降钙素原诊断临时性血液透析中心静脉留置导管相关性血流感染价值

目的探讨血清降钙素原（proealitonin,PCT）对临时性血液透析中心静脉留置导管相关性血流感染诊断价值。方法32例临时性血液透析中心静脉留置导管相关性血流感染患者（感染组）和30例无感染患者（对照组）,检测2组血清PCT、高敏C反应蛋白（highsensitivityC-reactiveprotein,hs-CRP）、白细胞计数（whitebloodcell,WBC）;绘制ROC曲线,评价PCT及相关炎症指标对导管相关性血流感染诊断价值。结果感染组PCT浓度、hs-CRP、WBC均高于对照组（P〈0．01）;PCT和hsCRP的AUC分别为0．796和0．318,且PCT的AUC较hsCRP大;双变量相关性分析显示,PCT和hs-CRP呈正相关（r=0．48,P=0．017）。结论血清PCT对临时性血液透析中心静脉留置导管相关性血流感染的诊断具有良好的敏感性和特异件。     

血液透析患者长期留置导管感染并发症的分析

对尿毒症患者而言，稳定、可靠的血管通路是进行血液透析的保证，临时血管通路插管方便，但保留时间短，并发症多。我们科从1998年开始，行永久性带涤纶套导管留置术，现报告近5年使用长期留置导管的感染并发症情况，并与临时性双腔导管作一比较，对感染并发症作回顾性分析，对防治措施进行探讨。     

血液透析病人临时性中心静脉留置导管的护理

总结125例血液透析病人临时性中心静脉留置导管的护理,包括导管相关性感染、穿刺部位伤口出血、导管脱出等的预防。     

血液透析患者中心静脉留置导管失功原因与处理

目的提高对中心静脉留置导管失功的认识和诊治水平,改善血液透析患者预后。方法分析156例中心静脉置管的维持性血液透析患者。采用Seldinger技术置管,其中36例为长期双腔导管,120例为临时双腔导管。结果导管失功有两大类：①导管通路功能障碍22例,原因以导管血栓形成为主（占59％）,导管纤维外鞘形成是长期双腔导管功能障碍的另一个重要因素,在导管使用过程发生;于置管后即刻发生者多由导管打折、贴壁等技术因素引起;②导管相关性感染27例：糖尿病肾病（DN）患者感染发生率显著高于非DN患者;股静脉置管的感染发生率显著高于颈内静脉置管;临时导管感染发生率显著高于长期导管,且留置越久,临时导管感染发生率越高。结论导管内血栓形成是两类导管通路障碍的主要原因,长期双腔导管发生障碍的重要原因还有纤维外鞘;临时导管留置时间延长及会增加感染的机会,影响感染的因素还有糖尿病和置管部位;需长期留置导管时,应用带涤纶套的导管可明显减少感染。     

中心静脉导管配合TEGO连接器预防血液透析导管相关性感染的临床效果

[目的]探讨中心静脉导管（CVC）在血液透析治疗中应用TEGO连接器预防导管相关性感染（CRI）的临床效果。[方法]将78例血液透析病人随机分为两组,CVC配合使用一次性肝素帽病人40例为对照组,CVC配合TEGO连接器病人38例为实验组,两组病人均规律性血液透析1年以上。[结果]实验组CRI发生率低于对照组（P〈0.05）。[结论]CVC配合TEGO连接器进行规律性血液透析能降低透析病人CRI发生率。     

目标性监测及干预对血液透析患者中心静脉留置导管相关性血流感染的影响

目的:探讨目标性监测及干预对血液透析患者中心静脉留置导管相关性血流感染的影响.方法:选取2017年1月1日～2018年12月31日行中心静脉置管血液透析患者752例为研究对象,根据透析时间分为实验组(2018年1月1日～12月31日)385例和对照组(2017年1月1日～12月31日)367例.对照组给予常规护理干预,...     

血液透析患者颈内静脉留置导管院内感染的预防

血液透析患者行经皮颈内静脉插管建立临时性血管通路,具有血流量充足且稳定（达200～300ml／min）、操作简单易行、可反复使用、安全、不易发生严重并发症等优点,但颈内静脉留置导管引起的感染可产生非常严重的并发症。为避免插管时皮肤表面微生物的污染、导管被污染或医务人员的手污染,采取正确的方法预防颈内静脉留置导管院内感染是至关重要的。     

