后入路颈内静脉穿刺置管386例分析

目的 探讨和总结后入路颈内静脉穿刺置管技术要点及术中注意事项.方法 我院自2011年1月至2012年1月接受后入路颈内静脉穿刺置管患者共386例,回顾性分析穿刺过程中及穿刺后并发症情况,总结穿刺技术要点.结果 术中并发症共15例(3.9％),其中误穿动脉5例(1.3％),穿刺置管失败5例(1.3％),血气胸2例(0.5％),心律失常1例(0.26％),术中出血2例(0.5％);术后并发症共13例(3.4％),其中导管感染5例(1.3％),导管周围渗液2例(0.5％),导管阻塞4例(1.0％),局部血肿2例(0.5％).结论 后入路颈内静脉穿刺置管术前定位非常重要,规范操作可以降低术中及术后并发症的发生率.     

颈内静脉穿刺置管211例体会

我院自1990年11月至1995年5月以来施行颈内静脉穿刺置管211例,现报告如下: 1 器械与方法 1.1 穿刺针与留置导管 选择进口或国产静脉穿刺套管留置针。型号分别是1.7×133mm,1.6×100mm,1.6×170mm。 小心静脉留置管(西德贝朗公司BRAUN生产)套装内包括金属穿刺针,(φ1.3×70mm)弹簧金属导丝,(φ0.89×5mmm血管扩张器,输血饥输液测压留置管(φ1.1×2(×)mm)等。     

颈内中心静脉穿刺置管术并发症的临床分析

目的分析、探讨颈内中心静脉穿刺置管术并发症和改进技术。方法对2003年8月至2006年12月158例应用颈内中心静脉穿刺置管术患者进行回顾性分析,了解颈内中心静脉穿刺和置管过程中并发症发生情况,研究相关的并发症和技术问题。结果颈内中心静脉穿刺置管术并发症发生率为7.59%,其中局部出血、血肿5例（3.16%）,误穿动脉3例（1.90%）,局部红肿感染2例（1.27%）,心律失常1例（0.63%）、气胸1例（0.63%）。结论颈内中心静脉穿刺置管术具有一定的危险性,需注意预防并发症的发生。     

肝移植术中心静脉穿刺置管的解剖定位研究

目的比较解剖定位颈内静脉和锁骨下静脉两种路径行中心静脉穿刺置管的成功率和并发症,为临床选择安全有效的穿刺路径提供参考。方法限期肝移植手术患者随机交叉研究,随机确定颈内静脉和锁骨下静脉穿刺的先后顺序。全身麻醉诱导后,由同一组麻醉医师依据解剖定位标志按确定的穿刺顺序完成颈内静脉穿刺置管、锁骨下静脉穿刺置管。记录成功置管前静脉穿刺次数、引导钢丝置入次数,置管时间;同时记录误入动脉、血肿形成、气胸等并发症的发生率。结果 42例限期肝移植手术患者入选该研究。颈内静脉和锁骨下静脉穿刺置管的次数分别为(2.3±0.7)次,(2.9±1.4)次(n=42,P0.05),置管时间分别是(1.58±0.49)min,(2.24±1.01)min(n=42,P0.05)。1例患者行颈内静脉穿刺时误入颈动脉,并发血肿;1例患者行锁骨下静脉穿刺后出现血肿。结论解剖定位穿刺颈内静脉比锁骨下静脉更容易更快捷。     

老年患者中心静脉置管分析

目的总结对老年患者施行中心静脉置管的经验,寻找对老年患者施行中心静脉置管的最短时间和最佳部位。方法对三年来施行过中心静脉置管术的病例进行分析。结果总置管成功率为96.2%,失败率为3.8%。虽然经右颈内静脉置管的首次成功率与经右锁骨下静脉置管的首次成功率相比无显著性差异（P〉0.05）,但经右颈内静脉置管时间较经右锁骨下静脉置管时间短（P〈0.05）。结论老年患者施行中心静脉穿刺置管术条件复杂、情况多变,置管难度较大,经右颈内静脉置管较经右锁骨下静脉置管更为省时、安全、可行。     

85例超声引导下颈内静脉穿刺置管临床体会

目的 探讨、评价超声引导下行颈内静脉穿刺置管的安全性和实用性,交流超声定位的方法与经验,提高定位的准确性.方法 超声探查颈内静脉,沿其走行做好体表标记,保持病人头、颈部位置绝对不动,沿体表标记线行血管穿刺术,用sedinger经皮穿刺法留置导管.结果 一次穿刺成功79例,成功率92.9%,二次穿刺成功4例,成功率4.7%,三次以上2例,占2.3%.结论 超声引导下行颈内静脉穿刺置管简便、安全,成功率高,可缩短穿刺时间,减少危重患者的体位不适及穿刺带来的风险,值得推广.     

血液透析患者中心静脉置管感染的预防

由于长期静脉穿刺使局部静脉闭锁增生往往导致穿刺失败;而对另外一类病人,则由于全身严重水肿,外周血管无法穿刺.对这些病人常常需要依靠中心静脉置管来进行透析,因此,预防其感染和阻塞是延长中心静脉置管使用寿命的关键.现将我院血液透析中心83例中心静脉置管护理经验介绍如下.     

