颈内和股静脉置管行血液透析感染发生因素

目的 探讨颈内静脉和股静脉置管感染的发生因素.方法 选取进行颈内静脉和股静脉置管进行血液透析的患者100例,按置管部位分为颈内静脉置管组和股静脉置管组,每组50例.颈内静脉组的导管尖端放于患者上腔静脉与右心房交界处,隧道的方向是外下方;股静脉实验组的导管尖端放于患者髂总静脉处,隧道的方向是直下方.每支导管平均留置1个月,拔管后剪下导管尖端,进行细菌培养阴性,观察有无感染及并发症发生情况.结果 颈内静脉和股静脉置管感染发生无统计学差异,主要感染菌为金黄色葡萄球菌、溶血葡萄球菌.结论 颈内静脉和股静脉置管感染没有统计学差异.     

96例中心静脉置管老年患者的护理

目的回顾性分析96例老年患者中心静脉置管,寻找对老年患者施行中心静脉置管的最佳部位和护理方法。方法96例老年患者均采用德国贝朗公司生产的单腔中心静脉导管,经右颈静脉或右锁骨下静脉穿刺置管。结果总置管成功率为94．5％。初次置管位置选择右颈静脉,失败后改穿右锁骨下静脉成功共16例;初次置管选择右锁骨下静脉,失败后改穿右颈静脉置管成功5例;永久性心脏起搏器植入术后需要置入中心静脉导管共2例,均经右颈内静脉穿刺置管成功。结论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。加强置管前后护理是施行经外周静脉穿刺置入中心静脉导管成功与否的关键。     

中心静脉置管的护理体会

经皮穿刺将导管经颈内静脉或锁骨下静脉插入上腔静脉,或用较长的导管经股静脉插入下腔静脉称为中心静脉置管。因其不仅是一条畅通的静脉通道成为大量快速输液、输入浓度高、刺激性强的药物以及胃肠外营养的最佳选择;更重要的是可直接测量中心静脉压,在危重病人监护中心,静脉置管应用广泛。1临床资料2001年～2004年12月,我科共行中心静脉置管术208例,男性162例,女性46例,年龄17～93岁;创伤性休克患者42例,感染休克15例,大手术循环动力不稳定患者70例,心功能不全患者58例,其他23例。其中静脉导管留置时间最长21天;发生导管堵塞12例,占手术总数的5.76%;导管脱落20例,占9.6%;穿刺部位感染2例,占手术总数的0.96%;并发全身感染0例;发生气胸1例占总数0.48%;经锁骨下穿刺置管后导管未进入上腔静脉而导管往上行入颈内静脉3例。2穿刺部位在局部浸润麻醉(深昏迷患者无麻醉)下采用单腔或双腔中心静脉导管经贵要静脉、左颈内静脉、左锁骨下静脉、右颈内静脉、股静脉进行穿刺置管。其中从贵要静脉穿刺置管4例,右颈内静脉置管183例,右锁骨下静脉置管18例,左颈内静脉置管3例。3护理3.1置管前评估置管前评估患者一...     

采用9号头皮针经颈内静脉置入隧道式经外周置入中心静脉导管的应用效果

目的观察采用9号头皮针经颈内静脉置入隧道式经外周置入中心静脉导管(PICC)的临床效果。方法选取接受中心静脉置管建立静脉通路的60例患者作为研究对象,采用随机数字表法分为对照组和实验组,每组30例。对照组采用盲穿法锁骨下静脉置入中心静脉导管(CVC)术,实验组采用超声引导下的9号头皮针经颈内静脉置入隧道式PICC术,比较2组一针穿刺成功率、操作痛发生情况、置管时间、非计划拔管发生率和相关并发症发生率。结果实验组的一针穿刺成功率高于对照组,操作痛评分和非计划拔管发生率低于对照组,置管时间长于对照组,差异有统计学意义(P0.05); 2组渗血程度比较,差异无统计学意义(P0.05);实验组导管相关性感染、导管移位和导管堵塞发生率均低于对照组,差异有统计学意义(P0.05)。结论采用9号头皮针经颈内静脉穿刺置入隧道式PICC,能够降低导管相关感染发生率,延长导管留置时间,为双上肢PICC置管受限的患者提供了一种安全、经济、有效的静脉通路。     

