中心静脉导管相关性感染的预防

随着医学的发展，中心静脉置管已成为临床治疗不可缺少的部分，为液体、血液制品、营养物质、药物的输入、血流动力学监测，采血及急救通道的维持提供了可靠途径，但它往往也是导致感染的重要原因。据报道，导管相关性感染率是1％-10％，导管相关性感染（cather-ralated infections，CRI）使平均住院时间延长7d，病死率也提高10％-20％，CRI已成为医院内最常见的感染之一。因此，应引起临床的高度重视。     

中心静脉导管不良事件120例临床分析及护理对策

目的探讨中心静脉导管在临床中的正确使用、风险评估、适应性以及预防不良反应的对策。方法总结中心静脉导管不良反应的患者120例的病例资料。结果一半病例为局部皮肤过敏并感染、导管堵塞、导管以及组件断裂变形,其他原因造成的置管不成功等,严重病例主要表现为置管段静脉血栓形成。结论深静脉导管使用风险大部分是可用护理措施预防的。     

锁骨下静脉穿刺置入中心静脉导管临床观察

目的探讨锁骨下静脉穿刺置入中心静脉导管的临床应用前景。方法病人取去枕平卧位，穿刺点为锁骨中点下缘下方1cm处，方向指向胸锁乳突头肌与锁骨形成的夹角平分线上，穿刺针刺入约3～4cm后回抽见血，导入导丝、最后导入导管。结果共行60例次，57例次成功，3例次失败，所有病例无严重并发症。结论锁骨下静脉穿刺置入中心静脉导管，具有穿刺成功率高、并发症少、安全有效易于掌握推广等优点。     

经皮胸腔置入中心静脉导管治疗气胸临床疗效分析

目的探讨经皮穿刺胸腔置入中心静脉导管持续引流替代反复多次胸腔穿刺抽气治疗各种病因所致的自发性气胸临床疗效和安全性。方法对我院2004年1月-2008年12月收治的各种病因的气胸病例中经胸部X线检查确诊为气胸的病例28例,随机分成2组（治疗组11例及对照组17例）,分别用中心静脉导管持续胸腔引流和反复多次的胸腔穿刺抽气治疗,对这两种治疗方法的效果、出现并发症情况、住院费用进行比较。结果治疗组11例患者均得到根治性治愈,治愈率达100％,鼹种方法相比：胸膜腔气体吸收时间（3.24±1.76天 vs 10.14±2.72天）,胸膜反应（0％ vs 11.76％）,住院费用（1291.52±716.59元 vs 1736.49±1211.43元）,各项指标对比其差异均有统计学意义（P〈0.05）。结论中心静脉导管胸腔置人治疗气胸简单易行,出血少,创伤小,抽气过程中可随意控制抽气速度,可反复使用,治疗彻底,值得临床推广。     

新型中心静脉导管在维持血液透析中的临床应用

血管通路是维持性血液透析(MHD)患者的生命线,其并发症是血液透析(HD)患者高发病率和死亡率的主要原因之一.理想的血管通路要求能长期保持功能良好且并发症少,从而使患者达到充分透析.     

老年患者中心静脉导管相关性血栓发生情况调查

目的调查老年患者中心静脉导管相关性血栓的发生情况,比较不同置管部位下,导管相关性血栓的发生率,将与血栓发生相关联的各种危险因素进行对比分析。方法选取接受中心静脉置管操作的老年患者405例,根据置管部位不同分为股静脉组46例,颈内静脉组40例,锁骨下静脉组319例。又根据导管相关性血栓的发生情况分为血栓组31例,非血栓组374例。对入选患者的性别、年龄、基础疾病、置管部位、导管留置时间、导管相关性血栓的发生情况等进行回顾性调查分析。结果锁骨下静脉组血栓发生率明显低于颈内静脉组和股静脉组(5.0%vs 15.0%,19.6%,P<0.05,P<0.01)。血栓组既往静脉血栓病史明显高于非血栓组(19.4%vs 6.4%,P<0.05)。结论老年患者通过锁骨下静脉途径进行置管,导管相关性血栓的发生率最低;静脉血栓史对老年患者中心静脉导管相关性血栓的发生同样具有预测作用。     