中心静脉置管的护理

中心静脉置管因其安全迅速、成功率高、减少反复静脉穿刺给患者带来的痛苦、避免刺激性药物及高渗性或粘稠性液体对外周血管的损害及患者可随意活动等有点被广泛应用于临床。但如果置管后护理不当,不但影响置管的继续使用,而且也给患者造成不必要的痛苦及经济损失。1998年7月始,我院相继在手术室、外科病房、肿瘤内科病房等科室引进此项技术,下面介绍一些临床护理实践中的体会。     

浅谈锁骨下静脉穿刺的教学方法

锁骨下静脉穿刺插管术,为全胃肠外营养、中心静脉压测定、周围血管不易穿刺的长期输液患者提供了方便。但此项技术在教学时危险性较大,很难尽快熟练掌握,操作不当时易发生各种并发症,而且实践机会少,不能反复操练,一次仅能带教一名实习生。为此,熟悉锁骨下静脉的解剖部位,了解各种穿刺方法及术后并发症极为重要,运用锁骨下静脉的情景教学法针对初上临床的实习生进行系统培训,对掌握锁骨下静脉置管也卓有成效。     

1例肺癌患者经外周中心静脉置管失败锁骨下静脉留管的护理体会

目的：通过对1例PICC常规置管失败、锁骨下静脉留管的特殊病例的成功护理经历,给由于某些原因导管尖端始终无法到达理想位置,导管尖端只能到达锁骨下静脉的PICC穿刺失败病例一点启示,表明只要防护措施得当保留导管、延长留管时间亦有可行性,减轻反复穿刺带来的痛苦和麻烦、减少经济浪费、提高患者生活质量并不是不可实现。方法1例肺癌患者按常规操作程序操作,X线示院导管在锁骨下静脉处反折,多次尝试,导管末端始终无法进入头臂静脉,患者要求中长度留管,汇报医生,鉴于Angle JF等[4]等剪短导管使尖端被放置在腋静脉或锁骨下静脉时,对非刺激性的物质如生理盐水及血液输注依然适用,考虑患者的治疗为姑息性、外周血管条件差等原因,将导管末端留置于锁骨下静脉。我科护士经过耐心的心理护理、细致的观察、切实有效的沟通和健康宣教、结合有效护理、到位的出院维护等综合防护措施,患者静脉炎、导管内回血得以有效控制,未见其他并发症的发生,携管出院期间预防措施落实得当,无特殊情况的发生,生命末期输液治疗得以安全、顺利进行。结果导管留置5月余未出现明显不良并发症,至患者疾病不治身亡,导管仍有效发挥输液作用,为患者在生命末期保留了一条生命通道、减轻了反复穿刺带来的痛苦和麻烦、减少了经济浪费、提高了生活质量,获得了床位医生、患者及家属的一致肯定。结论此次护理经历为我科在以后的工作中不断完善穿刺水平、提升PICC护理质量提供了宝贵的经验,希望也能给PICC穿刺和护理的同仁们一点点启示。让我们在以人为本的护理理念的指导下,以高度的责任心完成PICC各项工作,努力达到减轻患者痛苦、提高患者生活质量的目的,从而真正体现PICC护理的工作的内涵。     

Clinical Performance of a New Transparent Chlorhexidine Gluconate Central Venous Catheter Dressing

As the sciences of vascular access and infection prevention rapidly advance healthcare professionals are often faced with new technologies designed to help, but which are often so complicated to use that they cause unforeseen problems. As a vascular access team at a major mid-western hospital, we evaluated the ease-of-use and the performance characteristics of a new transparent catheter dressing, 3M Tegaderm CHG IV Securement Dressing^® (3M Health Care™, St. Paul, MN) containing the antimicrobial chlorhexidine gluconate (CHG), with a variety of central venous catheters insertion sites in comparison to a standard non-antimicrobial dressing Tegaderm^® (3M Health Care™, St. Paul, MN). Following IRB approval, sixty-three consenting patients were enrolled and randomized; 33 in the CHG antimicrobial dressing group and 30 in the standard dressing group. Thirty six patients had peripherally inserted central catheters (PICCs), 20 had intrajugular insertions (IJ), and 7 had subclavian insertions. The new 3M Tegaderm CHG IV Securement Dressing^® (3M Health Care™, St. Paul, MN) was evaluated for its ability to permit visualization of the insertion site, ease of use, ease of using correctly, ability to secure the catheter and absorb exudates and remain transparent.The new 3M Tegaderm CHG IV Securement Dressing^® (3M Health Care™, St. Paul, MN) was found to be as easy to use in central venous catheter care clinical practice as the standard of care non-antimicrobial transparent adhesive dressing. No additional training or education was required to properly use it. This dressing was applied and removed like standard transparent adhesive dressings, but offered many advantages over standard dressings. Advantages include that it is antimicrobial, handles moderate bleeding, remains transparent and appears to offer greater catheter securement than the Tegaderm^® (3M Health Care™, St. Paul, MN) standard dressing. The CHG gel pad also conformed well to the catheter.     

