成人全麻患者麻醉前评估临床实践指南分析

目的对成人全麻且无合并症患者的相关麻醉前评估指南进行内容分析,为构建我国麻醉前评估临床实践内容提供参考。方法检索国内外文献数据库、指南数据库及协会网站,按照纳入和排除标准筛选指南;采用内容分析法,对纳入指南进行文献内容分析。结果共纳入5份临床实践指南,均为国外发表。析出既往史和现病史、体格检查、实验室检查3个主题共39项内容。我国暂无针对无合并症全麻患者的指南。指南中推荐对患者进行实验室检查是应根据病史及临床症状进行。结论我国可依据国外指南推荐内容,结合我国国情加强临床实践规范,并构建适合本国成人全麻无合并症患者临床实践方案。     

循证指南与循证临床实践

循证医学（Evidence Based Medicine,EBM）是一种新兴的医学模式,是全新的临床实践思想。目前循证医学的观点在医学研究中的应用日益广泛和深入。循证思想强调任何医疗卫生的决策都应遵循和应用科学证据。这一新模式对医疗实践、政府医疗卫生决策等都有着重要指导和参考价值。随着循证医学的进展及当前医疗实践面临的种种实际问题,按照循证医学证据制定治疗方案的理念越来越受到临床医生的重视。[第一段]     

基于关键知情人访谈与参与式观察的PICC置管前评估现况调查

目的了解上海市PICC置管前评估的开展现状及存在问题,为构建PICC置管前评估的临床实践指南提供现实依据。方法采用现象学研究法对19位PICC专业护士、1位某品牌PICC导管公司临床专员、2位临床医生进行关键知情人访谈,并对3所医院的PICC置管前评估实施过程进行参与式观察。结果22位访谈对象肯定了PICC置管前评估的重要意义,评估内容包括患者诊断与治疗、静脉条件等多个方面,同时存在评估不全、第一评估人非穿刺者时或产生隐患、尚无评估表等问题。结论PICC置管前评估可提高置管成功率、降低并发症发生率、帮助建立静脉输液决策,但需进一步改进以完善其临床应用。     

肾脏病临床实践指南多维度教学的探索

肾脏病临床实践指南对规范肾脏病的治疗、提高临床实践的同质性和改善预后起到重要作用。目前发布的肾脏病相关指南有300余项。肾脏病临床实践指南的特点包括：发布单位多,部分内容重复;亚专科分类细,交叉学科多;学科发展快,指南内容更新快慢不一。临床教学实践中针对实习医生、规范化培训轮转住院医生,进修医生及临床医学硕士专业学位研究生,设计多层次递进式教学模式,有助于强化循证医学理念,培养主动循证意识,规范医疗行为。     

中国肝癌肝移植临床实践指南

据统计中国每年超过30万人死于肝细胞肝癌（以下简称肝癌）,占全球肝癌死亡人数的一半左右。而肝移植是被全世界认可的治疗终末期肝病最有效的手段之一。我国自20世纪90年代掀起第二次肝移植热潮以来,肝移植事业发展迅猛,呈专业化和规模化发展态势,在移植数量和质量方面已接近或达到西方发达国家水平。     

国外疼痛评估循证护理实践指南解读

从疼痛筛查、全面疼痛评估、疼痛的动态评估和再评估、评估患者及家属有关疼痛管理的知识及理念、选择患者适合的科学疼痛评估工具及疼痛评估的记录6个环节,解读国外3项疼痛评估循证护理实践指南的环节和内容,思考其对我国开展疼痛评估循证护理的启示,旨在为我国开展优质的疼痛评估循证护理提供参考。     

NCCN2013食管癌临床实践指南解读

美国国家癌症综合网络（NationalComprehensiveCancerNetwork,NCCN）是由美国2l家顶尖肿瘤中心组成的非盈利性学术组织,汇集了肿瘤防治领域相关的内科、外科、放射、生物、流行病、营养等临床专家,每年发布各种恶性肿瘤临床实践指南（clinicalpracticeguidelines）,注意利用循证医学证据达成广泛共识,因而得到了全球临床医师的认可与遵循。     

基于AGREEⅡ的成人癌症营养实践指南质量评价

目的对国内外近5年成人癌症营养实践指南进行质量评价,分析近年来癌症营养领域实践指南现状,并甄别出高质量指南供我国临床医护人员参考。方法系统检索数据库、指南网站和专业学会网站近5年成人癌症营养实践指南,采用AGREEⅡ对符合纳入、排除标准的指南进行质量评价。结果纳入成人癌症营养指南共20篇,A级推荐2篇,B级推荐11篇,C级推荐7篇;20篇指南在AGREEⅡ6大领域的平均标准化得分分别为清晰性85.09%、范围和目的77.13%、严谨性52.64%、参与人员41.11%、独立性29.44%、应用性21.46%。结论近5年的成人癌症营养指南的总体方法学质量一般,高质量指南均为国外指南,我国的癌症营养指南质量有待进一步提高。     

乳腺癌相关淋巴水肿评估与管理指南的质量评价与内容分析

目的 对乳腺癌相关淋巴水肿评估与管理的相关指南进行质量评价和内容分析,为我国本土化乳腺癌相关淋巴水肿评估与管理指南的制定提供参考.方法 计算机检索国内外指南网站、相关专业协会网站及中英文数据库,搜集乳腺癌相关淋巴水肿评估与管理相关指南.采用AGREE Ⅱ评价纳入指南的质量,并对各指南推荐意见进行汇总分析.结果 最终纳入...     

