恶性肿瘤中心静脉置管并发血栓22例分析

目的:探讨中心静脉置管肿瘤患者发生血栓的原因及治疗对策.方法:对2003年-2006年808例中心静脉置管的恶性肿瘤患者发生深静脉血栓的病例进行回顾性分析.结果:22例发生深静脉血栓,4例腋静脉,18例股静脉.结论:术后及下肢静脉置管的肿瘤患者易发生血栓.贵要和锁骨下静脉穿刺置管可减少血栓发生.     

中心静脉置管致深静脉血栓形成的危险因素及护理对策

总结了妇科肿瘤患者行中心静脉置管的临床资料,进行危险因素评估,制定有效的护理措施。置管前进行健康宣教,熟练掌握穿刺技术,置管期间规范化护理和管理,321例置管患者中发生深静脉血栓3例,经扩容、抗凝、溶栓和抗炎等治疗,各项检查指标均恢复正常,血栓基本溶解,血栓部位血管血运正常,无1例发生肺、脑栓塞等严重并发症。     

中心静脉置管致深静脉血栓形成的危险因素及护理对策

总结了妇科肿瘤患者行中心静脉置管的临床资料,进行危险因素评估,制定有效的护理措施。置管前进行健康宣教,熟练掌握穿刺技术,置管期间规范化护理和管理,321例置管患者中发生深静脉血栓3例,经扩容、抗凝、溶栓和抗炎等治疗,各项检查指标均恢复正常,血栓基本溶解,血栓部位血管血运正常,无1例发生肺、脑栓塞等严重并发症。     

口服阿斯匹林预防肿瘤患者深静脉置管相关血栓形成的观察

目的：探讨口服阿斯匹林预防肿瘤患者深静脉置管后静脉炎和血栓的发生情况及观察要点。方法：对口服阿斯匹林的副反应及其疗效进行观察。结果：64例具有高危因素深静脉置管肿瘤患者口服阿斯匹林后发生原穿刺点出血5例，其它部位穿刺点出血8例，静脉炎3例，血栓形成1例。结论：口服小剂量阿斯匹林肠溶片可有效降低肿瘤患者深静脉置管相关血栓形成。     

1例颈内静脉置管致深静脉血栓形成的原因分析及护理

目的 探讨中心静脉置管致深静脉血栓形成的原因及预防血栓形成的措施。方法 对1例颈内静脉置管致深静脉血栓形成的原因进行分析,给予抗凝治疗,监测凝血功能并给予相应的临床护理。结果 经过2周抗凝治疗,血栓消失,无出血及栓塞现象发生。结论 长期卧床的晚期癌症病人常伴凝血及纤溶功能异常,加上中心静脉置管所致的血管内皮完整性损伤及局部炎性反应,是导致深部静脉血栓的主要原因。因此对于中心静脉置管的病人应严格遵守无菌操作规范,密切观察病人的局部及全身变化,可有效地预防和降低中心静脉置管所导致的深部静脉血栓的发生。     

上腔静脉滤器在肿瘤合并上肢深静脉血栓形成中的应用

  目的  探讨应用上腔静脉滤器对肿瘤合并上肢深静脉血栓形成患者预防肺栓塞发生的安全性和有效性。  方法  回顾性分析20例上肢深静脉血栓形成患者资料。20例患者中肺癌6例, 胃癌4例, 乳腺癌2例, 卵巢癌、胰腺癌、鼻咽癌、白血病、恶性淋巴瘤、食管癌、贲门癌、胸腺瘤术后左颈部转移各1例。其中9例患者行PICC(Peripheral inserted central catheter)置管化疗, 2例行锁骨下静脉置管化疗。  结果  全部患者均成功置入上腔静脉滤器, 保留深静脉置管的患者术后成功拔除深静脉导管, 无手术相关并发症发生, 随访6~24个月, 术后无症状性肺栓塞、上腔静脉穿孔、滤器移位及上腔静脉综合征发生。  结论  恶性肿瘤及深静脉置管是上肢深静脉血栓形成最重要的原因, 上腔静脉滤器置入是预防肿瘤合并上肢深静脉血栓形成患者发生肺栓塞的一种安全和有效的措施。      

