深静脉穿刺-PPT课件

1、深静脉穿刺什么是深静脉穿刺？指经体表将导管或监测探头 置入上、下腔静脉及右心房、肺动脉内的一种有创的操作技术。适应症及用途监测中心静脉压衡量右心泵功能及时应用急救药物、输血、输液经导管安装临时起搏器漂浮导管(PCWP)长时间静脉营养(TPN)相对禁忌症Anticoagulation or thrombolytic therapyBleeding disordersCombative patientsDistorted local anatomyVasculitis Cellulitis, burns, severe dermatitis at site物品准备做穿刺前准备好物品和液体穿刺包，静

2、脉静脉导管无菌纱布、无菌手套、5ml一次性注射器两个，铺巾、中心静脉穿刺包（内有导丝、中心静脉导管、扩皮器等）薄膜敷贴等0.9%NS和利多卡因各一支在检查的过程中，使物品都处于备用状态穿刺的基本原则确定深静脉置管是否有必要签署同意书掌握解剖知识熟练使用穿刺用品取得病人配合严格无菌操作穿刺过程中总有一个手持导丝敢于请示上级（敢于放弃）穿刺时请保持穿刺针负压重新定位时须将针尖退至皮下术后胸片再次定位Seldinger technique粗针定位Use introducing needle to locate vein导丝顺针而入Wire is threaded through the needle

3、移开粗针 Needle is removed扩皮 Skin and vessel are dilated顺导丝置入导管Catheter is placed over the wire移开导丝Wire is removed固定导管Catheter is secured in place常用穿刺入路常用的有 锁骨下静脉、 颈内静脉，有时也可选用贵要静脉、颈外静脉股静脉。颈内静脉穿刺术解剖学关系体表标志穿刺方法禁忌症颈内静脉穿刺禁忌症上腔静脉血栓形成气管切开术后一侧穿刺失败后对侧穿刺解剖学关系解剖学位置颈内静脉的解剖：颈内静脉上部位于胸锁乳突肌前缘内侧；中部位于胸锁乳突肌锁骨头前缘的下部，颈总动脉的

4、前外方；下部在胸锁乳突肌锁骨头的后侧，在胸锁关节处与锁骨下静脉汇合成无名静脉。成人颈内静脉扩张时直径约2cm。右颈内静脉与无名静脉、上腔静脉几乎成一直线，同时胸导管在左侧，右侧胸膜顶较低，因此多选择右侧穿刺。操作方法颈内静脉穿刺入路有三种：前路中路后路常用入路为前路及中路前路定位及操作方法体位：病人仰卧，头低位，右肩部垫起，头后仰使颈部充分伸展，面部略转向对侧。穿刺点及进针：操作者以左手示指和中指在中线旁开3cm，于胸锁乳突肌的中点前缘相当于甲状软骨上缘水平触及颈总动脉搏动，并向内侧推开颈总动脉，在颈总动脉外缘约0.5-1cm处进针，针干与皮肤呈3045角，针尖指向同侧乳头或锁骨的中、内1/3

5、交界处。此路径进针造成气胸的机会不多，但易误入颈总动脉。 体表定位中路定位及操作体位：病人仰卧，头低位，右肩部垫起，头后仰使颈部充分伸展，面部略转向对侧。穿刺点与进针：锁骨与胸锁乳突肌的锁骨头和胸骨头所形成的三角区的顶点，颈内静脉正好位于此三角形的中心位置，该点距锁骨上缘约35cm，进针时针干与皮肤呈30角，与中线平行直接指向足端。如果穿刺未成功，将针尖退至皮下，再向外倾斜10左右，指向胸锁乳突肌锁骨头的内侧后缘，常能成功。一般选用中路穿刺。因为此点可直接触及颈总动脉，可以避开颈总动脉，误伤动脉的机会较少。另外此处颈内静脉较浅，穿刺成功率高。体表定位后路定位及操作方法体位：同前路，穿刺时头部尽

6、量转向对侧。 穿刺点与进针：在胸锁乳突肌的后外缘中，下1/3的交点或在锁骨上缘35cm处作为进针点。在此处颈内静脉位于胸锁乳突肌的下面略偏外侧，针干一般保持水平，在胸锁乳突肌的深部指向锁骨上窝方向。针尖不宜过分向内侧深入，以免损伤颈总动脉，甚至穿入气管内。 平行入针容易伤及臂丛神经，故少用后路定位锁骨下静脉穿刺术根据穿刺点与锁骨关系分为锁骨上入路及锁骨下入路锁骨下静脉穿刺禁忌症呼吸衰竭肺大疱高PEEP凝血功能异常上腔静脉血栓胸部外伤解剖解剖解剖特点1.起自腋静脉，跨第一肋骨上方，经锁骨中断的后方，在胸锁关节后与颈内静脉汇合无名静脉，入胸腔，后与对侧的无名静脉汇合上腔静脉；2.锁骨下静脉后方膈前

