血管通路器材选择 6

AnOverviewofVascularAccessDevicesAndEarlyAssessment血管通道器材概述以及合理选择巴德宁海燕新疆区域大客户经理TypesofVenousCatheters

静脉导管类型PIV:peripherallyintravenouscatheterVeryshortterm(days)外周静脉导管—短期（天）Midlinecatheter—LongertermthanPIV(weeks)中线导管—长于PIV（周）Peripherallyinsertedcentralcatheter:PICC(uptooneyear)外周插管的中心导管：PICC（最长1年）Centrallyinsertedcentralvenouscatheter:CVCorCICC中心插管的中心静脉导管：CVC或者CICCLongterm(years):Tunneled,cuffedShortterm(daystoweeks):Non-tunneled,“acute”CVC,non-cuffed长期（年）：隧道式，套袖式短期（数日至数周）：无隧道，“短期”CVC，无套袖GeneralOverview:TypesofDevices

概览：产品类型PIV外周静脉导管NoBASdirectproductsBAS没有相关产品PICCLines经外周植入的PICC导管Triple,Power,Valved,Non-Valved,Silicone,Polyurethane三腔，耐高压注射，有瓣膜，无瓣膜，硅胶，聚氨酯CVC中心静脉导管Hickman*,Groshong*,Broviac*,PowerLine*,andPowerHohn*CathetersPORTs植入式输液泵型中心静脉导管Chest,Double,Single,Arm,Power胸部，双腔，单腔，手臂，高压注射ComplicationsofPIV’sBleedingVeininjuryNerveinjuryInfiltrationPhlebitisThrombosisInfection外周静脉导管的并发症出血静脉损伤神经损伤渗液静脉炎血栓形成感染PeripheralIVs:PoorOutcomes外周静脉导管：效果差MidlineCathetersOverview概要Placedintheupperarmorantecubitalfossa

置于上臂或肘窝Tipresidesinperipheralvein,usuallytheaxillaryvein,anddoesnotenterthecentralvasculature

头端位于外周静脉，一般为腋静脉而不可使其进入中心血管NOTacentralline不是中心静脉导管中线导管MidlineCathetersAdvantagesLongerdwellthanPIVNochestx-rayrequiredComplicationsOcclusionPhlebitisDVTIdentificationofcomplicationsmaybedelayedOftenconfusedforacentrallineLesshemodilution,notappropriateforpHextremesorhyperosmolarsolutions中线导管优势留置时间长于外周静脉导管无需进行胸片检查并发症导管堵塞静脉炎深静脉血栓形成可能延迟的并发症诊断

常被误用作中心静脉导管血液稀释作用轻微，不适用于极端pH值和高渗的静脉输液PeripherallyInsertedCentralCatheter(PICC)CallPointIV/PICCNurseInterventionalRadiologist(IR)ICUInsertionUpperarmpreferredBedsideorIRU/SandMSTarebestpracticeBASproductsPer-Q-Cath*PICCPolyPer-Q-Cath*PICCPolyRadPICC*catheterPowerPICC*catheterPowerGroshong*PICCGroshong*PICCPowerPICCSOLO*catheter使用者IV/PICC护士放射介入医师（IR）重症监护室插管优先选择上臂床旁或放射介入科置管U/S和MST是最佳方法BAS产品Per-Q-Cath*PICCPolyPer-Q-Cath*PICCPolyRadPICC*导管PowerPICC*导管PowerGroshong*PICCGroshong*PICCPowerPICCSOLO*导管Overview:PICCLines

PICC导管概述PICC:PeripherallyInsertedCentralCatheterPICC：外周插管的中心静脉导管ISaCentralLine属于中心静脉导管Canbeusedfordeliveryofanyinfusate,includingthoseintendedforcentralvenousdelivery能够用于输送任何药物，包括那些需经中心静脉输送的药物incompatiblemedications不相容的药物pHextrememedications极端pH值的药物Hyperosmolarmedications高渗性的药物Vesicantandirritantmeds发泡剂及刺激性的药物Reliablemeansforbloodsampling可靠的采血方法Canbeplacedbyanurseatthebedside可由护士在床旁放置优势途径可靠可在床旁放置并发症阻塞

