长期颈内静脉双腔留置导管在血液透析中的护理

为分析颈内静脉留置双腔导管在血液透析过程中的应用、相关并发症的预防及处理，评价长期留置双腔导管的优缺点，2002年10月至2007年10月，我院血液透析中心应用颈内静脉双腔留置导管行血液透析病人共28例。介绍如下。     

双腔留置导管在血液透析中的应用

自1987年以来,我院应用双腔留置导管建立血液通路,对43例急、慢性肾功能衰竭患者进行269次血液透析,效果满意,现报告如下.1 资料与方法1.1 一般资料43例中,男36例,女7例;年龄21～65岁.共进行269次血液透析.1.2 透析方法局麻下,在腹股沟韧带下2cm处紧贴股动脉内侧以45°角进针.穿刺成功后即可抽到暗红色静脉     

血液透析患者中心静脉留置导管失功与处理

回顾性分析212例采用Seldinger技术中心静脉置管行维持性血液透析(HD)患者导管失功状况。212例中发生导管失功61例,发生率为28.77%,其中导管通路功能障碍28例,导管相关性感染33例。经对症处理,45例恢复正常HD,16例拔管。导管内血栓形成和导管相关性感染是失功主要原因,护理人员在HD过程中应熟练掌握操作技术,严格无菌操作,加强健康教育,及时发现异常及时处理,尽可能降低导管失功发生率。     

血液透析患者中心静脉长期导管感染相关因素的分析

目的：分析本院血液透析中心静脉长期导管感染的发病率、相关因素。方法：回顾性调查分析47例中心静脉长期导管患者的原发病,导管留置时间,病原菌分布。结果：原发病为糖尿病肾病,贫血越严重,导管留置时间越长者,中心静脉长期导管感染发生率越高,差异均有统计学意义（P〈0.01）。结论：血液透析患者中心静脉长期导管留置时间超过2年是引起中心静脉导管相关感染的主要原因,感染菌种以革兰阳性菌为主。缩短留置时间可减少血液透析中心静脉长期导管相关感染的发生。     

留置导管长期血液透析的应用

目的 介绍长期留置血液透析（下称血透）导管的置入方法、透析效果以及并发症。方法 采取带皮下隧道长期留置导管置入术建立血透通路15例,观察其透析效果与并发症的发生情况。结果 15根长期留置血透导管共使用2820d,平均每根留置时间188d,其透析效果优于人造血管和临时性血透导管,但不及动静脉内瘘。长期留置血透导管常见的并发症为血流不畅和感染。经干预均可控制。结论 长期留置血透导管对于老年人、心功能不全或造瘘困难者是较好的选择,其透析效果较好,并发症较少。     

预防维持性血液透析患者长期中心静脉导管功能不良的体会

资料与方法 1．病例资料：选取2007年1月至2010年1月在我院利用长期中心静脉留置导管进行维持性血液透析的患者16例,首次透析时血流量均大于250ml／min,观察期1年。     

血液透析中心静脉长期留置导管感染的防治

随着健康水平的提高,人类寿命不断延长使得65岁以上老年人越来越多,在中国尤其是在发达的大城市糖尿病尿毒症患病率在不断增加,社会医疗保障水平的提高也使得尿毒症透析患者的生存期限不断延长;这类人群的透析血管通路面临的问题也成为当今透析治疗的重要问题之一。中央静脉长期留置导管作为血液透析的血管通路在临床上应用非常普遍,采用经皮下隧道穿刺中心静脉留置的带涤纶套导管最初是在20世纪80年代中期开始被作为一种留置时间较长的血液透析通路而使用的,     

永久性经皮下隧道颈内静脉留置双腔导管26例体会

血液透析的血管通路最常用的仍是自体动静脉内瘘,但是随着老年人、糖尿病、儿童等终末性肾衰患者增多,由于患者血管条件所限,且不愿或无条件行腹膜透析[1].永久性中心静脉留置导管,目前已成为维持血透患者血管通路的极好补充.现总结本院资料完整的维持性血液透析患者26例,报道如下.     

Alternative puncture site for implantable permanent haemodialysis catheters

BACKGROUND.: Vascular access represents a major problem in long-term haemodialysispatients. In patients without patent internal arteriovenousfistula, the implantation of cuffed catheters to provide a temporaryor permanent central venous access is often necessary. Catheterizationof the subclavian vein should be avoided because of the highrisk of stenosis or thrombosis. The puncture of the internaljugular vein can be impossible in cases with stenosis or thrombosisdue to previous catheterization. To overcome these limitationswe evaluated an alternative puncture site for implantation ofpermanent central venous catheters. METHODS.: The very low, most central jugular approach, first describedby Rao et al., with the site of puncture just above the medialnotch of the clavicle, was used to introduce Dacron cuffed dialysiscatheters into the innominate vein in four chronic dialysispatients with impeded conventional vascular access. RESULTS.: In all four patients puncture of the internal jugular vein usingRao's technique was successful at the first attempt. All fourcatheters were introduced without any problems. Even in a casewith thrombosis of the internal jugular vein and the ipsilateralsubclavian vein, this technique was successfully applied. Nocomplications such as haematoma, pneumothorax, or catheter-associatedinfection were observed. The catheters remained in situ for2–12 months with excellent blood flow and without clinicalevidence of venous stenosis or thrombosis. CONCLUSIONS.: In case of failure to cannulate the internal jugular vein bya conventional approach, the technique of Rao et al. can beused before sacrificing the subclavian vein or changing to exotictechniques such as translumbar, transfemoral or transhepaticmethods.     

