确使用和维护并及时处理并发症,可最大限度地发挥导管的功能.     

带CUFF中心静脉导管作为血液透析通路的临床分析

目的总结留置带CUFF中心静脉导管的经验,探讨如何防治带CUFF中心静脉导管的并发症.方法分析1996年3月～2001年3月我院对20例患者留置带CUFF中心静脉导管25例次.其中,右侧颈内静脉留置导管8例次、左侧颈内静脉留置导管2例次、右侧锁骨下静脉留置导管12例次、左侧锁骨下静脉留置导管3例次.结果主要并发症导管位置不当4例次;感染的发生率为32%(8/25),平均1.3例次/1000天,治疗有效率为25%(2/8);血栓的发生率为24%(6/25),导管内血栓治疗的有效率为75%(3/4).总的带管时间为201个月,从2～27个月,平均带管时间为8个月.结论带CUFF中心静脉导管对于长期血液透析治疗而无血管通路或不能承受动静脉内瘘的患者是必不可少的,其并发症是可以防治的.     

中心静脉留置双腔导管血液净化的临床应用

目的探讨中心静脉留置双腔导管的效果和退出原因,延长其使用期限。方法随访血液净化患者留置导管的使用情况和并发症,记录导管使用终点。结果实施中心静脉留置导管135例次,其中13次为再次置管,经颈内静脉入路20例次(成功率98%),股静脉103例次(成功率100%),锁骨下2例次(成功率100%)。置管成功率100%。导管使用期限平均(10.5±8.4)个月,使用留置导管时间分别为:>12个月1例,>10个月7例,>6个月28例次,≥3个月15例次,<3个月54例次(大部分继续使用)。观察导管使用终点65例次,约占46%,导管退出时平均使用时间3～12个月。结论中心静脉留置导管进行血液净化可达到充足的血流量和充分透析,需良好的导管留置技术及护理以提高导管的使用效果,减少感染率;老年患者的并发疾病导致死亡是导管终止使用的主要原因。     

股静脉与颈内静脉留置双腔导管在血液透析中的应用

目的 比较股静脉与颈内静脉插管建立临时性血液透析通路的优缺点。方法 采用回顾性对照研究,106例尿毒症患者先后共留置股静脉导管72根,颈内静脉导管59根。观察两种插管途径的导管留置时间、导管相关并发症、血流量及 Kt/V值等。结果 颈内静脉插管的导管留量时间为 38±15天,明显长于股静脉插管21±11天(P<0.01);血流量分别为260±35ml/分、215±61ml/分(P<0.05);颈内静脉插管的血流量不足、感染及导管堵塞发生率低于股静脉插管;而且前者Kt/V值高于后者(1.1±0.4,0.8±0.5,P<0.05)。结论 相对而言,颈内静脉插管是一种更理想的临时性血液通路。     

深静脉置管行血液净化治疗临床病例分析

目的总结血液净化治疗患者留置临时性中心静脉导管的经验,探讨中心静脉留置导管在血液净化治疗中的应用以及中心静脉留置导管并发症的防治.方法2004年2月～2005年6月,中山大学附属第一医院肾内科行临时性单针双腔静脉导管留置术血液净化治疗病例223例,其中颈内静脉置管193例(右181例,左12例),右锁骨下静脉置管21例,股静脉置管9例(右8例,左1例).分析不同置管方法临床并发症的发生率及处理方法.结果置管术中的常见并发症有:误穿动脉8例(3.6%),皮下血肿10例(4.5%),穿刺部位渗血3例(1.3%).置管术常见远期并发症有:导管相关感染28例(12.6%),导管栓塞9例(4.0%),导管意外脱落5例(2.2%),血流量不足(血流＜180ml/min)21例(9.0%).带管时间3～155天.结论临时性中心静脉留置导管是建立血液净化治疗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.     

三种静脉插管行血液透析的临床比较

目的;比较股静脉,锁骨下静脉和颈内静脉插管留置双腔导管在血液透析中的应用。方法：１０６例尿毒症患者,４０例行股静脉插管,３６例行锁骨下静脉插管,３０例行颈内静脉插管进行血液透析（血透）。观察三种不同插管途径的血流速度,评估透析的充分程度,血尿素氮重复循环率,导管留置时间以及与导管相关的并发症。     