感染机械性静脉炎血栓PeripherallyInsertedCentralCatheter(PICC)AdvantagesReliableaccessCanbeplacedatbedsideComplicationsOcclusion InfectionMechanicalPhlebitisThrombusCentralVenousInjuryCentralVenousCatheters:CVCs

中心静脉导管Overview概要InsertedpercutaneouslybyMDs,possiblyRNsinthefuture由医生经皮插管，可能未来由RN执行Placedininternaljugular,subclavianorfemoralvein可放置在颈内静脉、锁骨下或股静脉Intendedforshorttermdwell(7-10days)适用于短期使用（7-10天）CRBSIratesvarybysiteofplacement在所有VAD中的CRBSI率最高CommonlyplacedinICU/CCUwithcomplex,criticallyillpatients多用于ICU/CCU中病情危重患者Canbeplacedemergently可急性放置Complications并发症Insertionrelated:植入相关：Pneumothorax气胸Arterialpuncture误穿动脉Nervedamage神经损伤Postinsertion:植入后Infection感染Accidentalremoval意外脱出Bleeding出血Thrombosis血栓CentralVenousInjury中心静脉损伤CentralVenousCatheters:CVCs中心静脉导管Ports

植入式输液泵型中心静脉导管Callpoint：Surgery外科InterventionalRadiology放射介入科BASImplantablePorts:巴德植入式输液泵PowerInjectablePorts:

耐高压注射型PowerPort*:

duoM.R.I*,M.R.I.*,isp*(Titanium),ispMRI*deviceNonPowerInjectablePorts:

非耐高压注射型M.R.I.*device:Dual-Lumen,Hard-Base,Low-Profile,UltraSlimPort*devicePeritoneal(Titanium)SlimPort*deviceDual-LumenRosenblatt*CatheterTitanium:Dome*,Low-Profile,SlimPort*X-Port*device:

duo*Dual-Lumen,inline*Dual-Lumen,isp*device多种选择：Groshong导管或ChronoFlex聚氨酯材质导管或者普通的硅胶导管OverviewTotallyimplanteddevicePlacedinIRorORMostcommonlyplacedinoncologypatientsAdvantagesLowinfectionratesConvenientforpatient(showering,etc)LongtermdwellComplicationsPinch-offSyndromeOcclusion,DVTExpensivetoreplacePorts

植入式输液泵型中心静脉导管概要完全植入体内的静脉输液器材在手术室或介入放射工作室放置最常置于肿瘤患者体内优势在所有VAD中的感染风险最低方便患者（洗浴等）使用时间长并发症导管夹闭综合症阻塞，深静脉血栓形成更换费用昂贵PortAdvantages输液港的优势Lowinfectionrisk低感染率Underneaththeskin埋于皮下Lessmanipulation操作简便Convenientforpatient病人舒适Showering/Swimming便于洗澡、游泳Lessobvious不影响外观和自身形象Lessflushing不需要频繁冲管Lesscareandmaintenance不需要频繁进行导管维护Lessneedlesticks不需要频繁穿刺Preservingvasculature保护血管Longtermdwell留置时间长PortandCatheterPlacement

输液泵与导管的植入Portsareusuallyplacedintheupperchest,justbelowtheclavicle输液泵通常被植入在锁骨下的胸部上方Surgeonsoftentunnelportcathetertothesubclavianvein外科医生经常会做皮下隧道使导管进入锁骨下静脉Interventionalradiologistsoftentunnelportcathetertotheinternaljugularveintoavoidpinchoffsyndrome放射介入医生常常做皮下隧道使导管直接进入颈内静脉以防止导管夹闭综合症Maybetunneledtobasilicveininarm,especiallyinbreastcancerpatients也可以做出隧道抵达上臂的贵要静脉，尤其适用于乳腺癌的患者Regardlessoftheveinaccessed,tipshouldbeatthejunctionofthesuperiorvenacavaandtherightatrium无论使用哪种方式，导管尖端均应位于右心房上部的上腔静脉DwellTime留置时间Product产品DwellTime留置时间PIV静脉留置针upto72hours少于72小时Midline中线导管upto4weeks少于4周AcuteCVC急性CVC导管<1week少于1周PICC>1week大于1周—1年Non-tunneledCVC非隧道式CVC<4weeks少于4周TunneledCVC隧道式CVC>4weeks超过4周Ports植入式输液泵>6weeks超过6周—终生InfectionRates