Management of central venous catheter-related atrial thrombus in a preterm neonate

The management of a 1200 g preterm infant with a large mobile septic right atrial thrombus attached to the tip of a central venous catheter is presented. The thrombus was successfully removed from the right atrium under direct vision utilizing vena caval inflow occlusion technique.     

Survey of permanent central venous catheters for haemodialysis in the UK

BACKGROUND: Venous catheter haemodialysis may be necessary in some patientswithout arterio venous fistulae on dialysis for end-stage renalfailure. We conducted a survey to compare management of thesecatheters in different units in the UK. METHODS: Postal questionnaires were sent to nurses in charge of 81 renalunits in the UK for a twelve month study period in 1994 to findout the type of catheter used, catheter after insertion care,the rate and management of exit site infections, and bacteraemia. RESULTS: (1) Total number of questionnaires returned 66 (81.5%). (2)63.6% of renal units used double lumen Permcath catheters, 16.7%single lumen (Francis/Kimal, Gambro or Vascath), 10.6% use bothdouble and single lumen catheters and 9.1% of renal units onlyuse temporary polyurethane catheters. (3) Catheter exit siteaseptic dressing technique was used in 84.8% of renal units,clean technique in 15.2%. 66.8% changed dressings at each dialysissession, 22.7% weekly. The majority of renal units (63.6%) hadone nurse to change the dressing, used Betadine as a cleaningagent and Mepore to cover the exit site. (4) 75.8% did not knowthe exact incidence of episodes of sepsis and/or exit site infections.Flucloxacillin was the antibiotic of choice for each catheterrelated sepsis episode. CONCLUSIONS: During this study period most renal units used Permcaths asfirst choice for long term catheter dialysis, the after insertioncare of which varied. The number of episodes of sepsis was unknown.We suggest UK collection of data for all long term cathetersand related problems for audit purposes.     

Acute vascular access catheters for haemodialysis: complications limiting technique survival

The use of acute vascular access catheters (AVACs) has facilitated the delivery of haemodialysis to patients lacking functioning access. A review of the experience of a tertiary Australian renal treatment centre, consisting of 205 sequential AVACs in 93 patients, was undertaken over 1 year, to identify issues limiting technique survival. Acute vascular access catheters were inserted as acute dialysis access for patients with chronic renal failure (CRF; 21%), failed grafts or fistulae (18%), acute renal failure (12%), failed chronic ambulatory peritoneal dialysis (CAPD; 8%) or failed prior AVACs (37%). The majority of AVACs were on the right (74%), and the placement site was simple jugular (69%), tunnelled jugular (15%), femoral (12%), or subclavian (4%). During follow up, 198 of 205 AVACs were removed. The mean AVAC survival was superior (P < 0.0001, Fisher's protected least significant difference (PLSD) for tunnelled jugular AVACS (62 +/- 46 (SD) days) compared with simple jugular (20 +/- 19), subclavian (18 +/- 13) and femoral (7 +/- 6). Causes for AVAC removal were: elective (47%), blockage (31%), infection (20%) or cracked catheter (1%). Routine postremoval tip cultures grew coagulase negative Staphylococcus (CNS, 46%), negative culture (33%), methicillin-resistant Staphylococcus aureus (MRSA; 9%), Staphylococcus aureus (9%), Gram-negative rods (1%), Pseudomonas (0.5%) or other uncommon organisms (2%). Blood cultures were drawn through the AVAC in the setting of suspected bacteraemia in 42 of 198 AVACs. Blood cultures were negative in 40%. Positive cultures included Staphylococcus species in 55%: including MRSA (19%), Staphylococcus aureus (29%) and CNS (34%). Rare cultures identified Escherichia coli (2%) or Serratia (2%). Infection and blockage significantly reduced AVAC survival, affecting more than 50% of cases. Approaches to minimize these complications are likely to lead to improved clinical outcomes with AVAC use.     