Vascular Access Tracking System: a Web-Based Clinical Tracking Tool for Identifying Catheter Related Blood Stream Infections in Interventional Radiology Placed Central Venous Catheters

Vascular access is invaluable in the treatment of hospitalized patients. Central venous catheters provide a durable and long-term solution while saving patients from repeated needle sticks for peripheral IVs and blood draws. The initial catheter placement procedure and long-term catheter usage place patients at risk for infection. The goal of this project was to develop a system to track and evaluate central line-associated blood stream infections related to interventional radiology placement of central venous catheters. A customized web-based clinical database was developed via open-source tools to provide a dashboard for data mining and analysis of the catheter placement and infection information. Preliminary results were gathered over a 4-month period confirming the utility of the system. The tools and methodology employed to develop the vascular access tracking system could be easily tailored to other clinical scenarios to assist in quality control and improvement programs.     

静脉导管相关性栖稻黄单胞菌脓毒症15例临床研究

目的探讨静脉导管相关性栖稻黄单胞菌脓毒症的临床特点。方法临床怀疑导管相关性脓毒症时,即采外周血和导管内血液行细菌培养,拔除静脉导管时送导管内容物及导管尖端行细菌培养。结果15例患者导管入口处均无红肿、疼痛、分泌物,临床表现为突然不规则发热、寒战,体温37.8～40℃,11例（73.3%）超过38.5℃,2例伴（13.3%）咳嗽、咳黏液脓性痰;栖稻黄单胞菌在15例患者外周血、导管内血液培养中均为优势生长菌,7例导管尖端培养阳性;15株栖稻黄单胞菌均对哌拉西林、替卡西林/克拉维酸、阿米卡星、头孢他啶、头孢哌酮/舒巴坦、亚胺培南/西司他丁、氧氟沙星敏感,均对头孢西丁、头孢呋辛钠、头孢唑林、氨曲南耐药,3株对阿莫西林耐药,2株对头孢噻吩、头孢曲松耐药。15例患者中,12例痊愈,3例死亡。结论导管相关性栖稻黄单胞菌脓毒症多发生于患有各种基础疾病、免疫功能低下者,对I代、Ⅱ代头孢霉素、氨曲南耐药性高。     

Establishing a Nurse-Led Central Venous Catheter Insertion Service

Background: Health care systems promote care models that deliver both safety and quality. Nurse-led vascular access teams show promise as a model to achieve hospital efficiencies and improve patient outcomes.Objectives: The aim of this paper is to discuss the process of establishing a nurse-led central venous catheter (CVC) insertion service in a university affiliated hospital using a process evaluation method.Method: Archival information, including reports, communications and minutes of departmental meetings were reviewed. Key stakeholders involved in establishing this nurse-led service at the time were interviewed.Results: A nurse-led CVC insertion service was first established in 1996 and has increased in service provision over 13 years. Initially there was scepticism from some medical practitioners about the feasibility of a nurse performing a traditional medical procedure. The service currently provides central venous access across the hospital including critical care areas. The service places up to 500 catheters per annum.Conclusions: Establishing a nurse-led CVC insertion service has increased organizational efficiencies and provided an infrastructure for support of best practice. The support of senior management and medical practitioners was crucial to the successful implementation of this model of care.     

血液透析专用中心静脉导管封管液的研究

在为血液透析专用中心静脉导管患者进行封管时,封管液的选择会影响封管的效果。目前对于何种封管液有最佳的抗栓效果及较好的安全性,国内外对枸橼酸钠与肝素封管液的效果存在一些争议。如何延长中心静脉导管留置的时间,以及减少导管并发症的发生是临床急需解决的问题。本文就血液透析专用中心静脉导管封管液枸橼酸钠和肝素对凝血功能、导管堵管率以及导管功能相关血流感染的影响等方面展开综述,为临床护理工作提供相关证据。     

Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection

BackgroundCentral line-associated blood stream infection (CLABSI) rates in adult care intensive care units have been decreasing across the board. However, we continued to see just a few infections in patients whose catheters are in for >4 days. Therefore, we looked at infections associated with intraluminal contamination to help reduce our infection rate.MethodsA protective cap trial was developed and implemented in 2 intensive care units. All of the central venous catheter and intravenous tubing access valves were covered with a protective cap saturated with alcohol. This intervention eliminated the need to wipe off intravenous access points with an alcohol swab. The study was done as a nonrandomized prospective trial occurring March 1, 2011 through February 29, 2012.ResultsDuring 2010, there were 4 CLABSI-related infections. By the end of the trial, we had incurred 1 catheter-associated blood stream infection. CLABSI rate reduced from 1.9 in 2010 to 0.5 during the 1-year trial period.ConclusionsThe implementation of the port protector cap system resulted in lower infection rates compared with an alcohol swab technique. Our results indicate that consistent use of the caps in tandem with strict compliance does influence CLABSI rates.