中心静脉导管留置感染的相关因素分析及预防对策

目的:探讨中心静脉导管留置感染的相关因素及预防对策。方法:根据中心静脉导管留置时间分为Ⅰ组、Ⅱ组、Ⅲ组,按穿刺部位分为颈内静脉置管组(A组)和股静脉置管组(B组)。比较其局部感染和导管堵塞发生率。结果:导管留置时间大于15d组(Ⅲ组)局部感染和导管堵塞发生率最高;股静脉置管组局部感染和导管堵塞发生率高于颈内静脉置管组。结论:局部感染和导管堵塞的发生与中心静脉留置时间有关,颈内静脉置管组优于股静脉置管组。     

SICU中心静脉导管相关性血行感染分析与集束干预策略

目的 探讨SICU中心静脉导管相关性血行感染（CVC- RI）的危险因素及集束干预策略.方法 对我院SICU2008年1月～2010年12月收治的225例病人进行回顾性调查,收集相关临床资料进行统计分析.结果 置管时间10～20天占CVC-RI 60.5％,股静脉置管占CVC-RI33.3％,基础疾病中肺炎合并呼吸衰竭、多脏器衰竭对CVC- RI的影响更大.颈内静脉置管占CVC- RI 17.2％,锁骨下静脉置管占CVC-RI 12.8％,两者比较无显著差异（P＞0.05）.股静脉置管CVC-RI发生率较颈内静脉置管和锁骨下静脉置管明显增加（P＜0.05）.结论 基础疾病、留置时间是中心静脉导管感染的高风险因子.     

锁骨下静脉上位置管与颈内静脉置管在血液透析中比较

目的比较锁骨下静脉上位置管与颈内静脉置管建立临时性血液透析通路的优缺点.方法采用回顾性对照研究,98例急需血液透析患者先后采用锁骨下静脉上位置管68例,颈内静脉置管30例.观察两种插管途经的穿刺成功率、完成插管时间、导管留置时间、导管相关并发症、血流量及Kt/V值等.结果锁骨下静脉上位穿刺成功率94.1%,显著高于颈内静脉80.0%(P＜0.01),完成插管时间亦优于颈内静脉(P＜0.05);锁骨下静脉上位插管的留置时间明显长于颈内静脉插管(P＜0.05),锁骨下静脉上位置管的血流量不足、感染及导管堵塞发生率均低于颈内静脉置管(P＜0.05),两部位插管的Kt/V值无显著性差异(P＞0.05).结论相对而言,锁骨下静脉上位插管是一种更理想的临时性血液通路.     

Use of femoral venous catheters in critically ill adults: prospective study

OBJECTIVE: To determine the frequency of clinically important complications of femoral venous catheters. DESIGN: Prospective survey of major and minor complications. SETTING: A mixed medical/surgical ICU in a university hospital. PATIENTS: One hundred twenty-three patients admitted to the ICU who underwent femoral venous catheterization over a 2-yr period. MEASUREMENTS AND MAIN RESULTS: There were 150 catheters inserted in 123 patients for a mean duration of 6.4 days. There were no major complications including catheter-related sepsis. Minor complications consisted of arterial puncture (9.3%), local bleeding (10%), and local inflammation (4.7%). Critical care fellows had a significantly lower rate (6%) of insertion complications than interns or medical students (16%). We did not specifically look at the frequency of deep venous thrombosis. CONCLUSIONS: Femoral venous catheterization offers an alternative site of insertion to the subclavian and jugular veins for central venous access in the critically ill. The occurrence rate of clinically important complications is acceptably low.     

Upper-extremity deep vein thrombosis after central venous catheterization via the axillary vein