口服阿斯匹林预防肿瘤患者深静脉置管相关血栓形成的观察

目的探讨口服阿斯匹林预防肿瘤患者深静脉置管后静脉炎和血栓的发生情况及观察要点.方法对口服阿斯匹林的副反应及其疗效进行观察.结果64例具有高危因素深静脉置管肿瘤患者口服阿斯匹林后发生原穿刺点出血5例,其它部位穿刺点出血8例,静脉炎3例,血栓形成1例.结论口服小剂量阿斯匹林肠溶片可有效降低肿瘤患者深静脉置管相关血栓形成.     

动态监测D-二聚体在肿瘤患者导管相关性血栓的临床意义

目的 探讨D-二聚体水平与肿瘤患者导管相关性血栓(Catheter related thrombosis,CRT)发生的相关性。方法 对100例住院的深静脉置管肿瘤患者进行前瞻性研究,动态监测血浆D-二聚体以及静脉多普勒超声检查,观察CRT的发生率、发生时间及血栓类型等。结果 CRT的发生率为12.6%,其中无症状血栓占83.3%。58.3%的血栓发生在置管后2周内,91.7%发生在置管后的置管后4周内。置管后2周血栓组D-二聚体水平显著高于非血栓组(P=0.013)。结论 肿瘤患者CRT大部分形成于深静脉置管后4周内,其中无症状性血栓的比例高,动态监测D-二聚体可能有助于其早期诊断。     

肿瘤患者合并深静脉血栓的临床分析

目的:探讨恶性肿瘤并发血栓性疾病的危险因素,为及早预防提供依据.方法:收集30例恶性肿瘤并发血栓栓塞患者为病例组,并收集同期不伴有血栓栓塞的38例恶性肿瘤患者为对照组,回顾性分析恶性肿瘤并发血栓栓塞的危险因素.结果:病例组30例患者中,下肢深静脉血栓形成者24例,上肢深静脉血栓5例,肺栓塞者1例.观察组红细胞计数和血红蛋白值均低于对照组,血小板计数和D-二聚体高于对照组,差异均有统计学意义(P<0.05).恶性肿瘤并发血栓性疾病的发生在并发感染、接受手术、地塞米松治疗和中心静脉置管上存在差异(P<0.05).30例患者在肿瘤确诊2个月内并发血栓性疾病.结论:恶性肿瘤并发感染、地塞米松的应用、接受手术和中心静脉置管的应用时易并发血栓形成.     

股静脉穿刺置管致下肢深静脉血栓5例

近年来。深静脉留置导管普遍用于肿瘤患者以及老年患者的治疗，因此深静脉留置导管所致并发症的预防应引起重视。股静脉穿刺置管是一种创伤极小的操作，穿刺安全简便，易于掌握，并发症少，为不能进行上肢穿刺的肿瘤患者建立起一个维持时间较长且安全的静脉通道，广泛地应用于肿瘤患者的治疗过程中。我科自2001年1月至2005年10月统一采用德国医疗责任公司生产的MonoV330深静脉留置导管行深静脉置管，所有病例按无菌技术进行管理，采用常规深静脉置管方法，每周换药2～3次，敷料破损、脱落、污染、渗液、渗血、出汗等随时更换。严格掌握深静脉置管适应症，为不宜作颈静脉、锁骨下静脉穿刺者，建立起一个维持时间较长且安全的外周静脉通道，由护理人员独立完成股静脉穿刺置管共计135例，其中有5例出现了下肢明显肿胀，排除癌栓脱落及癌细胞转移，临床诊断为深静脉血栓，现报告如下。     