老年患者留置中心静脉导管的护理

中心静脉导管（Central venous catheters,CVC）指末端位于大中心静脉的任何导管,由于导管开口于上腔静脉,临近右心房,管口周围血流量比末梢静脉大,液体容易输注,避免了刺激性药物及高渗性或粘稠性液体对病人外周血管损害,因而CVC在临床上应用较为广泛,在重症护理中,CVC常用于快速静脉内输入药物和液体,以及监护中心静脉压,更适合于老年危重患者,因为老年患者血管弹性差,     

经外周静脉置入中心静脉导管临床应用新进展

经外周静脉置入中心静脉导管（PICC）是由外周静脉（贵要静脉、肘正中静脉、头静脉）穿刺插管,其尖端定位于上腔静脉的导管,临床上广泛用于需长期静脉输液、化疗、胃肠外营养（PN）、使用刺激外周静脉的药物、缺乏外周静脉通路、家庭病床、早产儿、中心静脉压测量等患者。     

留置单腔中心静脉导管治疗胸腔积液的临床分析

目的观察留置单腔中心静脉导管胸腔治疗胸腔积液的临床疗效。方法回顾分析2006年1月1～2008年3月31日,乌苏市人民医院经中心静脉置管治疗胸腔积液89例患者的临床资料并复习相关文献。结果经该方法治疗的89例患者,胸腔穿刺1次率100%,气胸发生率0%,治愈率57%,好转率34%。结论使用单腔中心静脉置管治疗胸腔积液安全、简便、有效。     

中心静脉导管置入胸腔治疗结核性胸膜炎临床疗效分析

目的探讨中心静脉导管置入胸腔持续引流替代反复多次胸腔穿刺抽液治疗结核性胸膜炎临床应用价值。方法对我院2005年1月～2008年10月收治的结核性胸膜炎病例中经胸部X线和／或胸部超声检查确诊为中或大量胸腔积液的病例87例，随机分成2组（治疗组40例及对照组47例），分别用中心静脉导管持续胸腔引流和反复多次的胸腔穿刺抽液治疗，对这两种治疗方法的效果、出现并发症情况、住院费用进行比较。结果两种方法相比：胸水吸收时间、胸膜反应、胸水包裹发生率、气胸发生率、住院费用、治疗后第三个月的胸膜厚度等各项指标对比其差异均有统计学意义（P〈0．05）。结论中心静脉导管置入胸腔持续胸腔引流治疗结核性胸膜炎方法简单、方便、安全、经济，患者痛苦少、效果好，值得基层医院推广。     

重症监护室老年患者中心静脉导管相关血流感染的危险因素

目的探讨重症监护室（ICU）老年患者导管相关血流感染（CRBSI）的危险因素。方法ICU90例老年住院患者接受中心静脉置管,分为导管相关性血流感染（CRBSI）组和无感染（对照）组。CRBSI组患者为ICU住院的行深静脉置管伴CRBSI的病例（n=45）,而对照组为同期ICU住院的行深静脉置管但无CRBSI的病例（17=45）,采用回顾性和病例对照的研究方法,对两组患者进行风险困素分析。结果两组患者基础疾病构成、年龄、性别、感染前导管留鼍时间、机械通气、完全肠外营养、尿管留置等的差异无统计学意义（P〉0．05）。与对照组比较,CRBSI组使用碳青霉烯类抗生素、操作熟练程度、置管部位、低白蛋白血症、贫血、APACHEII评分差异有统计学意义（P〈0．01、P〈0．05）。使用碳青霉烯类抗生素、操作者、低A蛋白血症、APACHEII评分是CRBSI独立危险因素。结论碳青霉烯类抗生素使用、操作者人员熟练程度、低白蛋A血症及APACHEII评分是ICU老年患者CRBSI的独立危险因素。     

ICU中心静脉导管相关血行感染的病原菌及耐药性分析

目的探讨外科ICU中心静脉导管相关血行感染的细菌定植、感染的发生率、药物敏感性以及相关危险因素。为临床预防和治疗提供依据。方法回顾性分析疑似中心静脉导管感染病例,根据血培养和导管尖端培养结果,观察导管相关感染的发生率和病原菌分布及耐药情况并进行统计分析。结果疑似中心静脉导管感染患者143例中,确诊导管相关性血行感染（CRBSI）31例,发生率为21．7％（31／143）;共分离出病原菌31株：鲍曼不动杆菌8株（25．8％）、真菌6株（19．3％）、铜绿假单胞菌4株（12．9％）、凝固酶阴性葡萄球菌4株（12．9％）。结论鲍曼不动杆菌和真菌是外科ICU中心静脉导管相关血行感染的主要致病菌,医务人员应加强重视并早期监测,并根据药敏结果适时调整抗菌药物。     

