血管通路器材选择.ppt

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1、An Overview of Vascular Access DevicesAnd Early Assessment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,Types of Venous Catheters静脉导管类型,PIV:peripherally intravenous catheterVery short term(days)外周静脉导管短期（天）Midline catheterLonger term than PIV(weeks)中线导管长于PIV（周）Peripherally inserted central catheter:PICC(up to one y

2、ear)外周插管的中心导管：PICC（最长1年）Centrally inserted central venous catheter:CVC or CICC 中心插管的中心静脉导管：CVC或者 CICCLong term(years):Tunneled,cuffed Short term(days to weeks):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,General Overview:Types of Devices概览：产品类型,PIV 外周静脉导管No BAS direct pr

3、oductsBAS没有相关产品PICC Lines 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*,and PowerHohn*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,Complications of PIVs,Bleeding Vein injuryNerve in

4、juryInfiltrationPhlebitisThrombosisInfection,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,Peripheral IVs:Poor Outcomes,外周静脉导管：效果差,Midline Catheters,Overview概要Placed in the upper arm or antecubital fossa 置于上臂或肘窝Tip resides in peripheral vein,usually the axillary vein,and does not enter the central vasculature 头

5、端位于外周静脉，一般为腋静脉而不可使其进入中心血管NOT a central line 不是中心静脉导管,中线导管,Midline Catheters,AdvantagesLonger dwell than PIVNo chest x-ray requiredComplicationsOcclusionPhlebitisDVTIdentification of complications may be delayed Often confused for a central lineLess hemodilution,not appropriate for pH extremes or hyp

6、erosmolar solutions,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,Peripherally Inserted Central Catheter(PICC),Call PointIV/PICC NurseInterventional Radiologist(IR)ICUInsertionUpper arm preferredBedside or IRU/S and MST are best practiceBAS productsPer-

7、Q-Cath*PICCPoly Per-Q-Cath*PICCPoly RadPICC*catheterPowerPICC*catheterPowerGroshong*PICCGroshong*PICCPowerPICC SOLO*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*PICCPoly Per-Q-Cath*PICCPoly RadPICC*导管PowerPICC*导管PowerGroshong*PICCGroshong*PICCPowerPICC SOLO*导

8、管,Overview:PICC LinesPICC导管概述,PICC:Peripherally Inserted Central CatheterPICC：外周插管的中心静脉导管IS a Central Line属于中心静脉导管Can be used for delivery of any infusate,including those intended for central venous delivery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incompatible medications不相容的药物pH extreme medications极端pH值的药物Hyperos

9、molar medications高渗性的药物Vesicant and irritant meds发泡剂及刺激性的药物Reliable means for blood sampling可靠的采血方法Can be placed by a nurse at the bedside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,Peripherally Inserted Central Catheter(PICC),AdvantagesReliable accessCan be placed at bedsideComplicationsOcclusionInfectio

10、nMechanical PhlebitisThrombusCentral Venous Injury,Central Venous Catheters:CVCs中心静脉导管,Overview 概要Inserted percutaneously by MDs,possibly RNs in the future由医生经皮插管，可能未来由RN执行Placed in internal jugular,subclavian or femoral vein可放置在颈内静脉、锁骨下或股静脉Intended for short term dwell(7-10 days)适用于短期使用（7-10 天）CRBS

11、I rates vary by site of placement在所有VAD中的CRBSI 率最高Commonly placed in ICU/CCU with complex,critically ill patients多用于ICU/CCU中病情危重患者 Can be placed emergently可急性放置,Complications并发症Insertion related:植入相关：Pneumothorax 气胸Arterial puncture 误穿动脉Nerve damage 神经损伤Post insertion:植入后Infection 感染Accidental remov

12、al 意外脱出Bleeding 出血Thrombosis 血栓Central Venous Injury 中心静脉损伤,Central Venous Catheters:CVCs中心静脉导管,Ports植入式输液泵型中心静脉导管,Call point：Surgery 外科Interventional Radiology 放射介入科BAS Implantable Ports:巴德植入式输液泵Power Injectable Ports:耐高压注射型PowerPort*:duo M.R.I*,M.R.I.*,isp*(Titanium),isp MRI*deviceNon Power Inject

13、able Ports:非耐高压注射型M.R.I.*device:Dual-Lumen,Hard-Base,Low-Profile,Ultra SlimPort*devicePeritoneal(Titanium)SlimPort*device Dual-Lumen Rosenblatt*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,OverviewTota