血液透析颈内静脉置管并发感染的预防

目的 预防血液透析颈内静脉置管并发感染，延长颈内静脉导管留置的时间。方法 加强颈内静脉置管患者的置管后护理，严格执行无菌操作，并采取有效的干预措施，预防穿刺口和皮下隧道感染的发生。结果 留置时间最短21天，最长1例置管347天（中途换管1次，拔管后选择另一侧颈内静脉再次置管）。局部及皮下隧道感染率情况：留置时间〈20天为4例（2．82％），20—30天14例（9．86％），30—150天18例（12．68％），留置时间在150—347天血培养阳性者5例（3．52％）。结论 加强颈内静脉留置双腔导管的护理，可以延长颈内静脉留置的时间，缩短住院天数，减轻患者的痛苦和经济负担。     

血液透析患者中心静脉留置导管感染原因分析及护理

目的:探讨血液透析患者中心静脉留置导管的感染原因及护理方法.方法:回顾性分析84例血液透析患者的临床资料,分析置管途径及封管方式对感染的影响.结果:颈内静脉置管组感染情况优于股静脉置管组(P<0.05);抗生素肝素组感染情况优于单纯肝素组(P<0.05).结论:中心静脉通路应首选颈内静脉,封管方式优选浓肝素联合抗生素方式,可有效降低感染率.     

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.     

中心静脉置管在血液透析中的应用

目的 :对比临时性中心静脉置管和永久性中心静脉置管在血透通路中的留置优缺点和使用适应症。方法 :采用Seldinger技术和撕脱型扩张导管技术留置临时性中心静脉置管 74例 ,永久性中心静脉置管 5例。结果 :两种置管方式均能获得满意的血流量。临时性股静脉置管平均留置时间 2 8d ,最长 62d。临时性颈内静脉置管平均留置时间 4月 ,最长 2 4 2d。永久性颈内静脉置管留置时间均超过 6个月 ,最长 3 5 9d。临时性中心静脉置管的并发症较多 ,主要有感染 ,血流不畅 ,出血及局部血肿 ,导管内血栓形成。结论 :临时性中心静脉置管适用于危重病人和等待内瘘者 ;永久性中心静脉置管适用于各种原因无法建立内瘘及无条件腹膜透析的长期血透者。     

右侧颈内静脉带cuff隧道导管误入奇静脉1例

正导管异位是中心静脉置管的重要并发症之一,血液透析用经颈内静脉置管时导管可异位至腋静脉、锁骨下静脉,但导管异位奇静脉较少见。现将解放军火箭军总医院2016年6月收治1例尿毒症患者,经右侧颈内静脉置入带cuff隧道导管,误入奇静脉报道如下。1病例资料患者男性,84岁。因"发现泡沫尿7年余,双下肢水肿1月余"入院。患者7年余前无明显诱因出现泡沫尿,化验血肌酐(serum creatinine,Scr)143.8μmol/     

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.     

左颈内静脉置管误穿纵隔的处理及分析一例

中心静脉置管技术在临床上应用广泛,其置管相关并发症也不容忽视。该例维持性血液透析患者在彩色多普勒超声引导下行左侧颈内静脉留置长期透析导管术时出现抵抗感,置管完成后回抽导管动静脉端回血不畅,术后行胸部CT及数字减影血管造影检查发现导管末端进入中纵隔内,未伤及纵隔内血管,予以20 d后导管末端血肿机化后拔除留置导管。该例提示左颈内静脉置管误穿中纵隔可致一些严重甚至致命的并发症,熟悉相关解剖结构、提高置管技术、及时行相关医技检查及治疗是防治并发症的关键。     

Comparison of central venous catheterization sites in infants

This study aimed to compare the rates of success and complications between different sites of central venous catheterization in infants. A total of 272 infants were randomized to four groups: right subclavian group (G-RSCV), right internal jugular group (G-RIJV), left subclavian group (G-LSCV) and left internal jugular vein group (G-LIJV). In 77.2% of the patients, we successfully introduced a catheter at the first attempt. The rate of successful catheter placement was highest in the and LSCV 55.9%). With regard to complications, the rate of arterial puncture, guide wire advancement failure and malpositioning of the catheter were all significantly more frequent during SCV catheterization (SCV versus IJV: 10.1% versus 2.1%, 12.4% versus 0% and 13.4% versus 0.6%, respectively). Our results imply that IJV, especially RIJV, should be the first choice for central venous catheterization in infants.     

