中心静脉导管可以采集血液标本吗?

2019-02-18 陈冲 检验医学网

小编在工作中碰到过一个问题:为什么这个患者的采血样本特别稀?在跟临床沟通排除患者本身的病因外,发现往往是护士从中心静脉导管中取血导致的稀释,对检验结果的准确产生了很大的影响。而肿瘤患者由于放化疗治疗需要常常植入中心静脉导管,那么中心静脉导管可以用来临床采集检验标本吗?答案不尽相同。本文结合近期美国出版《Blood Collection, A SHORT COURSE》关于“外周静脉插管和中心静脉导


作者:天津医科大学肿瘤医院检验科  陈冲

小编在工作中碰到过一个问题:为什么这个患者的采血样本特别稀?在跟临床沟通排除患者本身的病因外,发现往往是护士从中心静脉导管中取血导致的稀释,对检验结果的准确产生了很大的影响。而肿瘤患者由于放化疗治疗需要常常植入中心静脉导管,那么中心静脉导管可以用来临床采集检验标本吗?答案不尽相同。本文结合近期美国出版《Blood Collection, A SHORT COURSE》关于“外周静脉插管和中心静脉导管标本采集”部分,寻找肿瘤患者中心静脉导管标本采集的临床解决方案。

中心静脉导管(central venous catheters, CVCs)是一种特殊类型的导管,需要由医护技术人员将其作为内部导管或外部导管插入身体的大血管中(图8-1)。CVCs用于肿瘤患者需要长期用药物治疗或营养支持;临床上不建议肿瘤患者长期使用中心静脉导管进行采集检验样本,但当肿瘤病人被禁止使用外周静脉血管和频繁抽血困难时,CVCs也会被考虑运用。

CVCs主要有四种类型:

①非隧道、非袖口型;

②隧道型;

③植入型;

④外周插入型中心导管(peripherally inserted central catheters, PICC)。

下面我简单介绍以下两种常见中心静脉导管标本采集方法。

01中心静脉导管标本采集

(1)中心静脉导管分为单、双、三腔导管,当病人持续输注时,在抽取样品前1分钟停止所有腔内的注射。如果使用多管腔导管,钳住所有管腔并从导管近端管腔取出。

(2)采集样本前用酒精擦拭清洗注射帽,使用强力摩擦,在顶部和凹槽中擦洗15秒。如果实验室抽血是为了血液培养,用酒精擦拭感染帽30秒(图8-2)。

(3)用10ml生理盐水冲洗(如果注射的是TPN或肝素,则用20ml生理盐水冲洗)。

(4)使用同一注射器连接到端口末端的接入装置上,抽取5毫升血液并弃掉,取下注射器,并将注射器丢弃在生物危害容器中。如果使用三腔导管,则夹紧所有端口,并从导管的近端口抽出。

(5)等待10-15秒后,换用新的注射器收集样本,收集每次测试所需的最小血量,将注射器和采血管连接到输血装置上,并按正确的采集顺序抽血。将血液输送装置连接到采集注射器上并插入真空管。让每根管子充满,不要从采集的注射器中强行抽取血液,因为这可能会导致样品中的红细胞溶血,并使某些实验室分析发生错误。

(6)真空管填充后,立即用温和的倒置法混合,以确保检测样本符合要求。

(7)对检测样本管进行适当的标记,并与病人或识别带确认信息无误,并将其放入生物危害传送箱中,送到检测实验室。

(8)用酒精擦洗中心15秒,清除血液。

(9)用预消毒的10毫升生理盐水注射器并冲洗导管,如果有管腔没有使用,也用10毫升盐水冲洗每个管腔。

(10)将用过的物料弃置于生物危害容器内,清洗所有使用过和没用过的设备,脱下手套,洗手。

02外周插入型中心导管(PICC)标本采集程序

(1)操作前应洗手并戴手套。

(2)如果正在输液,应暂停输液至少1分钟。用酒精擦洗清洗注射口30秒,用10毫升无菌生理盐水冲洗导管,然后轻轻吸出5毫升血液并丢弃。

(3)使用适当规格的注射器,缓慢而轻柔地取出所需数量的血液进行必要的实验室检测。如果从导管中吸入有任何困难,试着重新定位病人的手臂,弯曲、伸展或抬高病人的头部,试图冲洗导管并再次吸入。

(4)获取所需样本后,用10毫升或更大的注射器冲洗导管。用生理盐水冲洗时使用脉冲式运动,如果不能恢复静脉输液,则使用2毫升肝素冲洗溶液。

(5)PICC导管需要经常观察,为了避免感染,必须评估插入位置和更换敷料和注射帽。

(6)PICC导管采集样本特别注意要从PICC获得血液,导管的尺寸必须为4 French(Fr)或更大。如果PICC是用于全亲本营养(TPN),则不能用于抽血。不要用PICC将止血带或血压袖带压于手臂,因为这可能会阻塞或压垮导管。

临床上建议肿瘤患者在特殊情况下才使用中心静脉导管进行采集样本,否则长期使用可能会造成检验标本不符合检验要求,甚至会影响检验结果,但是肿瘤患者出现外周血采血困难或者禁止使用外周静脉血管时,合适尺寸的CVCs才会被考虑采集样本且结合临床谨慎使用。

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    2019-03-09 fusion
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