口岸消杀灭处理风险分析及风险管理

本文采取风险水平矩阵分析法,对消杀灭处理质量安全风险的可能性影响因素进行分析,评价口岸消杀灭处理质量安全风险水平,控制口岸处理质量安全风险,减少消杀灭处理事故的发生。     

三孔法腹膜后腹腔镜肾囊肿去顶减压术84例报告

目的:探讨三孔法行腹膜后腹腔镜肾囊肿去顶减压术的临床疗效。方法:回顾分析我院为84例肾囊肿患者用三孔法行腹膜后腹腔镜肾囊肿去顶减压术的临床资料,并评价三孔法腹膜后腹腔镜手术中直接扩张后腹膜腔的方法。结果:84例均顺利建立后腹膜腔操作空间,平均用时5.2min,无严重并发症发生。结论:三孔法Trocar直接穿刺、腹腔镜直接分离法操作简单、耗时少、创伤小、安全可靠,是一种值得推广的方法。     

ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis and therapy of complications)

When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, non-tunneled central venous catheters, through peripherally inserted central catheters (PICC), or – for limited period of time and with limitation in the osmolarity and composition of the solution – through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or – if planned for an extended or unlimited time – long-term venous access devices (tunneled catheters and totally implantable ports).The most appropriate site for central venous access will take into account many factors, including the patient's conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure.Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary.Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.

Summary of statements: Central Venous Catheters
Subject	Recommendations	Grade	Number
Choice of route for intravenous nutrition	Central venous access (i.e., venous access which allows delivery of nutrients directly into the superior vena cava or the right atrium) is needed in most patients who are candidates for parenteral nutrition (PN).	C	1
	In some situations however PN may be safely delivered by peripheral access (short cannula or midline catheter), as when using a solution with low osmolarity, with a substantial proportion of the non-protein calories given as lipid.
	It is recommended that peripheral PN (given through a short peripheral cannula or through a midline catheter) should be used only for a limited period of time, and only when using nutrient solutions whose osmolarity does not exceed 850 mOsm/L.
	Home PN should not normally be given via short cannulas as these carry a high risk of dislocation and complications.
	Peripheral PN, whether through short cannulas or midline catheters, demands careful surveillance for thrombophlebitis.
Choice of PN catheter device	Short-term: many non-tunneled central venous catheters (CVCs), as well as peripherally inserted central catheters (PICCs), and peripheral catheters are suitable for in-patient PN.	B	2
	Medium-term: PICCs, Hohn catheters, and tunneled catheters and ports are appropriate. Non-tunneled central venous catheters are discouraged in HPN, because of high rates of infection, obstruction, dislocation, and venous thrombosis.
	Prolonged use and HPN (>3 months) usually require a long-term device. There is a choice between tunneled catheters and totally implantable devices. In those requiring frequent (daily) access a tunneled device is generally preferable.
Choice of vein for PN	The choice of vein is affected by several factors including venepuncture technique, the risk of related mechanical complications, the feasibility of appropriate nursing of the catheter site, and the risk of thrombotic and infective complications.	C	3
	The use of the femoral vein for PN is relatively contraindicated, since this is associated with a high risk of contamination at the exit site in the groin, and a high risk of venous thrombosis.
	High approaches to the internal jugular vein (either anterior or posterior to the sternoclavicular muscle) are not recommended, since the exit site is difficult to nurse, and there is thus a high risk of catheter contamination and catheter-related infection.
Insertion of CVCs	There is compelling evidence that ultrasound-guided venepuncture (by real-time ultrasonography) is associated with a lower incidence of complications and a higher rate of success than ‘blind’ venepuncture. Ultrasound support is therefore strongly recommended for all CVC insertions. Placement by surgical cutdown is not recommended, in terms of cost-effectiveness and risk of infection.	A	4
	In placement of PICCs, percutaneous cannulation of the basilic vein or the brachial vein in the midarm, utilizing ultrasound guidance and the micro-introducer technique, is the preferred option	B	4
Position of CVC tip	High osmolarity PN requires central venous access and should be delivered through a catheter whose tip is in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium (Grade A). The position of the tip should preferably be checked during the procedure, especially when an infraclavicular approach to the subclavian vein has been used.	C, B	5
	Postoperative X-ray is mandatory (a) when the position of the tip has not been checked during the procedure, and/or (b) when the device has been placed using blind subclavian approach or other techniques which carry the risk of pleuropulmonary damage.
Choice of material for CVC	There is limited evidence to suggest that the catheter material is important in the etiology of catheter-related sepsis. Teflon, silicone and polyurethane (PUR) have been associated with fewer infections than polyvinyl chloride or polyethylene. Currently all available CVCs are made either of PUR (short-term and medium-term) or silicone (medium-term and long-term); no specific recommendation for clinical practice is made.	B	6
Reducing the risk of catheter-related infection	Evidence indicates that the risk of catheter-related infection is reduced by: • Using tunneled and implanted catheters (value only confirmed in long-term use) • Using antimicrobial coated catheters (value only shown in short-term use) • Using single-lumen catheters • Using peripheral access (PICC) when possible • Appropriate choice of the insertion site • Ultrasound-guided venepuncture • Use of maximal barrier precautions during insertion • Proper education and specific training of the staff • An adequate policy of hand washing • Use of 2% chlorhexidine as skin antiseptic • Appropriate dressing of the exit site • Disinfection of hubs, stopcocks and needle-free connectors • Regular change of administration sets Some interventions are not effective in reducing the risk of infection, and should not be adopted for this purpose; these include: • in-line filters • routine replacement of central lines on a scheduled basis • antibiotic prophylaxis • the use of heparin	B	6
Diagnosis of catheter-related sepsis	Diagnosis of CRBSI is best achieved (a) by quantitative or semi-quantitative culture of the catheter (when the CVC is removed or exchanged over a guide wire), or (b) by paired quantitative blood cultures or paired qualitative blood cultures from a peripheral vein and from the catheter, with continuously monitoring of the differential time to positivity (if the catheter is left in place).	A	7
Treatment of catheter-related sepsis (short-term lines)	A short-term central line should be removed in the case of (a) evident signs of local infection at the exit site, (b) clinical signs of sepsis, (c) positive culture of the catheter exchanged over guide wire, or (d) positive paired blood cultures (from peripheral blood and blood drawn from the catheter). Appropriate antibiotic therapy should be continued after catheter removal.	B	8
Treatment of catheter-related sepsis (long-term lines)	Removal of the long-term venous access is required in case of (a) tunnel infection or port abscess, (b) clinical signs of septic shock, (c) paired blood cultures positive for fungi or highly virulent bacteria, and/or (d) complicated infection (e.g., evidence of endocarditis, septic thrombosis, or other metastatic infections). In other cases, an attempt to save the device may be tried, using the antibiotic lock technique.	B	9
Routine care of central catheters	Most central venous access devices for PN can be safely flushed and locked with saline solution when not in use.	C	10
	Heparinized solutions may be used as a lock (after flushing with saline), when recommended by the manufacturer, in the case of implanted ports or opened-ended catheter lumens which are scheduled to remain closed for more than 8 h.
Prevention of line occlusion	Intraluminal obstruction of the central venous access can be prevented by appropriate nursing protocols in maintenance of the line, including the use of nutritional pumps.	C	11
Prevention of catheter-related central venous thrombosis	Thrombosis is avoided by the use of insertion techniques designed to limit damage to the vein, including • Ultrasound guidance at insertion • choice of a catheter with the smallest caliber compatible with the infusion therapy needed • position of the tip of the catheter at or near to the atrio-caval junction Prophylaxis with a daily subcutaneous dose of low molecular weight heparin is effective only in patients at high risk for thrombosis.	B	12