Retrieval of fractured dialysis catheter through phlebotomy of internal jugular vein: a case report

A central venous catheter is the most common access for initiating hemodialysis. Prolonged access through a central venous catheter increases the risk of infection and dysfunction of the catheter with potential development of catheter-induced thrombosis and embolism. However, fracture and dislodgement of the catheter with subsequent embolization is an unexpected complication. Endovascular treatment is a promising method to remove intravascular foreign bodies. We herein report a case of a 58-year-old woman undergoing prolonged hemodialysis who required central venous catheter removal because of mechanical fracture of the tunneled cuffed catheter and its migration in the internal jugular vein. An urgent chest X-ray showed that the two free ends of the fractured tunneled cuffed catheter were located in the right atrium and right internal jugular vein. Phlebotomy of the internal jugular vein was successfully performed to retrieve the fractured tunneled cuffed catheter and the associated thrombi. In this case, phlebotomy for retrieval of the embolized catheter fragment extending into the right atrium was a safe alternative to an endovascular technique of catheter fragment retrieval. Phlebotomy preserved the integrity of the catheter fragment and its associated thrombus and was both cost-effective and safe.     

Comparison of internal and external jugular cannulation of the central circulation in the pediatric patient

Percutaneous catheterization of the central circulation via the internal jugular vein was compared to cannulation via the external jugular vein, in a retrospective review of 200 pediatric patients. The internal approach resulted in an 86% rate of successful cannulations with 99.9% of the catheters positioned in the thorax; this technique was accompanied by an 8% incidence of carotid artery puncture. The external jugular route eliminated the risk of carotid artery puncture; however, it was successful in only 65% of the attempts, and 14% of the successful cannulations had catheter tips incorrectly positioned outside the thorax.     

桥式固定法对于提高PICC导管护理效果的评价

目的 探讨桥式固定法在经外周静脉穿刺置入中心静脉导管(PICC)维护中的应用效果。 方法 将70例行PICC置管的患者随机分为对照组和实验组,每组35例,2组均采用相同的中心静脉置管换药包,并按照标准的PICC导管维护流程进行维护。对照组导管按传统方法固定,实验组按照桥式固定法固定导管。比较2组导管部位压疮、导管折叠发生率和患者的舒适感。 结果实验组导管处压疮、导管折叠发生率低于对照组(χ²=11.667,P=0.001;χ²=12.992,P<0.001),患者的舒适感高于对照组(χ²=17.014,P<0.001)。 结论 在行PICC导管固定时,桥式固定法优于传统导管固定的方法,值得临床推广应用。     

心内心电图下三种路径置入中心静脉导管的应用研究

目的探讨在心内心电图（IVECG）辅助下置入中心静脉导管的可行性。方法选择拟在全麻下行择期手术需放置中心静脉导管的成年患者150例,随机分为A、B、C3组,每组50例,分别采用右侧颌内静脉、右侧锁骨上路锁骨下静脉、右侧锁骨下路锁骨下静脉插管术。3组均应用IVECG监测技术,分别记录P波最高振幅时的置管深度（Lmax）、实际置管深度（Lact）、按Peres公式计算的置管深度（Lpre）、Lmax—Lact值及Lpre—Lmax值。术后摄X线前后位胸片判断导管到位情况,以Lpre—Lmax／〉0．5cm视为导管过深而异位于右心房。结果3组共穿刺成功146例,4例穿刺失败,其中A、B组各1例,C组2例。146例Lmax—Lact及Lpre—Lact平均值分别为（2．4±0．3）cm和（2．1±0．8）cm。Lpre—Lmax≥0．5cm者22例,占15．07%,其中A、B、C组分别为7、8、7例。术后X线胸片提示,出现P波典型变化者导管尖端均位于上腔静脉,Lpre—Lmax≥0．5cm占导管均位于右心房内,IVECG与X线胸片检查导管位置的吻合率为100％。结论IVECG辅助下置入中心静脉导管操作简单,无放射性污染,可替代传统X线检查来确认导管的位置。     