血液透析256例中心静脉导管相关性血流感染预防及护理

目的:探讨减少血液透析患者发生中心静脉导管相关性血流感染(CRBSI)的预防与护理措施。方法:选取行血液透析治疗的256例留置中心静脉导管(CVC)的患者作为研究对象,通过制定标准化中心静脉导管上下机操作流程,并对护士进行严格、规范的操作培训,注重无菌观念及加强健康宣教等方法,减少导管相关血流感染的发生。开始监测时中心静脉导管均无细菌定植,计算2013年CRBSI发生率。结果:1~6月监测100例有3例患者存在导管相关血流感染,总导管使用天数6 721 d,导管相关血流感染发病率为0.446‰;7~12月监测156例总导管使用天数7 334 d,导管相关血流感染发病率为0.0%;全年导管相关血流感染发病率为0.213‰,明显低于全国平均水平(2.5‰~5.5‰)。结论:通过严格的无菌操作,规范导管护理操作流程,加强健康宣教,可明显降低导管相关性血流感染(CRBSI)发病率。     

血液透析中心静脉导管相关血流感染研究进展

血液透析治疗是终末期肾脏病患者主要的肾脏替代治疗方法,血管通路首选自体动静脉内瘘或移植血管内瘘,中心静脉导管通常是血透患者最后的通路选择。导管相关性血流感染是较严重的并发症,严重者可引起菌血症,威胁患者的生命安全。有效预防透析中心静脉导管相关血流感染非常重要。本文对透析中心静脉导管相关血流感染相关危险因素及减少感染预防措施进行综述,以期为有效预防导管相关血流感染提供借鉴。     

力健新封管预防血液透析导管相关性感染的效果分析

目的探讨力健新封管在血液透析深静脉导管相关性感染的应用价值。方法将46例随机分为试验组和对照组，每次血液透析结束后，对照组单纯采用肝素封管，试验组给予肝素与力健新混合进行封管。结果对照组出现导管感染4例，试验组中出现导管感染1例，肝素加力健新封管组的感染率明显低于对照组（P〈0．05）。结论力健新封管可预防血透患者中心静脉导管相关性感染。     

Infectious complications of percutaneous central venous catheterization in pediatric patients

Objective Analysis of infectious complications and risk factors in percutaneous central venous catheters. Design One-year observational, prospective, multicenter study (1998–1999). Setting Twenty Spanish pediatric intensive care units. Patients Eight hundred thirty-two children aged 0–14 years. Intervention None. Measurements and main results One thousand ninety-two catheters were analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI) were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0–8.0). Risk factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69; 95% CI 1.95–4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97–2.78; p = 0.05), silicone catheters (RR 2.82; 95% CI 1.49–5.35; p = 0.006), guidewire exchange catheterization (p = 0.002), obstructed catheters (RR 2.67; 95% CI 1.63–4.39; p < 0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63–9.41; p < 0.001). Multivariate Cox regression identified lower patient weight (HR 2.4; 95% CI 1.11–5.19; p = 0.002), guidewire exchange catheterization (HR 2.2; 95% CI 1.07–4.54; p = 0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI 0.89–4.36; p = 0.089) as significant independent predictors of CRBSI. Factors which protected against infection were the use of povidone–iodine on hubs (HR 0.42; 95% CI 0.19–0.96; p = 0.025) and porous versus impermeable dressing (HR 0.41; 95% CI 0.23–0.74; p = 0.004). Two children (0.24%) died from endocarditis following catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P. aeruginosa in the other. Conclusions Catheter-related sepsis is associated with lower patient weight and more than 12 days' indwelling time, but not with the insertion site. Cleaning hubs with povidone–iodine protects from infection. The named authors wrote this article on behalf of the Spanish Central Venous Catheter Pediatric Study Group, the members of which are listed in the Appendix.     

Indwelling time and risk of infection of dialysis catheters in critically ill cancer patients

Objective Despite the lack of evidence to support routine scheduled replacement of dialysis catheters (DCs) this practice continues to be widely used in many intensive care units (ICUs). This study evaluated whether additional risks of catheter-related infection (CRI) are incurred with a conservative attitude in critically ill cancer patients.Design and setting Prospective, observational study over a 14-month period in a 15-bed medicosurgical unit in a comprehensive cancer center.Patients Seventy-nine double-lumen DCs were evaluated in 47 patients. Incidence rates of infection per 1000 days of catheter use were examined over 7-day periods.Measurements and results The mean indwelling time was 6.9±5.5 days. Twelve DCs (15.2%) were removed for suspected CRI. Catheter-tip cultures remained negative in 74 cases (93.7%). Overall, one bacteremic CRI, two colonization episodes, and two contaminations were diagnosed, leading to DC colonization and DC-related bacteremia incidence rates of, respectively, 5.4 and 1.8 per 1000 days. When the catheter colonization rate was examined at 7-day intervals, the incidence rate was similar whatever the indwelling time: 5.8, 4.8, and 6.0 per 1000 days, respectively, for the 49 catheters left in place for 7 days or less, 8–14 days (21 DCs), and more than 14 days (9 DCs). The DC colonization incidence rate was similar to that of the 42 short-term catheters inserted during the same period in the same patients (5.9 per 1000 days).Conclusions The stable low risk for DC-related infections over time does not support the rationale for scheduled replacement, even in immunocompromised cancer patients.     