循证护理在PICC置管肺癌患者中的应用

目的:探讨PICC在肺癌化疗患者置管后常见并发症的护理.方法:运用循证护理原理对61例PICC置管后的患者进行护理.结果:经过循证护理,减少了PICC置管期间并发症的发生,延长了PICC的留置时间.结论:将与临床经验相结合,循证护理可提高肺癌化疗PICC置管的护理质量.     

Detection of peripherally inserted central catheter occlusion by in-line pressure monitoring

BACKGROUND: Peripherally inserted central catheters (PICC) are being increasingly used in neonatal practice. Their use is not without technical difficulty. This report describes the use of continuous pressure monitoring to detect catheter occlusion in critically ill neonates. METHODS: In-line venous pressure of the PICC line was monitored by pressure transducer in neonates; 28-gauge 20 cm PICC or 29-gauge 25 cm PICC were used. RESULTS: In-line pressure of the PICC was monitored 64 times in 50 neonates. Increases in the in-line pressure were observed when the catheter tip was against the vessel wall and the catheter was obstructed partially or completely. Decreases were observed when the infusion syringe was changed and when an inappropriate infusion rate was set. Two infants experienced marked variations of blood pressure due to intermittent catheter occlusion of the tip against the vessel wall. These infants were receiving dopamine via a PICC line. CONCLUSIONS: In critically ill infants, in-line pressure monitoring of the PICC is helpful in detecting the occlusion of the catheter.     

经外周置入中心静脉导管改良固定方法的固定效果观察

目的:探讨经外周置入中心静脉导管固定方法改良后的固定效果.方法:选取51例应用经外周置入中心静脉导管的患者作为观察组,导管采用改良的“C”型固定方法,同时选50例采用传统“S”型固定方法固定经外周置入中心静脉导管的患者作为对照组,比较两种固定方法的固定效果.结果:观察组与对照组患者在堵管、脱管、导管断裂、移位、置管处感染、导管压迫皮肤等方面比较差异显著(P＜0.05).结论:经外周置入中心静脉导管采用“C”型改良固定方法固定效果良好,可避免导管断裂、移位、脱管、堵管现象,减少了置管处感染,值得临床推广.     

Blind placements of peripherally inserted antecubital central catheters: initial catheter tip position in relation to carina

Background. We investigated how often blind placement of peripherallyinserted central catheters (PICCs) through the antecubital veinsresults in a correct tip location in relation to carina andevaluated the inter-observer agreement in locating the tip ofPICCs in plain radiography with digital imaging. Methods. In this study, 202 suitable chest radiographs withPICCs out of 803 patients were identified. An initial auditon the tip of these catheters in relation to carina was doneby a consultant anaesthetist and was recorded as the first observer.The same sets of CXRs were examined by a consultant radiologistand the tips were identified and recorded as the second observer.Inter-observer agreement was assessed. Results. In 75 of 202 (37%), PICCs had a central tip locationin relation to the carina. Fifty-five of 131 (42%) right-sidedcatheters had a central location compared with 20 of 71 (28%)of the left-sided catheters. The tip position for right-sidedcatheters was most frequently centrally located whereas thetip for left-sided catheters was most commonly positioned inthe ipsilateral innominate vein. There was excellent agreementbetween the observers in reporting the tip of PICCs at all positions(kappa=0.87) including central locations (kappa=0.83). Conclusions. Right antecubital PICCs are more likely to be placedin the central location in relation to the carina. PICCs insertedthrough the left antecubital veins need to be pushed furtherdown to aim for a central location. Inter-observer variabilityin identifying the tip of PICCs is least with the introductionof digital imaging.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

肿瘤患者PICC导管相关性血栓形成的相关因素分析

目的探讨肿瘤患者PICC导管相关性血栓形成的相关因素。方法对1 030例PICC带管肿瘤患者进行上肢静脉超声检查并分析临床资料。结果 PICC带管肿瘤患者PICC导管相关性血栓发生率为5.44%;其中无症状血栓占76.79%,有症状血栓占23.21%。肠外营养的使用、导管相关并发症、高血压、带管时间、年龄60岁5个因素对血栓的发生有显著影响(P0.05,P0.01)。结论 PICC导管相关性血栓临床表现多数无症状,PICC导管相关性血栓形成的风险因素较多,需针对风险因素进行预警管理干预,以降低其发生率。     