Left ventricular lead insertion using a modified transseptal catheterization technique: A totally endocardial approach for permanent biventricular pacing in end-stage heart failure

This article describes a new technique of LV lead insertion, using transseptal catheterization performed through the right internal jugular vein, to obtain a totally endocardial biventricular chronic pacing in end-stage heart failure. Three patients with QRS widening (> 180 ms) linked to complete left bundle branch block (n = 2) or right ventricular pacing (n = 1) were included in this preliminary study. Catheterization was performed under fluoroscopy and transesophageal echocardiography guidance. Transseptal catheterization was achieved by puncture of the right internal jugular vein at the base of the neck and by using a Brockenbrough needle, the tip curve of which was more curved than the standard model. A flexible long sheath was advanced in the left atrium through the interatrial septum and then a unipolar electrode was placed easily in the LV. The proximal tip of the LV lead was tunneled from the neck to the subclavian area and connected to the ventricular channel of a dual (n = 1) or simple (n = 2) chamber pacemaker. Efficient acute sensing (V wave amplitude = 13 +/- 3 m V) and pacing (acute pacing threshold = 0. 7 +/- 0.4 V) were obtained in the three patients. Early loss of capture occurred in two patients requiring lead replacement. Functional status dramatically improved in all three patients. At 6-month follow-up, biventricular pacing was maintained in all patients (mean threshold 1.4 V) who were free of clinical embolic event with oral anticoagulation therapy. This modified technique of jugular transseptal catheterization appears promising for the development of left heart pacing.     

Unidirectional 8-MHz continuous wave Doppler equipment can facilitate catheterization of the internal jugular vein

In a prospective study, 8-MHz unidirectional, continuous wave Doppler equipment was shown to improve the success rate of internal jugular vein catheterization. In the first series of 100 patients, punctures were randomly divided into two groups, via the anterior or posterior route, representing the standard technique. The second series of 50 patients underwent punctures guided by the Doppler technique. The Doppler route was successful in 48 test punctures with 47 catheter placements. Via the anterior route, 14 of 50 test punctures were positive, with 11 catheter placements; for the posterior route, test punctures were positive in 25 of 50 cases, with 18 catheter placements. With the Doppler technique, it should be possible to increase the rate of successful catheterization of the internal jugular vein while reducing complications.     

经皮下隧道静脉置管与直接静脉置管对导管留置时间的影响

目的 观察经皮下隧道静脉置管与直接静脉置管对导管留置时间的影响.方法 将60例危重病病人随机分为试验组（30例）和对照组（30例）,试验组采取经皮下隧道右贵要静脉穿刺置管,对照组采取直接右贵要静脉穿刺置管,观察导管性感染和导管留置时间.结果 试验组的导管留置时间比对照组明显延长,具有显著性差异.试验组在穿刺处局部感染率、导管尖端培养和血培养阳性率以及感染相对危险性等方面均比对照组低,有显著性差异（均为P＜0.05）.结论 经皮下隧道贵要静脉置管能有效地防止导管性感染,延长导管留置时间,值得推广.     

约束板下送管在PICC置管患者中的应用

目的探讨约束板下送管在PICC置管患者中的应用效果。方法选取2018年3月至2019年3月收治的行PICC置管患者160例,随机将其等分为研究组和对照组,对照组患者在常规护理下PICC置管送管,研究组患者在PICC置管约束板下送管,比较两组患者导管异位率、首次置管成功率和舒适度评分。结果研究组患者导管异位入颈内静脉发生率低于对照组(P<0.05),首次置管成功率高于对照组(P<0.05),置管过程舒适度评分高于对照组(P<0.05)。结论PICC置管在约束板辅助下送管,可有效避免导管异位入颈内静脉,提高置管过程中的舒适度,值得临床推广应用。