7、角肌与锁骨下动脉伴行，锁骨下静脉在前，锁骨下动脉在后；3.胸骨顶在锁骨下静脉后方约5mm处 误伤胸膜是经皮锁骨下静脉穿刺可能遇到的最大危险。解剖特点锁骨下静脉解剖标志清楚，位置较浅表，粗大(内径12cm)，成人粗如拇指，血流快，经常处于充盈状态，故易于穿刺。锁骨下静脉插管不影响气管插管及人工呼吸；置管后不影响病人活动，便于护理。体表标志锁骨下静脉穿刺定位及操作体位：多选用右侧，仰卧位、头自然偏向一侧手臂贴近躯干、头低位、肩部放松穿刺方法：从锁骨中内1/3的交界处，锁骨下缘约11.5cm（相当于第二肋骨上缘）进针。针尖指向胸骨上窝，针体穿刺与胸壁皮肤的夹角小于10，如果以此方向进针已达45cm仍

8、无回血时，不可再向前推进，应徐徐向后退针并边退边抽，仍无回血，可将针尖撤到皮下而后再改变方向。缓慢向前推进，边进针边回抽，直到有暗红色血为止。股静脉穿刺禁忌症下腔静脉病变（血栓、滤网）局部感染心肺复苏术后腹腔内压增加股静脉穿刺置管术股静脉的解剖：股静脉位于股鞘内，紧靠股动脉内侧。股静脉的体表投影位置为腹股沟韧带中、内1/3交点下方约2.5cm处。体位及穿刺点穿刺点：病人仰卧，大腿稍外展，在腹股沟韧带中、内1/3交点下方约2.5cm处触及股动脉搏动的内侧进针：向内上方呈45角，进入2.54cm并发症血栓并发症机械并发症：误穿动脉、气胸、血胸、血气胸、出血、动静脉瘘、胸导管损伤、神经损伤感染并发症

9、： 穿刺部位感染：红肿、硬结、脓性分泌物 导管细菌定植：导管培养（+），外周血培养 （-） 导管相关性血行感染：外周血和导管培养出相 同细菌各种入路穿刺方法比较穿刺入路优点缺点颈内静脉一旦出血可快速发现，并且易于按压止血；气胸发生率相对较低；导管不易移位容易误穿颈内动脉；仍有一定气胸发生率锁骨下静脉病人舒适容易并发气胸，插管病人不宜使用；一旦出血不易按压止血；病人年龄2岁不宜使用导管移位发生率高股静脉容易定位；无气胸发生可能；推荐于急诊使用；极少发生不良并发症DVT；穿刺点容易感染；对于长期制动、卧床患者不建议使用Practical problems common to most techni

10、ques of insertionArterial punctureUsually obvious but may be missed in a patient who is hypoxic or hypotensive. If unsure, connect a length of manometer tubing to the needle / catheter and look for blood flow which goes higher than 30cm vertically or is strongly pulsatile. Withdraw the needle and ap

11、ply firm direct pressure to the site for at least 10 minutes or longer if there is continuing bleeding. If there is minimal swelling then retry or change to a different routeSuspected pneumothoraxIf air is easily aspirated into the syringe (note that this may also occur if the needle is not firmly a

12、ttached to the syringe) or the patient starts to become breathless. Abandon the procedure at that site. Obtain a chest radiograph and insert an intercostal drain if confirmed. If central access is absolutely necessary then try another route ON THE SAME SIDE or either femoral vein. DO NOT attempt eit

13、her the subclavian or jugular on the other side in case bilateral pneumothoraces are produced.Arrhythmias during the procedureUsually from the catheter or wire being inserted too far (into the right ventricle). The average length of catheter needed for an adult internal jugular or subclavian approac

14、h is 15cm. Withdraw the wire or catheter if further than this.Air embolusThis can occur, especially in the hypovolaemic patient, if the needle or cannula is left in the vein whilst open to the air. It is easily prevented by ensuring that the patient is positioned head down (for jugular and subclavia

15、n routes) and that the guidewire or catheter is passed down the needle promptly.The wire will not thread down the needleCheck that the needle is still in the vein. Flush it with saline. Try angling the needle so the end of it lies more along the plane of the vessel. Carefully rotate the needle in ca

16、se the end lies against the vessel wall. Reattach the syringe and aspirate to check that you are still in the vein. If the wire has gone through the needle but will not pass down the vein it should be very gently pulled back. If any resistance is felt then the needle should be pulled out with the wire still inside, and the procedure repeated. This reduces the risk of the end of the wire being cut off by the needle tip.Persistent bleeding at the of entryApply firm direct pressure with a sterile dressing. Bleeding should usually stop unless there is a coagulation abnormality. Persistent seve