PICC初级16

PICC 培训吴丽芬,2003 Becton, Dickinson and Company,PICC证书,Historical Perspective 历史回顾,Prior1940,1990- 今天,1980 -1990,1960,1940 -1960,Wren 注射鸦片及酒; 第一次在人体上输血医生参与作为急诊使用钢针的使用,Ada Plumer 建立了每一个IV小组Meng et al 报道CVC在狗身上进行试验,Dudrick建立 TPN理论第一个PICC应用在新生儿,护士开始植入 PICC第一个中等长度导管被应用PICC及中等长度导管被应用:NICU家庭护理成人,护士开始植入CVC导管超声诊断血管通路专家,1970-1980,1940 -1970,1940之前,什么是PICC?,开口于上/下腔静脉的外周插入中心静脉导管理想位置SVC的下1/3或上腔及右心房交界区以上或：隔肌以上的下腔的静脉开口心房腔静脉交界区以下（新生儿/儿童）,PICC Catheter,PICC的特征,穿刺部位Antecubital veins肘部静脉Basilic贵要V, Cephalic头V, Median cubitals正中静脉Dwell time留置时间Not established (INS recommends up to 1 year)目前尚无具体留置时间（INS建议为1年）Appropriate infusates 输注液体的要求Any solutionInsertion technique 植入技术Maximum sterile barrier precautions最大程度上的无菌操作X-ray Tip verification required 导管尖端位置需要用X光确认,PICC的优点,相对外周留置针:减少治疗中断保护静脉系统提供可依赖的通路Compared to other Central Venous Catheters, PICCs provide:相比中心静脉导管减少CVC置管并发症降低费用减少病人外伤的发生减少导管相关性感染增加病人满意度,Therapy Considerations治疗评估,Clinician Responsibility临床医护人员的职责Ensure the safe administration of drugs and solutions保证药物及输注液体安全Select the best catheter tip location based on 选择最佳导管尖端位置取决于Osmolarity of the infusate输注液体的渗透压pH of the infusate PH值Chemical properties of the infusate 化学特性Duration and purpose of infusion therapy 输液治疗的留置时间,Overview 概论,2003 Becton, Dickinson and Company,pH,pH reflects the Hydrogen ion concentration of a solutionPH反映溶液H离子浓度Acidity 酸性 = pHAlkalinity 碱性= pHRisk风险pH 8 may result in severe histological changes in the venous endothelium pH 8将严重破坏组织细胞,Therapy Considerations,Hemodilution and Catheter Tip Location血液稀释与导管头端位置,Affected by blood flow血流影响Laminar flow层流式贵要静脉，颈静脉Turbulent flow脉冲式Vein size (diameter)血管大小Catheter tip location导管尖端位置Risk of mechanical damage to the venous endothelium血管内皮损伤的风险,Therapy Considerations,Patient Considerations病人评估,Overview总论,Disease States疾病状况Special Considerations特殊考虑Allergies过敏Care Setting 护理要求Educational Needs教育需求,拒绝PICC治疗同意书,病人有权力接受或拒绝治疗拒绝PICC治疗同意书的内容：拒绝治疗后的不益之处病人需了解所有相关文件可以通过文字或口头的形式,患者教育,患者教育不是可供选择额外的事情应人施教主要内容：基本信息特殊导管信息更换敷料指导冲管指导注射器规格指导原则处理解决并发症家庭护理,Site Assessment & Evaluation穿刺部位的评估,Overview,The Skin皮肤Associated Structures相关组织Veins Anatomy Upper Extremities and Thorax 上臂及胸腔的血管解剖Site Selection血管部位的选择Venous Assessment血管评估Measuring for Location血管部位的测量,2003 Becton, Dickinson and Company,Associated Structures Nerves 神经,4 major nerves pass through the antecubital fossa 肘窝处4个主要神经Medial cutaneous正中皮神经Median正中神经Radial桡神经Ulnar尺神经,Site Assessment & Evaluation,Associated Structures - Right Atrium右心房,Central venous catheter tips should not be placed to the right atrium中心静脉导管不应该置入至右心房Standards of practice state that central venous catheter tip is in the vena cava实践标准指出中心静脉导管的头端是在腔静脉Optimal tip placement优化的头端置入,Site Assessment & Evaluation,Measuring for Tip Placement导管头端的测量,Measure