关于中心静脉导管,你掌握多少?

2017-11-15 黄金燕 中国护理管理

中心静脉导管,简称CVC(Central venous catheter)是指经皮穿刺颈内静脉、锁骨下静脉和股静脉,使导管尖端到达中心静脉(上、下腔静脉)的方法,常用于监测中心静脉压(CVP)及建立有效输液给药途径。

中心静脉导管,简称CVC(Central venous catheter)是指经皮穿刺颈内静脉、锁骨下静脉和股静脉,使导管尖端到达中心静脉(上、下腔静脉)的方法,常用于监测中心静脉压(CVP)及建立有效输液给药途径。

CVC的优点

1.价格相对低廉。

2.适用于所有类型的静脉治疗,尤其适用于需快速补液和补充血容量的患者,特别是手术患者。

CVC的缺点

1.置管操作较为复杂,风险较大,穿刺过程中可能发生气胸、大血管穿孔等并发症,可威胁患者生命安全,是一种医疗行为。

2.感染发生率高,静脉输液的其他并发症也较多,只能进行短期治疗,一般使用时间小于30d,需要频繁更换导管。

CVC的适用范围

1.常用于输注刺激性、浓度较高、化疗等其他特殊性质的药物或者需多管腔输注不相容的药物。曾外周置管发生静脉炎仍需化疗者,可避免加重静脉炎和再度发生静脉炎。

2.手术、急救或者危重需快速补液的患者。

3.血液透析的患者。

4.监测中心静脉压的患者。

5.外周静脉穿刺困难的患者。

CVC的禁忌症

1.血小板低或凝血功能障碍者。

2.有肿瘤上腔静脉压迫的患者。

如何做好CVC的护理?

1.评估CVC穿刺局部状况况和全身情况,跟患者解释操作目的,注意事项及配合技巧。

2.协助患者取合适体位,充分暴露穿刺部位。

3.由尾端向穿刺点逆导管方向拆除原有贴膜和胶布,免牵拉导管。观察穿刺点及周围皮肤有无发红、避肿胀、渗出物以及缝线是否完整、导管有无移位第触痛、快速手消毒剂消毒手。

4.检查并打开一次性护理包。备10cmX12em透明贴膜、输液接头、导管固定装置、一次性20ml注射器、10ml注射器。

5.戴无菌手套,以无菌方式抽吸0.9%氯化钠注射液、肝素盐水备用。

6.取无菌治疗巾建立无菌区。

7.用75%乙醇和1%活力碘棉球消毒穿刺点及周围皮肤各3遍,消毒范围及方法同PICC维护。并用力擦拭消毒导管体外部分及延长管2遍。

8.再次核对导管体内长度,摆放导管于合适位置,注意不要让导管移位。

9.待消毒液完全干燥后,以10cmX12cm无菌透明贴膜行封闭式无张力粘贴,注意排尽贴膜下的空气。

10.夹闭导管夹,取下输液接头,予75%乙醇棉片消毒导管螺旋接口15秒。

11.连接注射器后打开导管夹,抽回血检查导管通畅性,并以生理盐水冲洗导管。连接新的输液接头,正压封管。

12.脱手套,条形胶布蝶形固定好导管体外部分和输液接头,在贴膜上标明导管体内长度、外露长度及维护时间、责任人。

13.行健康指导。在护理记录单上记录导管维护情况。

护理CVC时的注意事项

1.置管后应予常规胸片检查,以确认导管尖端位于上腔静脉下1/3段到上腔静脉与右心房连接处或下腔静脉内,位置正确后方可使用。

2.导管固定以皮肤缝合固定,如果出现缝线松脱或不再完好时,可使用思乐扣等其他固定方式,有效防止导管脱出。

3.严密观察生命体征,注意穿刺点有无红肿痛、分泌物等局部情况。如发生局部感染应及时对症处理,处理导管相关性全感染时,应遵医嘱酌情拔除导管。

4.穿刺部位首选无菌透明敷料进行覆盖,至少每7d更换一次;无菌纱市数料应至少每2d更换一次。当败料出现潮湿、松动或有渗血、渗液时应及时更换。

5.每次使用导管前,评估导管功能,可通过抽回血的方式判断导管是否在血管内,并观察输液滴速判断导管是否通畅。若回抽无回血或出现滴速减慢,应查明原因,不可盲目冲管,及时给予对症处理。

6.输液时确保输液管路各部件装置连接紧密,严防发生空气栓塞。连续输液时每24h更换1次输液管。

7.使用乙醇棉球消毒时,注意避开穿刺点,以免引起学性静脉炎;应充分包裹导管螺旋接口并着力摩擦,以防消不彻底而致接头污染引起相关性血流感染。

8.冲洗导管前先抽回血,并注意观察有无血凝块,切将含有血凝块的血液冲人患者体内。

9.当导管老化、折断或自静脉内脱出后,可造成液体自导管的破损处或穿刺点渗漏,应及时拔管。

10.取下接头时应确保导管处于夹闭状态,必须开放时应尽量缩短开放时间,以防发生空气栓塞。

11.给药前后以及输人高渗溶液或静脉高营养液、血液制品后宜用生理盐水脉冲式冲洗导管,但必须使用10ml及以上注射器或一次性专用冲洗装置。输液完毕应用导管容积加延长管容积2倍的生理盐水或肝索盐水正压封管。肝索盐水的浓度为100Uml,使用时应密切观察有无血小板减少的症状。