14、lly implanted devicePlaced in IR or ORMost commonly placed in oncology patientsAdvantagesLow infection ratesConvenient for patient(showering,etc)Long term dwellComplicationsPinch-off SyndromeOcclusion,DVTExpensive to replace,Ports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

15、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,Port Advantages输液港的优势,Low infection risk 低感染率Underneath the skin 埋于皮下Less manipulation 操作简便Convenient for patient 病人舒适Showering/Swimming 便于洗澡、游泳Less obvious 不影响外观和自身形象Less flushing 不需要频繁冲管Less care and maintenance 不需要频繁进行导管维护Less needle sticks 不需要频繁穿刺Preservin

16、g vasculature 保护血管Long term dwell留置时间长,Port and Catheter Placement输液泵与导管的植入,Ports are usually placed in the upper chest,just below the clavicle输液泵通常被植入在锁骨下的胸部上方Surgeons often tunnel port catheter to the subclavian vein外科医生经常会做皮下隧道使导管进入锁骨下静脉Interventional radiologists often tunnel port catheter to th

17、e internal jugular vein to avoid pinch off syndrome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May be tunneled to basilic vein in arm,especially in breast cancer patients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Regardless of the vein accessed,tip should be at the junction of the superior vena cava and the right atrium无论使用

18、哪种方式，导管尖端均应位于右心房上部的上腔静脉,Dwell Time留置时间,Infection Rates感染率,Device types ranked lowest to highest infection rates(depending on location of CVC):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Midline Catheter 中线导管PICC 经外周植入的中心静脉导管Peripheral IV 静脉留置针Tunneled CVC 隧道式CVC导管Non tunneled CVC 非隧道式CVC导管Acute CVC 短期CVC

19、导管,CSR-BSI Considerations and Central Venous Access Devices,Infection Control Issues感染控制的问题,Site Preparation,Sources:CDC 2002,Moreau,2002,Ryder,1996,Lowenthal et.Al.2002,Skiest,2000,Thiagajarian,1997,Alhimyary,1996,Abi-Nader,1993,Ng,1997,Graham,1991,Device Selection Overview 器材选择概述,Different trade-o

20、ffs between VADs 不同类型的VAD的优劣PIV 静脉留置针Low infection rates,very inexpensive,very short dwell times低感染率，非常便宜，非常短的留置时间Midline 中线导管Low infection rates,inexpensive,medium dwell times低感染率，便宜，较短留置时间PICC Low infection rates,inexpensive,short or long dwell times低感染率，便宜，短期或长期留置Acute CVC 短期CVC导管Very high infect

21、ion rates,inexpensive,medium dwell times非常高的感染率，便宜，较短留置时间CVC,non-tunneled CVC导管，非隧道式CVCHigher infection rates,more expensive,medium dwell times很高的感染率，更贵，较短留置时间CVC,tunneled 隧道式CVC导管Higher infection rates,more expensive,indefinite dwell times高感染率，更贵，无限期留置Ports 植入式输液泵Very low infection rates,most expen

22、sive,indefinite dwell time非常低的感染率，最贵，无限期留置,Device Selection工具的选择,Material材质Multi-lumen多管腔Open vs.Closed Ended末端开口或封闭Valved vs.Non-valved有瓣膜和无瓣膜Power Injection Capabilities加强造影注射可能,Our goal is to place the optimal device,suitable for the duration of treatment,based on the patients individual clinical

23、 variables.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,Catheter Material导管材质,Silicone advantages硅胶的优点Soft and pliant柔软，柔韧Biocompatible生物相容性好Resistant to moisture and many chemicals对化学药物和潮湿有很好抵抗力Slippery surface secondary to decreased surface area表面光滑降低表面面积Silicone disadvantages缺点Need stylet or guidewire for

24、insertion or repositioning需要导丝递送导管和再定位Poor tolerance for pressures 40 psi抗压力差不能承受大于40PSI,Catheter Material,Polyurethane advantages聚氨酯Biocompatible好的生物相容性Good tensile strength抗张力强度Wear-resistant抗磨损性Softens somewhat within the body进入机体内变得柔软Resistant to many chemicals耐受化学药物Thin wall construction 薄壁Poly

25、urethane disadvantages缺点Prolonged exposure to acetone may weaken polyurethane不能耐受丙酮,Open vs.Distally Valved PICCs前端开口和有瓣膜,Open ended,Non-valved:前段开口无瓣膜Trimmable 可修剪Can be placed over a wire可通过导丝递送CVP monitoring capability可测量中心静脉压May be power injectable可以进行高压注射Requires either heparin or positive disp