OBJECTIVE: To determine the frequency of central venous catheter-induced thrombosis of the axillary vein. DESIGN: Prospective, controlled study. SETTING: Tertiary care university center. PATIENTS: Sixty patients in a medical-surgical intensive care unit who required central venous catheterization via the axillary vein. INTERVENTIONS: Single-lumen, silicone elastomer or polyurethane catheters were inserted for a mean duration of 14.7+/-7.4 days (range, 4-33 days). On catheter removal, bilateral upper-extremity phlebographic examination was performed in each patient. The incidence of deep vein thrombosis in catheterized arms was compared with that in uncatheterized arms. MEASUREMENTS AND MAIN RESULTS: Of the 60 patients who underwent axillary vein cannulation, one patient had clinical signs of arm vein thrombosis, but no patient had clinical sign of pulmonary embolism. There were 35 patients (58.3%) who developed positive phlebographic examinations homolateral to the catheter. Fibrin sleeves that developed around the catheters were observed in 28 patients (47%). Five patients (8.3%) had phlebographic signs of partial axillary vein thrombosis: nonobstructive clots adherent to the vessel wall and/or the catheter. Two patients (3.3%) had phlebographic signs of complete axillary vein thrombosis. No thrombosis was observed in patients with catheterizations lasting < or =6 days, two cases were observed for duration of 7-14 days, and five cases were observed for duration of > or =15 days (p < .01). In the seven patients with axillary vein thrombosis, the vessel was cannulated with fewer than three puncture attempts, and the mean duration for catheter insertion (10+/-2.5 min) was not different from that of patients with no axillary vein thrombosis (14+/-9 min). CONCLUSIONS: Based on the data from the present study, we conclude that axillary vein catheterization is associated with a 11.6% frequency of upper-extremity deep vein thrombosis. This rate of vein thrombosis is similar to that observed after internal jugular or subclavian vein cannulation. Given the acceptable rate of this clinically important complication, axillary vein cannulation offers an attractive alternative site for catheter insertion to the internal jugular or subclavian vein in the critically ill. Because thrombosis is rare or absent in catheterizations lasting <15 days, it seems wise to withdraw axillary catheters after a maximum of 2 wks.     

246例次深静脉置管急诊血液透析治疗的安全性分析

目的 深静脉置管急诊血液透析是肾脏替代治疗的一种有效手段。本文通过对不同深静脉置管部位出现的并发症进行分析,以寻找最佳的深静脉置管急诊血液透析的方式。方法 本文分析了1993年1月至2000年6月期间,因急慢性肾功能衰竭行深静脉置管急诊血液透析治疗的住院患者。置管部位为股静脉、锁骨下静脉和颈内静脉。肝素封管方法为大剂量常规肝素一次性封管和小剂量肝素多次封管两种。结果 219例患者接受了246例次深静脉置管急诊血液透析治疗,平均置管保留时间为19.6天,合并症发生率为28.0％。股静脉置管平均保留时间为(16.89±8.11)天,合并症发生率为30.4％;锁骨下静脉置管平均保留时间为(19.85±12.10)天,合并症的发生率为38.9％;颈内静脉置管平均保留时间为(25.21±10.95)天,合并症的发生率为10.2％,与股静脉或锁骨下静脉置管相比有显著性差异(P<0.05)。结论 颈内静脉置管行急诊血液透析置管保留时间最长,合并症发生率最低,最为安全可靠,应为急诊血液透析治疗首选的临时血普通路。股静脉置管方法操作方便,相对安全,但影响患者活动。锁骨下静脉置管可出现较为严重的并发症,危险性较大,不建议作为急诊血液透析治疗时的临时血管通路。     

Influence of insertion site on central venous catheter colonization and bloodstream infection rates

OBJECTIVE: To compare colonization and catheter-related bloodstream infection (CR-BSI) rates among three insertion sites (subclavian, internal jugular, femoral) used for central venous catheter (CVC) placement. DESIGN: Twenty-four-month prospective study, with relative effects analyzed by Cox proportional hazards regression. SETTING: Eight-bed intensive care unit. PATIENTS: Four hundred and ten critically ill patients requiring CVC placement. MEASUREMENTS AND RESULTS: All short-term multi-lumen CVCs, including antimicrobial-coated devices, were studied with management standardized. Six hundred and five CVCs (4,040 catheter days) were analyzed. Colonization and CR-BSI incidence were, respectively, 15.1 (95% CI 13.5-21.0) and 1.8 (95% CI 1.2-4.2) per 1,000 catheter-days. Colonization was higher at the internal jugular (HR 3.64; 95% CI 1.32-10.00; p=0.01) and femoral (HR 5.15; 95% CI 1.82-14.51; p=0.004) sites than at the subclavian site. The femoral site carried a greater risk of being colonized by non-S. epidermidis species than the subclavian and internal jugular sites combined (HR 4.15; 95% CI 1.79-9.61; p=0.001). CVCs inserted in the Department of Emergency Medicine were more colonized than those inserted in the ICU or operating room (HR 2.66; 95% CI 1.27-5.56; p=0.01), and CVCs were less colonized in females than in males (HR 0.49; 95% CI 0.26-0.89; p=0.02). No difference in CR-BSI rates was noted between the three sites. CONCLUSIONS: Colonization was lowest at the subclavian site. Regional differences exist with respect to type of pathogen isolated. Colonization was influenced by insertion location and gender. The incidence of CR-BSI was not different.     