Therapy Insight: venous-catheter-related thrombosis in cancer patients

Central venous catheters (CVCs) have improved the management of patients with cancer substantially, by facilitating chemotherapy and supportive therapy. The use of CVCs is associated with complications such as infection and upper-limb deep vein thrombosis (UL-DVT). The incidence of clinically overt UL-DVT related to the use of CVCs ranges between 2% and 4%. In the most recent study, the incidence of CVC-related thrombosis, as screened by venography, was approximately 18% in the absence of prophylaxis. In cancer patients with CVC-related UL-DVT, the incidence of clinically overt pulmonary embolism was between 15% and 25%, and the incidence of autopsy-proven pulmonary embolism was up to 50%. Pathogenic factors for CVC-related thrombosis include vessel injury caused by the CVC insertion procedure, venous stasis because of the indwelling CVC, and hypercoagulability associated with cancer. Recent studies have not confirmed a benefit for prophylaxis with antithrombotic agents for CVC-related thrombosis. The recommended treatment for CVC-related thrombosis is based on long-term anticoagulant therapy, with or without catheter removal.     

Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: a prospective comparison of silver-coated and uncoated catheters

BACKGROUND: Catheter-related venous thrombosis is one of the most frequent complications of central venous catheters (CVCs). This complication occurs in 4- 40% of patients with hematologic malignancies receiving conventional chemotherapy after placement of CVCs. METHODS: The objective of this prospective study was to assess whether a silver-coated CVC poses an additional risk in the development of catheter-related thrombosis in hematologic-oncologic patients. Patients were randomized to receive either silver-coated polyurethane catheters (BactiGuard; Metacot, Stockholm, Sweden) or uncoated standard polyurethane catheters (Cavatheter, Fresenius AG, Bad Homburg, Germany) for central venous access. Silver-coated catheters (n = 120) and standard catheters (n = 113) were inserted into the jugular vein in 233 consecutive patients. Variables that may be significant for the development of thrombosis were comparable in the two groups. After removal of the CVC, the patency of both jugularian veins internal as well as external was assessed with real-time ultrasound (Sonolayer-SAL-35A; Toshiba, Tokyo, Japan). RESULTS: Four of 233 patients (1.5%) were found to have venous thrombosis. Incomplete occlusion of the internal jugular vein occurred in 2 patients (0.75%, parietal thrombosis), and complete thrombosis, although clinically silent, was found in 2 patients (0.75%). There was no difference between patients with silver-coated and uncoated CVCs. CONCLUSIONS: The authors concluded that this novel silver-coated CVC does not cause a higher rate of central venous thrombosis compared with standard CVCs. The low overall incidence of central venous thrombosis might be attributed to the routine application of low-dose heparin in our patients during chemotherapeutic treatment.     

Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer.

PURPOSE: In this multicenter, randomized, placebo-controlled clinical trial, we studied whether warfarin 1 mg daily reduces the incidence of symptomatic central venous catheter (CVC) -associated thrombosis in patients with cancer. PATIENTS AND METHODS: Two hundred fifty-five patients with cancer who required a CVC for at least 7 days were randomly assigned to receive warfarin 1 mg or placebo. RESULTS: There were 11 (4.3%) symptomatic CVC-associated thromboses among 255 patients, with no difference in the incidence of symptomatic CVC-associated thrombosis between patients taking warfarin 1 mg daily (six of 130 patients; 4.6%) and patients taking placebo (five of 125 patients; 4.0%; hazard ratio, 1.20; 95% CI, 0.37 to 3.94). Warfarin had no effect on CVC life span (84 days v 63 days in control and warfarin groups, respectively; 95% confidence limit, -16 to 55 days; P = .09), and it did not affect the number of premature CVC removals (23.2% v 25.4% in control and warfarin groups, respectively; 95% confidence limit of difference -8.34 to 12.71; P = .68) or the frequency of major bleeding episodes (2% v 0% in control and warfarin groups, respectively; P = .5, Fisher's exact test). CONCLUSION: Symptomatic CVC-associated thrombosis in patients with cancer, although significant, is less common than previously reported. In this study, the administration of warfarin 1 mg daily did not reduce the incidence of symptomatic CVC-associated thrombosis in patients with cancer. However, the low rate of symptomatic CVC-associated thrombosis means that a much larger trial is required to address this issue definitively.     