Reduction of catheter-related infections in neutropenic patients: a prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter

Antiseptic coating of intravascular catheters may be an effective means of decreasing catheter-related colonization and subsequent infection. The purpose of this study was to assess the efficacy of chlorhexidine and silver sulfadiazine (CH-SS)-impregnated central venous catheters (CVCs) to prevent catheter-related colonization and infection in patients with hematological malignancies who were subjected to intensive chemotherapy and suffered from severe and sustained neutropenia. Proven CVC-related bloodstream infection (BSI) was defined as the isolation of the same species from peripheral blood culture and CVC tip (Maki technique). This randomized, prospective clinical trial was carried out in 106 patients and compared catheter-related colonization and BSI using a CH-SS-impregnated CVC (n=51) to a control arm using a standard uncoated triple-lumen CVC (n=55). Patients were treated for acute leukemia (n=89), non-Hodgkins lymphoma (n=10), and multiple myeloma (n=7). Study groups were balanced regarding to age, sex, underlying diseases, insertion site, and duration of neutropenia. The CVCs were in situ a mean of 14.3±8.2 days (mean±SD) in the study group versus 16.6±9.7 days in the control arm. Catheter-related colonization was observed less frequently in the study group (five vs nine patients; p=0.035). CVC-related BSI were significantly less frequent in the study group (one vs eight patients; p=0.02). In summary, in patients with severe neutropenia, CH-SS-impregnated CVCs yield a significant antibacterial effect resulting in a significantly lower rate of catheter-related colonization as well as CVC-related BSI.     

4种不同体位对机械通气危重症患者中心静脉压的影响

【】目的 分析4种不同体位对机械通气危重症患者中心静脉压(CVP)测量的影响,并探讨平卧位与其他3种体位CVP间的定量关系。方法：采用前瞻性自身对照研究,选取45例机械通气危重症患者作为研究对象,分别测量研究对象平卧位(0°)、30°、45°和60°卧位时的CVP、平均动脉压(MAP)、血氧饱和度(SpO₂)、心率(HR)、呼吸频率(RR)。采用重复测量方差分析和配对t检验比较不同体位CVP间的差异,采用简单回归分析方法探讨平卧位与其他卧位CVP间的定量关系。 结果：①平卧位、30°、45°和60°卧位CVP测量值分别为(10.71 ± 4.85)cmH₂O、(9.64 ± 4.93)cmH₂O、(9.11 ± 4.97)cmH₂O和(8.58 ± 5.06)cmH₂O,两两比较差异均有统计学意义(P<0.05)。②平卧位与30°卧位CVP间相关系数为0.99(P<0.01),线性回归方程为CVP_平卧=0.98*CVP_30°卧位 1.31;平卧位与45°卧位CVP间相关系数为0.99(P<0.01),线性回归方程为CVP_平卧=0.96*CVP_45°卧位 1.94;平卧位与60°卧位CVP间相关系数为0.98(P<0.01),线性回归方程为CVP_平卧=0.94*CVP_60°卧位 2.63。 结论：机械通气危重症患者测量体位角度越高,CVP值越低;平卧位与其他卧位间的CVP存在线性定量关系。     

Upper body peripherally inserted central catheter in pediatric single ventricle patients

BACKGROUND There is risk of stenosis and thrombosis of the superior vena cava after upper extremity central catheter replacement. This complication is more serious among patients with single ventricle physiology, as it might preclude them from undergoing further life-sustaining palliative surgery.AIM To describe complications associated with the use of upper extremity percutaneous intravenous central catheters(PICCs) in children with single ventricle physiology.METHODS A single institution retrospective review of univentricular patients who underwent superior cavopulmonary anastomoses as their stage 2 palliation procedure from January 2014 until December 2018 and had upper body PICCs placed at any point prior to this procedure. Clinical data including ultrasonography, cardiac catheterization, echocardiogram reports and patient notes were used to determine the presence of thrombus or stenosis of the upper extremity and cervical vessels. Data regarding the presence and duration of upper extremity PICCs and upper extremity central venous catheter(CVC), and use of anticoagulation were recorded.RESULTS Seventy-six patients underwent superior cavopulmonary anastomoses, of which 56(73%) had an upper extremity PICC at some point prior to this procedure. Median duration of PICC usage was 24 d(25%, 75%: 12, 39). Seventeen patients(30%) with PICCs also had internal jugular or subclavian central venous catheters(CVCs) in place at some point prior to their superior cavopulmonary anastomoses, median duration 10 d(25%, 75%: 8, 14). Thrombus was detected in association with 2 of the 56 PICCs(4%) and 3 of the 17 CVCs(18%). All five patients were placed on therapeutic dose of low molecular weight heparin at the time of thrombus detection and subsequent cardiac catheterization demonstrated resolution in three of the five patients. No patients developed clinically significant venous stenosis.CONCLUSION Use of upper extremity PICCs in patients with single ventricle physiology prior to super cavopulmonary anastomosis is associated with a low rate of catheterassociated thrombosis.     