Full-size table

Risk of thrombosis and infections of central venous catheters and totally implanted access ports in patients treated for cancer

Introduction

Thrombosis and infections are well known complications of central venous catheters and totally implanted access ports. These complications lead to increased costs due to prolonged hospitalisation, increased antibiotics use and need for replacement.The objectives of the study were to document the occurrence of catheter related thrombosis and infections in patients with central venous catheters and totally implanted chest ports in cancer patients and to investigate whether factor V Leiden is a risk factor for catheter related thrombosis.

Materials and methods

Between February 2002 and November 2004, 43 patients with central venous catheter or totally implanted access port were followed up to document the occurrence of catheter related thrombosis and infections. Patients received chemotherapy either for haematological malignancy or for solid tumours. Factor V Leiden (R506Q) was determined by restriction fragment length polymorphism analysis. Follow-up period ended in April 2007.

Results

Catheter related thrombosis occurred in 4 patients (4/43; 9.3%) with a totally implanted access port. None of the 3 patients with factor V Leiden had catheter related infection or thrombosis. Catheter related infections occurred in 15 patients: 10 patients (23.3%; 10/43) with central venous catheter and 5 patients (11.6%; 5/43) with totally implanted access ports. Time to infection was 32.5 days in the central venous catheter group compared to 88 days in the totally implanted access port group.

Conclusion

A higher incidence of catheter related infections was observed in patients with central venous catheters in contrast to patients with totally implanted access ports were venous thrombosis was more frequent.     

Totally implantable vascular access devices in 131 pediatric oncology patients

The use of totally implantable vascular access devices (TIVAD) has gained acceptance in oncology patients, with lower overall complications and maintenance costs than percutaneous silastic catheters. We inserted 135 TIVAD in 131 selected pediatric oncology patients (mean age 8.9 years) for chemotherapy of 68 solid tumors, 39 leukemias, and 24 lymphomas. Patients were required to have an absolute neutrophil count of 1,000/l prior to TIVAD insertion. The cumulative duration of access was 45,098 days, with a mean of 334 days per device (range 5 to 981 days). At the time of review, 53 (39%) TIVAD were functioning without complication, 69 (51%) were removed at the end of therapy or were functioning at the time of death, and 13 (9.6%) were removed due to complications. Complications (n = 23) included 12 episodes of septicemia and 4 pocket infections for an infection rate of 11.8% (1 in 2,819 access days). Infections were more common in patients with leukemia compared to all others (P <0.001). Coagulase-negative staphylococci were isolated in 10 of the 16 infections; 7 infections resolved with antibiotic therapy. Mechanical complications were associated with 7 (5.2%) devices (1 in 6,443 access days). These data suggest that in selected non-neutropenic pediatric oncology patients, TIVAD can be utilized with minimal morbidity in the delivery of long-term chemotherapy.     