The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population

OBJECTIVE: The objective was to assess the risk of central venous catheter infection with respect to the site of insertion in an intensive care unit population. The subclavian, internal jugular, and femoral sites were studied. DESIGN: An epidemiologic, prospective, observational study. SETTING: The setting is a well-functioning intensive care unit under a unified critical care medicine division in a university teaching hospital. Critical care medicine attendings and fellows covered on site 17 and 24 hrs per day, respectively. PATIENTS: Patients were critically ill. All patients were triaged into the intensive care unit by on-site critical care medicine fellows. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In an intensive care unit population, we prospectively studied the incidence of central venous catheter infection and colonization at the subclavian, internal jugular, and femoral sites. The optimal insertion site for each individual patient was selected by experienced intensive care physicians (critical care medicine attendings and fellows). All of the operators were proficient in inserting catheters at all three sites. Confounding factors were eliminated; there were a limited number of experienced operators inserting the catheters, a uniform protocol stressing strict sterile insertion was enforced, and standardized continuous catheter care was provided by dedicated intensive care nurses proficient in all aspects of central venous catheter care.Two groups of patients were analyzed. Group 1 was patients with one catheter at one site, and group 2 was patients with catheters at multiple sites. Group 1 was the primary analysis, whereas group 2 was supporting.A total of 831 central venous catheters and 4,735 catheter days in 657 patients were studied. The incidence of catheter infection (4.01/1,000 catheter days, 2.29% catheters) and colonization (5.07/1,000 catheter days, 2.89% catheters) was low overall.In group 1, the incidence of infection was subclavian: 0.881 infections/1,000 catheter days (0.45%), internal jugular: 0/1,000 (0%), and femoral: 2.98/1,000 (1.44%; p = .2635). The incidence of colonization was subclavian: 0.881 colonization/1,000 catheter days (0.45%), internal jugular: 2.00/1,000 (1.05%), and femoral: 5.96/1,000 (2.88%, p = .1338). There was no statistically significant difference in the incidence of infection and colonization or duration of catheters (p = .8907) among the insertion sites.In group 2, there was also no statistically significant difference in the incidence of infection and colonization among the three insertion sites. CONCLUSION: In an intensive care unit population, the incidence of central venous catheter infection and colonization is low overall and, clinically and statistically, is not different at all three sites when optimal insertion sites are selected, experienced operators insert the catheters, strict sterile technique is present, and trained intensive care unit nursing staff perform catheter care.     

血液透析患者临时中心静脉导管相关感染的回顾性研究

目的 通过对临床病例资料的回顾性研究,探讨使用临时中心静脉导管的血液透析患者发生中心静脉导管相关感染（Central venous catheters related infections,CVC-RI）的情况及危险因素.方法 以同济大学附属东方医院肾内科2010年1月至2013年6月临时中心静脉插管的132例血液透析患者为研究对象,收集资料,分析CVC-RI的发生情况及危险因素.结果 ①132例患者中,共行中心静脉置管术149例次,符合中心静脉导管相关感染诊断标准的病人31例,CVC-RI发病率为23.5％.②置管后发生感染的时间最短9d,最长41d,不同置管时间的感染率有统计学差异（P＜0.05）.③颈内静脉和股静脉置管的感染分别为13例（41.9％）和18例（58.1％）.二者比较无统计学意义（P＞0.05）.④CVC-RI患者相关培养中革兰阳性菌17例（54.8％）和革兰阴性菌14例（45.2％）,二者比较无统计学差异（P＞0.05）.⑤年龄、留置时间、穿刺过程是否顺利、有无他处感染、糖尿病、是否使用免疫抑制剂均是导致CVC-RI的危险因素（P＜0.05）.结论 ①年龄、留置时间、穿刺过程是否顺利、有无他处感染、糖尿病、是否使用免疫抑制剂是导致CVC-RI的危险因素.②静脉置管时间大于2周的患者CVC-RI发生率明显增高.③颈内静脉和股静脉置管患者CVC-RI的发生无明显差异.④CVC-RI患者中革兰阳性菌和阴性菌发生感染的比例无明显差异.     