Analysis of risk factors for central venous port failure in cancer patients

AIM： To analyze the risk factors for central port failure in cancer patients administered chemotherapy, using univariate and multivariate analyses. METHODS： A total of 1348 totally implantable venous access devices （TIVADs） were implanted into 1280 cancer patients in this cohort study. A Cox proportional hazard model was applied to analyze risk factors for failure of TIVADs. Log-rank test was used to compare actuarial survival rates. Infection, thrombosis, and surgical complication rates （Χ^2 test or Fisher＇s exact test） were compared in relation to the risk factors. RESULTS： Increasing age, male gender and open- ended catheter use were significant risk factors reducing survival of TIVADs as determined by univariate and multivariate analyses. Hematogenous malignancy decreased the survival time of TIVADs; this reduction was not statistically significant by univariate analysis [hazard ratio （HR） = 1.336, 95% CI： 0.966-1.849, P = 0.080）]. However, it became a significant risk factor by multivariate analysis （HR = 1.499, 95% CI： 1.079-2.083, P = 0.016） when correlated with variables of age, sex and catheter type. Close-ended （Groshong） catheters had a lower thrombosis rate than open-ended catheters （2.5% vs 5%, P = 0.015）. Hematogenous malignancy had higher infection rates than solid malignancy （10.5% vs 2.5%, P 〈 0.001）.CONCLUSION： Increasing age, male gender, open- ended catheters and hematogenous malignancy were risk factors for TIVAD failure. Close-ended catheters had lower thrombosis rates and hematogenous malig- nancy had higher infection rates.     

中心静脉置管与深静脉血栓的关系

目前深静脉置管被广泛应用于临床,主要由于它具有方便、操作简单、减少患者因反复穿刺引起静脉炎,并且拔管后静脉仍可复通等优点,为患者抢救、治疗开通了快速输液通道,并可监测中心静脉压.但是该操作也存在一些潜在的危险,如感染、导管阻塞及血栓形成等并发症,严重栓塞者甚至会危及生命.目前在深静脉血栓形成之前是否需要使用抗凝剂预防、血栓形成后抗凝药的规范使用以及手术时机的选择等方面还没有定论.本文主要针对中心静脉置管相关性血栓的原因、临床表现及防治进行分析,寻找与血栓形成最相关的因素,进而能够更好地预防深静脉血栓的形成.     

中心静脉氧饱和度的监测及其应用

通过中心静脉导管监测中心静脉氧饱和度(ScVO2)是一个方便、可靠的方法,它能快速反映危重患者全身氧的供需平衡的瞬时变化,能早期发现组织缺氧,且优于其它传统的血流动力学参数,是评估组织氧合充分与否的有用的间接指标,也是评估危重患者院内病死率及预后的重要指标;用ScVO2、平均动脉压和中心静脉压来指导早期目标指导性治疗,可提高严重脓毒血症或感染性休克患者的存活率.因此,ScVO2的监测对危重患者的评估和管理是非常重要和有用的.     

Factor V leiden mutation does not account for central venous catheter-related thrombosis

Indwelling central venous access devices are frequently associated with catheter-related thrombosis. The factor V Leiden gene mutation decreases the sensitivity of factor V to the anticoagulant activity of activated protein C, and has been shown to be the most common inherited defect associated with a hypercoagulable state. In this study, we sought to determine whether an increased prevalence of the factor V gene mutation could be identified in individuals with malignancies who had catheter-related thrombosis. Twenty-seven patients who had catheter-related thrombosis were identified and two (7%) tested positive for the heterozygous presence of the factor V gene mutation. Since the vast majority of patients with venous access devices who developed catheter-related thrombosis did not have the factor V gene mutation, pre-catheter placement testing for this mutation would have limited clinical utility. Am. J. Hematol. 58:150–152, 1998. © 1998 Wiley-Liss, Inc.