Training of basic laparoscopy skills on SimSurgery SEP

While sharp trocars are necessary for establishing secondary ports during transperitoneal laparoscopy, their use during retroperitoneal laparoscopy is unwarranted and could even be dangerous in the hands of a beginner because of the confined space. This paper describes our recent experience of the use of blunt trocars in establishing secondary ports for retroperitoneal laparoscopy.     

Totally implantable venous access devices via subclavian vein: A retrospective study of 368 oncology patients

Totally implantable catheters and totally implantable venous access devices (TIVADs) represent a valid method of administering long-term chemotherapy. TIVADs have several advantages over other methods of venous access: they are easy to implant under local anesthesia, they cause less discomfort for patients, and they can be implanted and managed on an outpatient basis. A total of 368 oncology patients were scheduled for percutaneous venous access devices. The purpose of this study was to examine the early and late complication rates of TIVADs used to deliver long-term chemotherapy. From June 2001 to January 2006, we placed 368 TIVADs, under x-ray guidance, for long-term chemotherapy in general oncology patients under local anesthesia (95% solid, 5% hematologic tumors). Percutaneous venous access devices were inserted into the subclavian vein, and adequate follow-up was provided in all cases (median, 145 d; range, 1–348 d). A total of 112 devices (30%) remained in situ at the end of the study. Early complications of TIVADs included 9 (2.4%) arterial punctures, 2 (0.5%) malpositions, and 1 (0.3%) pneumothorax, which required no thoracic aspiration. Late complications included 3 cases (0.8%) of venous thrombosis, 2 cases (0.5%) of pocket infection, and 1 case (0.3%) of port-related bacteremia. This study describes a series of patients with subcutaneous infusion ports connected to various catheters. This device is a good option for long-term access to the subclavian vein; major complications related to implantation are rare, and ongoing management of these devices supports their increased use in oncology patients.     

节奏策略中枢控制的实验验证

目的:本研究从运动疲劳的中枢模型出发,假设并采用实验验证在计时类竞技运动过程中,整体的功率输出分配或者说节奏策略是由中枢神经系统所控制的。方法:选取了18名省级水平的赛艇运动员参与实验。令运动员完成两组测试最大能力的6分钟赛艇运动,组间休息15分钟,记录运动员测试功率,同时测试运动员的心率、血乳酸、RPE、肌电图(EMG)。结果:两组测试中的节奏策略是相似的,同时两组测试过程中功率输出与iEMG变化总是动态相随。结论:本实验为节奏策略的中枢控制提供了证据。     

国境口岸应对突发公共卫生事件立法探析

〔目的〕探析完善我国国境口岸应对突发公共卫生事件立法体系,提供国境卫生检疫部门应对突发公共卫生事件处置的法律依据,提高口岸卫生核心能力。〔方法〕分析我国目前应对公共卫生突发事件体制的现状和《国际卫生条例(2005)》对口岸核心能力的要求,提出国境卫生检疫部门在应对口岸突发公共卫生事件方面的立法建议。〔结果〕有利于充分发挥卫生检疫部门的技术指导和快速应对的作用,提高口岸处置突发公共卫生事件的能力,更有效保障人民的生命和财产安全。〔结论〕通过立法赋予国境卫生检疫部门参与甚至主导国境口岸突发公共卫生事件的足够权责,更有利于发挥国境卫生检疫部门在处置口岸突发公共卫生事件的作用,提高口岸卫生检疫核心能力。     

Three-Port laparoscopic partial hepatectomy using an ultrasonically activated device (USAD)

Background/Purpose We provide an initial report of the indications and procedure for three-port laparoscopic partial hepatectomy. Methods Three-port laparoscopic partial hepatectomy was performed in nine patients (age, 49 to 73 years) at our department. Eight patients (seven men and one woman) had hepatocellular carcinoma (HCC); six of these patients had liver cirrhosis (LC) and two had chronic hepatitis (CH). The ninth patient, a woman had a single metastatic liver tumor from colon cancer. The tumors were located in regons S₂, S₃, S₄, S₅, S₆, and S₈. Preoperative liver function assessment revealed Child-Pugh classification A or B. All the tumors were located superficially, and their diameter averaged approximately 3 cm. Hepatectomy was performed laparoscopically, using an ultrasonically activated device (USAD) with or without microwave coagulation therapy (MCT). Results The operative time was 50 to 168 min, and the intraoperative blood loss ranged from 32 to 158 g. The postoperative hospital stay was 5 to 17 days. No recurrences, including local relapse, were observed. Conclusions Three-port laparoscopic partial hepatectomy is safe and feasible for patients with Child-Pugh liver function classification A or B if the tumor is located superficially and is less than 3 cm in diameter.