Haemodynamic study of patients with severe sepsis during haemodialysis

A study was perfomed in order to observe haemodynamic changes induced by haemodialysis in 14 patients with acute renal failure and severe sepsis. Left ventricular function, as assessed by changes in pulmonary wedge pressure and left ventricular stroke work index through plasma volume expansion, did not change during haemodialysis. Ultrafiltration-induced decreases in cardiac index provoked in 8 patients, with nearly normal initial systemic arteriolar resistance, had adequate and constant increase in their resistance (p<0.001), whereas 6 patients with low initial systemic arteriolar resistance did not increase their resistance and had a frequent (9/13 measurements) and significant (p<0.001) fall in mean aortic pressure. This abnormality of vascular tone is probably due to severe sepsis and explains why hypotension is a frequent occurrence during haemodialysis in such patients.     

Peripherally inserted central venous catheters for autologous blood progenitor cell transplantation in patients with haematological malignancies

Background In contrast to the high risk of haemorrhage associated with the implantation of a central venous catheter (CVC) via the internal jugular or subclavian access, the use of a peripherally inserted catheter (PICC) offers the advantage of a lower risk of bleeding complications. However, the rate of phlebitis is higher with the PICC and its use has been declining. We have studied the benefits and adverse events of a new type of PICC and a common type.Methods From October 1999 to October 2001, 70 PICCs (Olimpicc, Vygon, Germany, n=40; and LIFECATH-PICC(PUR)5FR Vygon, Germany, n=30) were inserted into 66 patients with haematological malignancies and used for high-dose chemotherapy, total parenteral nutrition and autologous blood stem cell transplantation. While removing the catheter, central and peripheral blood cultures were taken. The catheter tip was investigated by the semi-quantitative roll-out method of Maki.Results Sixty-five PICCs were removed after a median of 8.9 days. In five cases a catheter-associated significant colonisation with coagulase-negative staphylococci occurred. In two instances catheter-related bacteraemia was found.Conclusion In our study this catheter system was inserted in 94% of patients without problems and showed a low incidence of phlebitis (5/65). Because of the high rate of catheter malfunction reported during and after our study, the Olimpicc catheter is no longer available. The PICC system, and the LIFECATH-PICC(PUR)5FR in particular, offers a safe and effective alternative for central venous access to the internal jugular vein.     

Indwelling time and risk of colonization of peripheral arterial catheters in critically ill patients

Objective  Despite the lack of evidence to support routine scheduled replacement of peripheral arterial catheters this practice continues to be widely used in many intensive care units (ICU). This study evaluated whether additional risks of catheter colonization are incurred with a conservative attitude in severely ill patients. Design and setting  Observational study over a 18-month period in a 15-bed surgical ICU of a 1,000-bed French university-affiliated hospital. Catheters  A total of 295 peripheral arterial catheters were inserted in 295 patients. Measurements and main results  Hazard rates of catheters colonization (defined as quantitative culture of a catheter tip showing at least one microorganism at a concentration of 1,000 or more colony-forming units per milliliter) according to indwelling time were determined over 5-day periods by survival analysis. The mean indwelling time was 8 ± 6 days (median 6 days). Overall, 47 (16%) colonization episodes were diagnosed, leading to catheter colonization incidence density of 19.9 per 1,000 catheter-days. Risk factors for catheters colonization increase in proportion to the duration of catheter use. Hazard rates of catheter colonization were 1.0, 1.9, 3.5, 7.0, 6.0 and 5.7%, for the 111 arterial catheters left in place for 4 days or less, 5–9 days (87 catheters), 10–14 days (55 catheters), 15–19 days (27 catheters), 20–24 days (10 catheters) and more than 24 days (5 catheters). Conclusions  Systematic replacement of peripheral arterial catheters might be useful in preventing catheter-related colonization, especially after 2 weeks of use.     