Local infusion of urokinase for the lysis of thrombosis associated with permanent central venous catheters in cancer patients

We assessed the efficacy of local fibrinolytic therapy in 35 axillary-subclavian vein thromboses (SVT) that occurred in cancer patients with percutaneous central venous catheters (CVC). These catheters were indwelling for a median of 1 month (range, one day to 10 months) before thrombosis developed. Urokinase was administered at a dose of 500 to 2,000 U/kg/h. Complete lysis occurred in 25 of 30 thrombi that were directly infused, after a median of four days. Complete lysis occurred in one of 12 thrombi that could not be directly infused with urokinase and in two of six with associated phlebitis. Eighty-one percent of the thrombi that were symptomatic for less than 1 week before treatment resolved, compared with 56% present for longer than 1 week. Sixteen patients who had complete (12) or partial (four) thrombolysis did not have their CVCs removed. All four patients with partial thrombolysis had recurrent thrombosis at a median of eight days (range, one to 90). Only two patients who had complete thrombolysis had recurrent thrombosis, at 8 and 16 months. Only minor hemorrhagic toxicity was seen.     

Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients.

PURPOSE: The extent of venous thromboembolism (VTE) associated with central vein catheters (CVC) in cancer patients remains unclear. The aim of this study was to evaluate the efficacy and safety of the low molecular weight heparin, enoxaparin, in the prevention of VTE. PATIENTS AND METHODS: In a multicenter, double-blind study, consecutive cancer patients scheduled for CVC insertion were randomly assigned to receive either subcutaneous enoxaparin 40 mg once a day or placebo. Treatment was started 2 hours before CVC insertion and continued for 6 weeks. The primary end points of the study were deep vein thrombosis (DVT), confirmed by venography of the CVC limb performed 6 weeks after randomization, or clinically overt pulmonary embolism, confirmed by objective testing during the study drug administration. Patients were assessed for bleeding complications. RESULTS: Three hundred eighty-five patients were randomized, of which 321 (83.4%) underwent venography. A venography was adequate for adjudication in 155 patients in each treatment group. A DVT was observed in 22 patients (14.1%) treated with enoxaparin and in 28 patients (18.0%) treated with placebo, corresponding to a relative risk of 0.78 (95% CI, 0.47 to 1.31). No major bleeding occurred. Five patients (2.6%) in the enoxaparin group and two patients (1.0%) in the placebo group died during the treatment period. CONCLUSION: In this study, no difference in the rate of CVC-related VTE was detected between patients receiving enoxaparin and patients receiving placebo. The dose of enoxaparin used in this study proved to be safe. Clinical trials evaluating higher enoxaparin doses could optimize the efficacy of this agent for this indication.     

原发性肝癌合并胆管癌栓的外科治疗

目的：提高对原发性肝癌合并胆管癌栓的认识，探讨其诊断、治疗方法及疗效。方法：回顾性分析我院1998年1月至2004年1月间收治的42例原发性肝癌合并胆管癌栓的临床资料，施行根治性手术26例，其中18例肝叶切除＋胆总管切开取栓、T管引流术；8例肿瘤局部切除＋胆总管切开取栓、T管引流术；姑息性手术16例，其中6例胆总管切开取栓、T管引流术，10例胆总管切开取栓、T管引流术＋患侧肝动脉结扎术（其中4例＋门静脉DDS泵置入术）。均获得病理诊断，肝细胞癌32例（76．2％）。结果：根治性手术及姑息性手术1年、3年、5年生存率分别为65．4％（17／26），42．3％（11／26），15．4％（4／26）及18．8％（3／16）、6．3％（1／16），0（0／16）；总的1年、3年、5年生存率分别为47．6％（20／42），28．6％（12／42），9．5％（4／42）。结论：外科治疗明显改善患者生活质量，提高了生存时间，而根治性手术是原发性肝癌合并胆管癌栓的积极有效方法。     

Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer

BACKGROUND:

The use of central venous catheters (CVCs) has greatly improved the quality of care in children with cancer, yet these catheters may cause serious infectious and thrombotic complications. The aim of this prospective registry study was to assess the host and CVC‐related risk factors for CVC‐created thrombotic complications.