Incidence of the JAK2 V617F mutation among patients with splanchnic or cerebral venous thrombosis and without overt chronic myeloproliferative disorders

Background: Thrombosis of splanchnic or cerebral veins is a typical manifestation of polycythemia vera (PV) or essential thrombocythemia (ET). The recently identified Janus kinase 2 (JAK2) V617F somatic mutation is closely related to chronic myeloproliferative disorders (CMD). Objective: To assess the incidence of the JAK2 V617F mutation among patients with splanchnic or cerebral venous thrombosis with or without overt CMD. Patients and methods: We searched for the mutation in 139 adult patients (> 18 years old) with thrombosis of hepatic veins (HVT, n = 15), or extrahepatic portal vein (PVT) and/or mesenteric vein (MVT) (n = 79), or cerebral veins (CVT, n = 45). Only 19 patients fulfilled criteria for diagnosis of PV (n = 8) or ET (n = 11) at the time of thrombosis: four had HVT, 11 PVT and/or MVT, and four CVT. Results: The JAK2 V617F mutation was found in 94.7% [95% CI 75.3-99.0] of the patients with overt CMD at the time of thrombosis, in 21.5% (95% CI 13.8-31.7) of the patients with abdominal venous thrombosis and without overt CMD, and in 4.8% (95% CI 1.3-16.1) of the patients with CVT and without overt CMD. Among the patients without overt CMD or thrombophilia and with unprovoked thrombosis, 29.4% (95% CI 16.8-46.1) with splanchnic venous thrombosis and 42.8% (95% CI 24.4-63.4) with PVT had the JAK2 V617F mutation. Conclusions: A substantial proportion of patients with splanchnic venous thrombosis and a small, but significant, number of patients with CVT can be recognized as carriers of the JAK2 V617F mutation in the absence of overt signs of CMD. The clinical significance of such findings deserves further investigation.     

Mechanical complications of central venous catheters

We analyzed 385 consecutive central venous catheter (CVC) attempts over a 6-month period. All critically ill patients 18 years of age or older requiring a CVC were included. The rate of mechanical complications not including failure to place was 14%. Complications included failure to place the CVC (n = 86), arterial puncture (n = 18), improper position (n = 14), pneumothorax (n = 5 in 258 subclavian and internal jugular attempts), hematoma (n = 3), hemothorax (n = 1), and asystolic cardiac arrest of unknown etiology (n = 1). Male patients had a significantly higher complication rate than female patients (37% vs 27%, P = .04). The subclavian approach had a higher complication rate than the internal jugular or the femoral approach (39% vs 33% vs. 24%, P = .02). The complication rate increased with the number of percutaneous punctures, with a rate of 54% when more than 2 punctures were required.     

What is the best site for central venous catheter insertion in critically ill patients?

The choice of the best central venous access for a particular patient is based on the rate and the severity of failures and complications. Based on two recent papers, internal jugular access is associated with a low rate of severe mechanical complications in the intensive care unit as compared with subclavian access, and it is preferable for short-term access (<5–7 days) and for haemodialysis catheters. Subclavian access is associated with a lower risk for infection and is the route of choice, in experienced hands, if the risk for infection is high (central venous catheter placement >5–7 days) or if the risk for mechanical complications is low. The femoral route is associated with a higher risk for infection and thrombosis (as compared with the subclavian route). It should be restricted to patients in whom pneumothorax or haemorrhage would be unacceptable.     

The safety of prolonging the use of central venous catheters: a prospective analysis of the effects of using antiseptic-bonded catheters with daily site care

OBJECTIVE: To determine rates of catheter colonization and catheter-related bloodstream infection (CRBSI) when antiseptic-bonded central venous catheters (CVCs) and standardized daily site care are used with no predetermined interval for removal. DESIGN: Prospective observational study. SETTING: Two major trauma centers. PATIENTS: All trauma patients admitted to two major trauma centers that received a CVC from May 1996 through May 1998. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Catheters were semiquantitatively cultured to identify bacterial colonization and CRBSI. Monitored variables included total catheter days, anatomical site of catheter insertion, and area in hospital of catheter insertion. CVC tips and intracutaneous segments were semiquantitatively cultured. A total of 460 (92%) of 501 catheters placed in 324 trauma patients were evaluable, representing 95.5% of all catheter days during the study period. Rates of catheter colonization and CRBSI were 5% (5/1000 catheter days) and 1.5% (1.511000 catheter days), respectively. Subclavian catheters were in place longer than femoral or internal jugular catheters (p < .0001), but the colonization rate was significantly lower (p = .03; relative risk, 0.34; 95% confidence interval, 0.15-0.77). No differences in CRBSI rates among anatomical sites or between catheters used < or =14 days and those used >14 days were identified. CONCLUSION: Femoral and internal jugular antiseptic-bonded CVCs develop bacterial colonization earlier than subclavian CVCs. Subclavian antiseptic-bonded CVCs combined with standardized daily site care may be safely used >14 days in trauma patients.