from the proposed insertion site, along the track of the vein to the desired tip position从需穿刺的点量起，沿着血管到预定的头端位置PICC measure with arm abducted 90 from the insertion site to the head of the right clavicle and down to the third intercostal space手臂向外伸展90度，从穿刺点至右侧锁骨然后至第三肋间Midline 中等长度导管 measure with arm abducted at 45 from the proposed insertion site to the level of the axillary fold测量时手臂伸展45度角，从预定置入位置折到腋下,Site Assessment & Evaluation,Overview总论,Criteria for Choosing a Vascular Access Device (VAD)选择血管通路工具（VAD）的条件Types of VAD VAD的类型Advantages and Disadvantages of PICCs and MidlinesPICC和中等长度导管的优势和劣势Introducer Options穿刺鞘的选择Selecting Catheter Size选择导管的规格Physical Characteristics of VADs VAD的物理特性Trimming Considerations 切割器的选择Stylet Considerations导引钢丝的考虑,2003 Becton, Dickinson and Company,VADs种类,短期外周导管Dwell time up to 96 hours短期CVCDwell time up to 30 days隧道式 CVCs No established dwell time 输液港No established dwell time,Device Selection,Jane banton sending 3 pictures. Use them plus the first one Here but with safety catheters,Types of VADs 血管通路工具的种类,Midline Catheter中等长度导管No established dwell time尚无固定的留置时间 2-4 weeks most common dwell time 最常见的留置时间为2-4周PICCNo established dwell time尚未确定留置时间INS recommendation up to 1 year INS推荐为1年CDC 2002美国疾控中心2002PICCs may be the preferred CVC for short, intermediate and long-term therapies PICC是首选的中心静脉导管，适用于短，中及长期的治疗AHRQ 2002 美国卫生研究及质量机构2002PICCs reduce the incidence of complications associated with other CVCs PICC相比其他中心静脉导管而言，能明显降低相关并发症,Device Selection,Selecting Catheter Size选择导管的规格,Size of vein at insertion site根据置管部位的血管大小，导管选择最小原则Characteristics of the vein血管的特性Beyond the point of insertion穿刺点外的状况Tip placement尖端位置Therapy and fluid requirements治疗及输液的要求,Device Selection,导入工具的选择,Device Selection,防针刺伤可撕裂导入鞘,革新的防针刺伤技术经临床实践证明，该技术降低95%静脉输液相关的针刺伤。轻按保护按钮，穿刺针自动回缩，易于医护人员快速掌握减少感染因素，保护医生患者的安全,防针刺伤可撕裂导入鞘,卓越的套管尖端技术高质量套管尖端处理技术，将穿刺针和鞘间莱距离最为优化提高首次穿刺成功率，减少病人痛苦,防针刺伤可撕裂导入鞘,人性化的递送技术其未端新增“漏斗型”导管递送孔方便医护人员递送PICC导管，缩短整体操作时间，降低感染的发生,Trimming Considerations切割的考虑,Follow manufacturers recommendations根据厂家的推荐Benefits优点Avoids excess catheter to manage剪去多余的导管Prevents migration避免移位Cautions注意Never cut through a wire stylet 不要切割导引钢丝Always cut straight across要直着切割,Device Selection,Clinician Considerations医护人员的评估,2003 Becton, Dickinson and Company,Overview总论,Professional Issues专业要求Competency and Credentialing能力及资格Policies and Procedures规章及程序Outcomes Monitoring结果监测,2003 Becton, Dickinson and Company,结果监测,保证患者安全性及积极的患者最终利益前后一致的监测导管的完整性全整跟踪：植入-维护-取管,Site Preparation穿刺部位的准备,2003 Becton, Dickinson and Company,Infection Control Measures感控的评估Principles of Infection Control感控的原则Skin Preparation皮肤准备Universal and Standard Precautions通用及标准的预防Maximum Sterile Barrier Precautions最大程度的消毒,Overview总论,2003 Becton, Dickinson and Co