Antidote removal during haemodialysis for massive acetaminophen overdose

Abstract

Context. Haemodialysis is sometimes used for patients with massive acetaminophen overdose when signs of “mitochondrial paralysis” (lactic acidosis, altered mental status, hypothermia and hyperglycaemia) are present. The role of haemodialysis is debated, in part because the evidence base is weak and the endogenous clearance of acetaminophen is high. There is also concern because the antidote acetylcysteine is also dialyzable. We prospectively measured serum acetylcysteine concentrations during haemodialysis in three such cases. Case details. Three adults each presented comatose and acidemic 10 to ? 18 h after ingesting > 1000mg/kg of acetaminophen. Two were hypothermic and hyperglycaemic. Serum lactate concentrations ranged from 7 mM to 12.5 mM. All three were intubated, and initial acetaminophen concentrations were as high as 5980 μM (900 μg/mL). An intravenous loading dose of 150 mg/kg acetylcysteine was initiated between 10.8 and ? 18 h post ingestion, and additional doses were empirically administered during haemodialysis to compensate for possible antidote removal. A single run of 3–4 h of haemodialysis removed 10–20 g of acetaminophen (48–80% of remaining body burden), reduced serum acetaminophen concentrations by 56–84% (total clearance 3.4–7.8 mL/kg/min), accelerated native acetaminophen clearance (mean elimination half-life 580 min pre-dialysis, 120 min during and 340 min post-dialysis) and corrected acidemia. Extraction ratios of acetylcysteine across the dialysis circuit ranged from 73% to 87% (dialysance 3.0 to 5.3 mL/kg/min). All three patients recovered fully, and none developed coagulopathy or other signs of liver failure. Discussion. When massive acetaminophen ingestion is accompanied by coma and lactic acidosis, emergency haemodialysis can result in rapid biochemical improvement. As expected, haemodialysis more than doubles the clearance of both acetaminophen and acetylcysteine. Because acetylcysteine dosing is largely empirical, we recommend doubling the dose during haemodialysis, with an additional half-load when dialysis exceeds 6 h.     

Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children

Objective: To determine whether heparin bonding reduces the incidence of catheter-related thrombosis and infection in critically ill children. Design: A prospective double-blind randomized controlled study. Setting: A tertiary paediatric intensive care unit. Patients: Two hundred and nine patients, 123 males and 86 females, aged 0–16 years, admitted to the intensive care unit and needing a central venous line (CVL), were randomized to receive either a heparin-bonded (HB, n = 102) or a non-heparin-bonded line (NHB, n = 107). Nine patients were excluded owing to incomplete data. Intervention: HB or NHB CVL. Measurements: Blood cultures were carried out on insertion of the line and every 3 days thereafter. Ultrasound was performed within the first 3 days and every 3 days thereafter. On removal the line was sent for culture. Results: The two groups were comparable for age, sex, severity of illness and length of time that the catheter was in situ. Proportional hazards modelling showed that heparin bonding was associated with a significant reduction in infections (hazard ratio 0.11, P < 0.00 005). The incidence of infection was 4 % and 33 % in HB and NHB CVLs, respectively (4/97 vs. 34/103, P < 0.0005). The incidence of thrombosis was 0 % and 8 % in HB and NHB CVLs, respectively (0/97 vs. 8/103, P = 0.006). The number of HB CVLs which would need to be used to avoid one episode of infection or thrombosis was 3 and 13, respectively. Conclusion: Our study shows a significant reduction in the incidence of infection and thrombosis associated with the use of HB CVLs. Received: 17 July 1999/Final revision received: 20 February 2000/Accepted: 25 February 2000     

Totally implanted catheters to reduce catheter-related infections in patients receiving interleukin-2: a 2-year experience

A high incidence of bacterial infections has been previously reported during interleukin-2 (IL-2) treatment, mainly due to catheter-related infections. Antibiotic prophylaxis has been successfully used to decrease such infections. The goal of this study was to evaluate an alternative way to reduce catheter-related infections in IL-2-treated patients by the use of totally implanted catheters. A total of 74 patients with metastatic renal cell carcinoma, referred to our institution to receive IL-2 from March 1989 to July 1991, were included in this prospective study. IL-2 was given on a 2-days-a-week schedule (24x10⁶ IU m^-2 day^-1) either alone (41 patients) or in association with interferon (33 patients). All these patients were prospectively evaluated for fever, bacteremia and line-site infection. Seven patients (9.5%) had one (2 patients) or more (5 patients) positive blood cultures with Staphylococcus aureus. Antibiotics were used only in 5 patients, and the catheter had to be removed in only 2 of these patients. In the other patients, no further infection developed despite the lack of antibiotics. Moreover, 9 patients had positive blood cultures with Staphylococcus epidermidis (1.9% of total number of blood cultures). In conclusion, a totally implanted catheter appears to reduce the incidence of infections in IL-2-treated patients, at least on a 2-days-a-week schedule.     

长期血液透析患者的生存质量及相关性调查

目的 了解血液透析（HD）患者的生存质量（QOL）状况，探讨其相关性影响因素，寻求相应的护理措施，以提高HD患者的QOL。方法 自制一般状况调查表，并以健康调查问卷（SF-36量表）对175例HD患者进行问卷调查，应用描述性研究法对被调查对象的QOL水平进行分析，将其与一般人群比较，测评被调查对象的人口学特征、疾病状况对其QOL的影响。结果 HD患者的QOL的各维度得分显著低于一般人群，家庭关系、费用支付能力、并发症、原发病与患者的QOL有显著关联性。结论在护理HD患者中，应关注其QOL采取有效的护理干预措施，消除或减低其负面影响因素的作用，提高HD患者的QOL。