血液透析患者永久性双腔导管的操作流程改良

目的 探讨永久性双腔导管的操作流程改良对预防透析导管堵管和感染的效果.方法 将透析中心置入长期透析导管的21例患者,随机分对照组10例按照2010版血液净化标准进行导管使用和护理,观察组11例强化双腔导管的细节管理,即整个操作过程不让血液在导管内停留,同时操作环节没有导管口的暴露机会.结果 对照组1 200个导管日,导管不全堵塞71例次,完全堵塞12例次,感染6例次;观察组1 200个导管日,导管不全堵塞11例次,完全堵塞2例次,感染0次,两组比较,差异有统计学意义(P＜0.05,P＜0.01).结论 在导管使用和维护中,注重细节管理,可有效防范导管护理不良事件的发生.     

Percutaneous placement of permanent central venous catheters: experience with 200 catheters

The prospective registration of 200 percutaneous placements of permanent central venous catheters (Hickman catheters and subcutaneous infusion ports) was conducted in 172 patients aged 3 months-95 years. The insertions were reviewed to assess whether certain groups of patients or physicians were associated with more complications than others. Complications occurred in 16 patients (8.0%), of which 12 were arterial punctures. Two attempts (1%) at catheter placement failed. None of the complications required treatment. Of the catheter placements, 70% were performed by one of the three authors, and the rest by seven other experienced anesthesiologists. The complication rates were not different between the two groups. Nor was the complication rate significantly higher in small children. Percutaneous placement of permanent central venous catheters thus proved to be a safe and reliable technique, even in small children. The method is easily learnt by physicians experienced in central venous catheterization. Using this method, permanent venous access may be offered to a large number of patients.     

A new technique to remove a “stuck” totally implantable venous access catheter

Removal of a totally implantable venous access device (port) is usually a simple procedure; however, if a catheter has been in place for a very long period, it may adhere firmly to the vessel wall. We report a new technique to facilitate removal of a stuck catheter. A 16-year-old girl was admitted for removal of her port, which had been inserted for chemotherapy 11 years earlier. After her disease was controlled, the catheter could not be pulled out during surgery. To remove the catheter, we inserted a guidewire to straighten the catheter and then applied a “push-in” force to detach the adherence from the central vein. The catheter was then removed successfully. We believe that this is a new and simple method for removing a “stuck” catheter.     

Durability of central venous catheters. A randomized trial in children with malignant diseases

In a prospective randomized study the durability of tunnelled and non-tunnelled central venous catheters was investigated in children with malignant diseases. Twenty children were included in the study but four (two in each group) had to be excluded; three because the entry criteria turned out not to be fulfilled and one because of lack of data. The median duration of the tunnelled catheters was 224 days with a range of 25–846 days which was significantly longer than that of conventional catheters (39.5 days, range 9–228 days). In addition six of eight conventional catheters were accidentally removed whereas all catheters in the tunnelled group had to be removed via a small incision. Three cases of catheter related sepsis, two in the tunnelled group and one in the conventional group, were registered. The corresponding number of infections per catheter days were 1 in 1189 days and 1 in 522 days, respectively. In conclusion cuffed, tunnelled central venous catheters are less prone to displacement than traditional percutaneous central venous catheters when used in children with malignant diseases.     

单通道负压吸引鞘在经皮肾镜中的临床应用

目的探讨单通道负压吸引鞘在经皮肾镜治疗肾结石的安全性和有效性。 方法回顾性分析北京平谷区医院和哈尔滨工业大学附属黑龙江省医院从2018年1月至2019年11月住院期间的111例肾结石患者,一组行负压吸引鞘（Y型鞘）经皮肾镜手术56例（负压组）,一组行常规鞘（常压鞘）经皮肾镜手术55例（常压组）。分别记录两组的手术时间、肾盂压力、术中患者出血量、术后结石清除率、术中术后并发症等临床资料,对两组患者的临床资料进行分析和总结。 结果观察组的手术时间、肾盂压力明显低于对照组并且差异有统计学意义（P<0.05）。观察组结石清除率,术中出血量,术后出血发生率两组比较,两组差异无统计学意义（P>0.05）,术后发热发生率,术后总并发症发生率、术后第1天降钙素原（PCT）值、C反应蛋白（CRP）值明显低于对照组且差异有统计学意义（P<0.05）。 结论单通道负压吸引鞘在经皮肾镜中应用安全性高,并发症少。     

双腔中心静脉导管穿刺置管术治疗多发伤患者创伤后局限性积液

目的 探讨在多发伤患者中使用双腔中心静脉导管置管术治疗不同部位局限性积液的治疗结果.方法 19例多发伤患者创伤后形成局限性积液,其中胸部积液15例,腹部积液3例,背部皮下积液1例.所有患者在B超证实积液后,行中心静脉导管穿刺置管.结果 所有患者均一次穿刺置管成功.术后均未发生穿刺相关并发症,所有胸腔积液患者均治愈.腹腔积液患者2例积液消失,1例好转.1例背部皮下血肿完全治愈.结论 作为一种微创方式,中心静脉导管穿刺置管可以有效引流创伤后不同部位的局限性积液,为临床治疗各种局限性积液提供了另一种新的治疗性选择.