感染率Devicetypesrankedlowest

to

highest

infectionrates(dependingonlocationofCVC):器材类型相关感染率排序由低到高（取决于CVC导管的位置）

Port植入式输液泵MidlineCatheter中线导管PICC经外周植入的中心静脉导管PeripheralIV静脉留置针TunneledCVC隧道式CVC导管NontunneledCVC非隧道式CVC导管AcuteCVC短期CVC导管CSR-BSIConsiderationsandCentralVenousAccessDevicesInfectionControlIssues感染控制的问题SitePreparationSources:CDC2002,Moreau,2002,Ryder,1996,Lowenthalet.Al.2002,Skiest,2000,Thiagajarian,1997,Alhimyary,1996,Abi-Nader,1993,Ng,1997,Graham,1991DeviceSelectionOverview器材选择概述Differenttrade-offsbetweenVADs不同类型的VAD的优劣PIV静脉留置针Lowinfectionrates,veryinexpensive,veryshortdwelltimes低感染率，非常便宜，非常短的留置时间Midline中线导管Lowinfectionrates,inexpensive,mediumdwelltimes低感染率，便宜，较短留置时间PICCLowinfectionrates,inexpensive,shortorlongdwelltimes低感染率，便宜，短期或长期留置AcuteCVC短期CVC导管Veryhighinfectionrates,inexpensive,mediumdwelltimes非常高的感染率，便宜，较短留置时间CVC,non-tunneledCVC导管，非隧道式CVCHigherinfectionrates,moreexpensive,mediumdwelltimes很高的感染率，更贵，较短留置时间CVC,tunneled隧道式CVC导管Higherinfectionrates,moreexpensive,indefinitedwelltimes高感染率，更贵，无限期留置Ports植入式输液泵Verylowinfectionrates,mostexpensive,indefinitedwelltime非常低的感染率，最贵，无限期留置DeviceSelection工具的选择Material材质Multi-lumen多管腔Openvs.ClosedEnded末端开口或封闭Valvedvs.Non-valved有瓣膜和无瓣膜PowerInjectionCapabilities加强造影注射可能Ourgoalistoplacetheoptimaldevice,suitableforthedurationoftreatment,basedonthepatient’sindividualclinicalvariables.我们的目的是基于每个个体患者的临床情况选择最优化的工具满足治疗的需要CatheterMaterial导管材质Siliconeadvantages硅胶的优点Softandpliant柔软，柔韧Biocompatible生物相容性好Resistanttomoistureandmanychemicals对化学药物和潮湿有很好抵抗力Slipperysurfacesecondarytodecreasedsurfacearea表面光滑降低表面面积Siliconedisadvantages缺点Needstyletorguidewireforinsertionorrepositioning需要导丝递送导管和再定位Poortoleranceforpressures>40psi抗压力差不能承受大于40PSICatheterMaterialPolyurethaneadvantages聚氨酯Biocompatible好的生物相容性Goodtensilestrength抗张力强度Wear-resistant抗磨损性Softenssomewhatwithinthebody进入机体内变得柔软Resistanttomanychemicals耐受化学药物Thinwallconstruction薄壁Polyurethanedisadvantages缺点Prolongedexposuretoacetonemayweakenpolyurethane不能耐受丙酮Openvs.DistallyValvedPICCs前端开口和有瓣膜Openended,Non-valved:前段开口无瓣膜Trimmable可修剪Canbeplacedoverawire可通过导丝递送CVPmonitoringcapability可测量中心静脉压Maybepowerinjectable可以进行高压注射Requireseitherheparinorpositivedisplacementendcaps需要肝素或末端正压连接注射帽