METHODS:

Patients undergoing CVC insertion for chemotherapy were followed prospectively for CVC complications. At the time of enrollment, demographic, clinical, and CVC‐related data, and family history of thrombosis were collected. Survival and Cox regression analyses were performed.

RESULTS:

A total of 423 CVCs were inserted into 262 patients for a total of 76,540 catheter days. The incidence of CVC‐related deep‐vein thrombosis (DVT) was 0.13 per 1000 catheter‐days (95% confidence interval [CI], 0.06‐0.24). Insertion of peripherally inserted central catheters (PICCs) and insertion in an angiography suite significantly increased the risk of symptomatic CVC‐related DVT. The incidence of CVC occlusion was 1.35 per 1000 catheter‐days (95% CI, 1.1‐1.63). Positive family history of thrombosis significantly increased the risk of CVC occlusion (hazard ratio [HR], 2.16; 95% CI, 1.2‐3.8). The CVC‐related risk factors were insertion of Hickman catheters, insertion in angiography suite, and proximal‐tip location. Patients developing at least 1 episode of both CVC occlusion and infection had an increased risk for developing symptomatic CVC‐related DVT (HR, 4.15; 95% CI, 1.2‐14.4).

CONCLUSIONS:

Both patient‐related and CVC‐related factors are associated with higher risk of symptomatic thrombotic complications. These risk factors could be used in the clinical setting and in developing future studies for CVC thromboprophylaxis. Cancer 2010. © 2010 American Cancer Society.     

Risk factors for catheter-related thrombosis in cancer patients

We investigated the risk factors for venous thrombosis in cancer patients with implantable ports undergoing chemotherapy. One hundred and seventy one ports were placed in a central ("chest ports") and 84 in a peripheral vein ("arm ports"), 181 received prophylactic nadroparin and 10 coumarin. Clinically overt thrombosis was confirmed by ultrasound or angiography. Catheter-related thrombosis incidence without anticoagulants was 28% in arm and 33% in chest ports, but with anticoagulants this was 32% in arm and only 1% in chest ports (odds ratio (OR) 34.8 95% confidence interval (CI) 7.3-165). Left-sided placement compared with right-sided and catheter tip position in the superior vena cava compared with right atrium were associated with a 3.5 respectively 2.6-fold increased risk. Thrombosis was associated with elevated homocysteine levels (OR=3.8, 95% CI 1.3-11.3), but not with factor V Leiden or prothrombin 20210A gene mutations, or high concentration of factor VIII, IX or XI. Prophylaxis with anticoagulants is recommended for chest, but not for arm ports. Determination of plasma homocysteine levels may identify patients at an increased risk for thrombosis.     

大肠癌术后中心静脉导管真菌感染相关因素分析

目的：探讨大肠癌患者术后中心静脉导管（CVC）真菌感染的相关因素,寻求有效的预防改进措施。方法：回顾性分析100例住院的大肠癌手术患者（手术组）留置CVC的感染情况,并分析感染的相关因素。与同时期62例术后化疗患者（化疗组）留置CVC的感染情况进行比较。结果：手术组中7例（7．00％）发生CVC相关性真菌感染,其中6例单纯CVC感染,1例同时合并真菌血症。7例患者均为念珠菌感染,主要为近平滑念珠菌57．1％（4／7）。其感染与术后并发吻合口瘘有关,而与患者年龄、性别、手术方式、肿瘤大小、分期、导管留置时间和置管位置无关。6例患者拔除CVC后感染自愈,1例真菌血症患者抗真菌治疗后痊愈。化疗组没有患者发生导管相关真菌感染,与手术组感染率相比差异有统计学意义,P〈10．05。结论：大肠癌手术后CVC相关真菌感染的主要病原菌是近平滑念珠菌,吻合口瘘可能是其高危因素,及时拔除感染的CVC,可有效地防治导管相关的血行感染。