CVP常见并发症

1.气胸

锁骨下静脉置管可发生气胸、血胸。气胸多限于肺尖部,以瘦弱营养不良者发生居多,因皮肤穿刺点与胸膜顶距离仅1cm左右,在置管时病人体位不当及穿刺方向不对可能刺破肺脏而发生气胸。少量气胸可在几天内自行吸收,不必特殊处理。病人一般在30min后开始出现呼吸时患侧胸痛,留意患者主诉,听诊患侧呼吸音低,拍胸片示气体量多或张力性气胸应行闭式引流,观察48-72h肺再张情况,然后闭管24h再拍胸片决定是否拔除胸腔引流管。造成气胸原因主要是进针角度或进针方向向肺尖偏移所致。

2.感染

穿刺点处皮下感染,表现为导管周围皮肤红、肿、痛,严重者有脓液溢出。多由于导管留置时间较长,局部观察处理不严密所致。为预防感染,穿刺点局部每周换药2次,或使用无菌透气 膜 局 部 封 闭穿刺点,每周更换1-2次,便于随时观察穿刺点有无红肿,同时也可起固定导管作用。中心静脉导管留置期间病人有突发寒战,高热。在排除其它原因的情况下,可考虑为导管感染。其原因可能为,皮肤表面的致病菌通过导管和表皮组织间的间隙进入血液循环引起菌血症。

3.淋巴管损伤

穿刺过程中可能会刺入淋巴导管,可吸出混浊白色液,也有少数置管成功后局部较多无色或淡黄液漏出,考虑为淋巴液漏出,要及时更换局部敷料,加压固定;如漏出液较多,应通知并辅助医生做相应检查。

4.空气栓塞

如果20ml空气进入,可使病人发生严重后果,死亡率可达50%。操作者在操作时,嘱病人要平静呼吸,操作时各环节衔接要严密,防止空气进入,导管护理时,要防止接头脱开,输液时严禁液体走空,长期置管病人,空气可经导管与皮肤形成的组织间隙在拔管时进入,故拔管后穿刺点处密封24h。

原始出处:

[1]蒋宏林. 经锁骨下静脉穿刺中心静脉置管术并发症的预防及护理[J]. 护士进修杂志,2015,30(16):1526-1527.

[2]穆成云. 临床护理路径在ICU降低CVC并发症中的应用[J]. 内蒙古中医药,2016,35(06):144-145.

[3].付艳枝,田玉凤,许新华《肿瘤化学治疗护理》[M].人民军医出版社,2015.5.

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  3. 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topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Thu Nov 16 06:05:46 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261605, encodeId=1691261605bd, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Thu Nov 16 05:39:34 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261594, encodeId=798c261594bd, content=学习了很不错哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-19 大爰

    学习了谢谢分享!!

    0

  4. 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  5. 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likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-16 swfzhanggui

    学习了非常好.谢谢分享

    0

  6. 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createdName=guojianrong, createdTime=Sat Oct 06 11:52:00 CST 2018, time=2018-10-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262499, encodeId=ca9b26249927, content=学习了谢谢分享!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200816/e4675a86ea694f12b82202b320dc2654/12f6b900498349e994ce8f516a584d6a.jpg, createdBy=09431951290, createdName=大爰, createdTime=Sun Nov 19 09:20:58 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1365544, encodeId=b0a61365544cb, content=<a href='/topic/show?id=e2ff2218823' target=_blank style='color:#2F92EE;'>#中心静脉导管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22188, encryptionId=e2ff2218823, topicName=中心静脉导管)], 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topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Thu Nov 16 06:05:46 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261605, encodeId=1691261605bd, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Thu Nov 16 05:39:34 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261594, encodeId=798c261594bd, content=学习了很不错哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-16 大爰

    学习了谢谢分享!!

    0

  7. 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topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Thu Nov 16 06:05:46 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261605, encodeId=1691261605bd, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Thu Nov 16 05:39:34 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261594, encodeId=798c261594bd, content=学习了很不错哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-16 明月清辉

    谢谢分享.学习了

    0

  8. 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topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Thu Nov 16 06:05:46 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261605, encodeId=1691261605bd, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Thu Nov 16 05:39:34 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261594, encodeId=798c261594bd, content=学习了很不错哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-16 1e17414fm02(暂无匿称)

    学习谢谢.

    0

  9. 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likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-16 yjs木玉

    好好好好好好好好就

    0

  10. 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likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Nov 16 01:58:57 CST 2017, time=2017-11-16, status=1, ipAttribution=)]
    2017-11-16 飛歌

    学习了很不错哦

    0

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