经外周静脉置入中心静脉导管后相关性深静脉血栓形成研究进展

系统研究关于经外周静脉置入中心静脉导管相关深静脉血栓(peripherally inserted central catheter-related deep vein thrombosis,PICC-DVT)的文献,对其危险因素、临床体征、诊断、治疗、预防加以总结。PICC-DVT的形成受患者、导管、操作者相关危险因素的影响。超声检查是其诊断的最常用的方法,静脉造影是对超声不能确诊的补充。低分子量肝素作为其治疗方法至少需要使用3个月。但目前关于PICC-DVT的预防仍不成熟,需待完善。总结后发现PICC-DVT在临床上是常见的,现有的研究可以为其诊断、治疗、预防提供指导。     

Sequential inferior vena cava filter insertion and peripherally inserted central catheter placement through upper extremity veins

PurposeTo report the sequential placement of inferior vena cava filter (IVCF) and peripherally inserted central catheter (PICC) using the same upper extremity venous access.Material and methodsThis is a retrospective study that reviewed the medical records of 379 consecutive patients who underwent IVCF insertion during a 39-month period at our center. Of these 379 patients, 28 patients had sequential insertion of an IVCF and a PICC through the same upper extremity venous access. The same vein entry site was used for placement of the IVCF followed by PICC insertion. Data collected included: indication and duration of IVCF and PICC placement, access site location, complications, and the type of IVCF.ResultsIVCFs were placed for prophylactic purposes in 15 patients (53.6%) and therapeutic purposes in 13 patients (46.4%). Right upper extremity veins were used for venous access in 27 patients (96.4%): brachial (n = 16), basilic (n = 9), and cephalic (n = 2). The left basilic vein was used in one patient (3.6%). IVCFs were temporary in 20 patients (71.4%) and permanent in 8 patients (28.6%). There were no procedural complications. The OptEase filter was used in 23 patients (82.1%) and the TrapEase filter was used in 5 patients (17.9%).ConclusionSimultaneous IVCF and PICC insertion using the same upper extremity venous access was feasible and safe in our series. This combined technique provides the patient with central venous access for repeated blood collections and intravenous therapy.     

持续改进护理在预防恶性肿瘤患者化疗期间外周置入中心静脉导管感染的效果观察

目的观察持续改进护理在预防恶性肿瘤患者化疗期间外周置入中心静脉导管（PICC）感染的疗效。方法采用回顾性对照研究,选择2012年1月至2012年12月123例PICC置管化疗的恶性肿瘤患者作为对照组,选取2013年1月至2013年12月129例PICC置管化疗的恶性肿瘤患者为观察组,比较持续改进护理前后护理人员PICC相关知识及处理能力改进情况,同时比较两组患者PICC置管期间感染发生率。结果持续改进护理实施后,本院肿瘤科护士PICC理论知识及感染处理能力均有显著提高,实施后与实施前比较差异具有统计学意义（P均〈0．05）。对照组PICC感染发生率为13．82％,观察组PICC感染发牛率为3．83％,两组比较差异具有统计学意义（x^2=4．100,P〈0．05）。结论应用持续改进护理循环管理模式,有利于减少和消除护理不当导致的PICC相关感染,具有较好的防控作用,为恶性肿瘤患者化疗的顺利完成创造了必要的条件。     

PICC置管患者导管断裂的护理干预

目的探讨PICC置管患者导管断裂的处理方法及护理措施。方法对10例导管体外部分断裂患者采取修复导管,对1例导管断裂体内患者经静脉切开术取出断端导管。结果 10例导管体外部分断裂患者通过导管修复后继续使用,未出现导管修复后相关性并发症,患者均按计划完成全部化疗疗程后顺利拔除PICC。1例经静脉切开术取出断端导管患者,术后血管恢复良好,术后第12天复诊行切口拆线,伤口愈合良好,未出现出血、感染等并发症。结论及时发现、正确处理断裂导管,同时增强护理人员防范意识,正确维护导管,规范操作,加强患者健康教育,可减少和预防PICC断裂并发症的发生。     

Extravasation of hyperalimentation into the liver parenchyma from a peripherally inserted central catheter

A neonate receiving hyperalimentation through a peripherally inserted central catheter (PICC) had acute abdominal distension and respiratory distress. She was found to have extravasated a 9-cm x 9-cm pocket of hyperalimentation into the liver parenchyma, most likely caused by arterial placement of the PICC. She had severe anasarca and markedly decreased synthetic liver function. After 3 weeks of intensive care, she began to diurese. Her respiratory status subsequently improved, she started feeding, and her liver function test results returned to normal. This case shows the remarkable regenerative capacity of the neonatal liver and provides a rationale for conservative management of this rare but morbid PICC complication.