26、lacement end caps需要肝素或末端正压连接注射帽Open system if cap accidentally removed如果注射帽偶然脱落则系统开放状态Not ideal for home use不能用于带管回家,Products-Per-Q-Cath*Catheter,Per-Q-Cath*CatheterPositioning定位Time-tested BAS nursing PICC经受时间考验的BAS护理PICC产品Cost Effective PICC option性价比高Description描述Open-ended Silicone PICC末端开口的的硅胶导

27、管Mature product line成熟的产品线Favored by被以下人员所青睐:Traditional clinicians传统的医护人员Prefer silicone偏好硅胶产品,Open vs.Distally Valved PICCs,Distally valved,Closed ended末段封闭，有瓣膜:Safe for home use适于带管回家Saline flush,no heparin只需生理盐水冲管无需肝素Cannot be placed over a wire不能通过导丝置管No CVP monitoring不能监测中心静脉压Not trimmable不能修剪

28、,Benefits of Using the Groshong*Catheter使用三相瓣膜导管的好处,Outcomes结论No heparin无需肝素May prevent Heparin-induced thrombocytopenia(HIT)可能会减少肝素引起的血小板减少症Groshong*Catheter valve may prevent blood backflow三相瓣膜会阻止血液反流May decrease occlusion rates会降低堵管率Convenience便利Limited flushing减少冲管频率Once per week每周一次Easy to dres

29、s容易维护,Multiple lumens多腔导管,Single Lumen单腔:Simple single medication course单一药物的应用No drug levels or coagulation labs needed无药物浓度或实验室凝血需要Dual Lumen双腔:Infusates requiring a dedicated lumen(TPN,heparin,etc.)药物输注需要专一官腔（TPN,肝素）Lab draws for antibiotic levels and coagulation studies anticipated实验室为抗生素浓度抽取和预期

30、的凝血研究Triple Lumen三腔:Complex IV therapies复杂的静脉治疗Ideal for critical care危重治疗Need for two dedicated lumens需要2个专用管腔,Power Injectable Options耐高压注射,Power Injection Overview 高压注射概述Power Injectable Products 高压注射型产品Important factors for Power Injection影响高压注射的重要因素,Scanner with Power Injector带加压注射器的CT 扫描仪,高压注射

31、器,CT 扫描架/孔,控制台,CT 台,Contrast media with PICC对比模式下的PICC导管,No contrast,With contrast,Wheres the PICC?PICC导管在哪里？,Benefits-Patient对于患者的益处,Fewer sticks 更少的针刺次数Patients will not need additional vascular access for CT scan 实施CT检查时患者不需要额外放置其他的血管通道器材Faster injection 更快的输注5 ml/sec means quicker injections of

32、contrast media 5ml/秒意味着更快的对比剂输注速度Optimal flow rate for CT scans 获得CT扫描需要的理想输注速度PICC placement solely for CECT not indicated不推荐专为CECT扫描而植入PICC,PowerPICC*Catheter PowerPICC*导管,PowerPICC*Catheter Indications:PowerPICC*导管适应症：Short and long-term peripheral access to the central venous system for intraven

33、ous therapy 短期（30天）经外周静脉置入的中心静脉输注治疗途径建立Power injection of contrast media 造影剂静脉团注Blood sampling,infusion or therapy 采血，输液治疗Central Venous Pressure Monitoring 可实施中心静脉压监测,PowerPICC*Catheter Characteristics PowerPICC*导管特点,Polyurethane material 医用聚氨酯材质Patented bifurcation design 专利的分叉结构设计5ml/sec maximum

34、injection rate 最大5ml/秒的输注速度“Check blood return and flush”“随时检查回血和延长管是否注满”Purple hub color 紫色连接处“Power injectable”“耐高压注射”标识,Product Features产品特征,Summary总结,可实施高压注射,检查回血和液体是否注满，最高流速5ml/秒,检查回血和液体是否注满，最高流速5ml/秒,可实施高压注射,不可实施高压注射不能输注造影剂,单腔和双腔,三腔导管,巴德期待与您携手推进人类健康事业的进步！,技术支持：巴德医疗器械（北京）有限公司 巴德医疗科技（上海）有限公司华北：01065065252，华东：02160825361，华南：02083752119,