血管通路器材选择课件.ppt

1、 MC-PP-349BAS Confidential and Proprietary.For Internal Educational Purposes OnlyAn 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 catheter Very short term(days)外周静脉导管短期（天）Midline catheterLonger term th

2、an PIV(weeks)中线导管长于PIV（周）Peripherally inserted central catheter:PICC(up to one year)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 CICC Long 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）：

3、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 products BAS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,Dou

4、ble,Single,Arm,Power 胸部，双腔，单腔，手臂，高压注射Complications of PIVs Bleeding Vein injury Nerve injury Infiltration Phlebitis Thrombosis Infection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 CathetersOverview概要 Placed in the upper arm or antecubital fossa 置于上臂或肘窝 Tip res

5、ides in peripheral vein,usually the axillary vein,and does not enter the central vasculature 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 NOT a central line 不是中心静脉导管中线导管Midline Catheters Advantages Longer dwell than PIV No chest x-ray required Complications Occlusion Phlebitis DVT Identification of complications may

6、be delayed Often confused for a central line Less hemodilution,not appropriate for pH extremes or hyperosmolar 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 Radiolo

7、gist(IR)ICU InsertionUpper arm preferredBedside or IRU/S and MST are best practice BAS productsPer-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-Cat

8、h*PICCPoly Per-Q-Cath*PICCPoly RadPICC*导管PowerPICC*导管PowerGroshong*PICCGroshong*PICCPowerPICC SOLO*导管Overview:PICC LinesPICC导管概述导管概述PICC:Peripherally Inserted Central CatheterPICC：外周插管的中心静脉导管IS a Central Line属于中心静脉导管属于中心静脉导管Can be used for delivery of any infusate,including those intended for centra

9、l 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 Hyperosmolar 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Perip

10、herally Inserted Central Catheter(PICC)Advantages Reliable access Can be placed at bedside Complications Occlusion Infection Mechanical Phlebitis Thrombus Central Venous InjuryCentral Venous Catheters:CVCs中心静脉导管中心静脉导管Overview 概要概要 Inserted percutaneously by MDs,possibly RNs in the future 由医生经皮插管，可能未

11、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）CRBSI 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

12、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 removal 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 Interventi

13、onal Radiology 放射介入科BAS Implantable Ports:巴德植入式输液泵巴德植入式输液泵 Power Injectable Ports:耐高压注射型 PowerPort*:duo M.R.I*,M.R.I.*,isp*(Titanium),isp MRI*device Non Power Injectable Ports:非耐高压注射型 M.R.I.*device:Dual-Lumen,Hard-Base,Low-Profile,Ultra SlimPort*device Peritoneal(Titanium)SlimPort*device Dual-Lumen

14、Rosenblatt*Catheter Titanium: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 Overview Totally implanted device Placed in IR or OR Most commonly placed in oncology patients Advantages Low infection rates Convenient for pa

15、tient(showering,etc)Long term dwell Complications Pinch-off Syndrome Occlusion,DVT Expensive to replacePorts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 MC-PP-349BAS Confidential and Proprietary.For Internal Educational Purposes

16、 OnlyPort 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 Preserving vasculature 保护血管 Long te

17、rm 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 the internal jugular vein to

18、 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无论使用哪种方式，导管尖端均应位于右心房上部的上腔静脉 Dw

19、ell Time留置时间留置时间ProductProduct产品产品Dwell TimeDwell Time留置时间留置时间PIV PIV 静脉留置针静脉留置针 up to 72 hours up to 72 hours 少于少于7272小时小时Midline Midline 中线导管中线导管 up to 4 weeks up to 4 weeks 少于少于4 4周周Acute CVC Acute CVC 急性急性CVCCVC导管导管 1 week 1 week 1 week 大于大于1 1周周11年年Non-tunneled CVCNon-tunneled CVC非隧道式非隧道式CVCCVC

20、 4 weeks 4 weeks 4 weeks 超过超过4 4周周Ports Ports 植入式输液泵植入式输液泵 6 weeks 6 weeks 超过超过6 6周周终生终生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 Tunn

21、eled CVC 隧道式CVC导管 Non tunneled CVC 非隧道式CVC导管 Acute CVC 短期CVC导管CSR-BSI Considerations and Central Venous Access DevicesInfection Control Issues感染控制的问题Sources:CDC 2002,Moreau,2002,Ryder,1996,Lowenthal et.Al.2002,Skiest,2000,Thiagajarian,1997,Alhimyary,1996,Abi-Nader,1993,Ng,1997,Graham,1991Device Sele

22、ction Overview 器材选择概述器材选择概述Different trade-offs 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

23、感染率，便宜，短期或长期留置Acute CVC 短期CVC导管 Very high infection 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CVC Higher 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，

24、无限期留置Ports 植入式输液泵 Very low infection rates,most expensive,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Catheter Material导管材质Silicone advantages硅胶的优点 Soft and pliant柔软，

25、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 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40PSICatheter Material

26、 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 Polyurethane disadvantages缺点 Prolonged exposure to acetone may weaken polyurethane不能耐受丙酮Open vs.Distall

27、y 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 displacement 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

28、home use不能用于带管回家Products-Per-Q-Cath*CatheterPer-Q-Cath*Catheter Positioning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

29、品Open vs.Distally Valved PICCsDistally 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 Hepa

30、rin-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 dress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 le

31、vels 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 de

32、dicated 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Power InjectorCT Gantry/ApertureTable ControlsCT Table高压注射器CT 扫描架/孔控制台CT 台Contrast media with

33、 PICC对比模式下的PICC导管Wheres the PICC?PICC导管在哪里？导管在哪里？Benefits-Patient对于患者的益处对于患者的益处 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 contrast media 5ml/秒意味着更快的对比剂输注速度 Optimal flow rate

34、 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PICCPowerPICC*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 intravenous 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 inje

35、ction 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*导管特点导管特点Polyurethane materialPolyurethane material 医用聚氨酯材质Patented bifurcation designPatented bifurcation design 专利的分叉结构设计5ml/sec maxim

36、um injection 5ml/sec maximum injection raterate 最大5ml/秒的输注速度“Check blood return and flush”“Check blood return and flush”“随时检查回血和延长管是否注满”Purple hub colorPurple hub color 紫色连接处“Power“Power injectableinjectable”“耐高压注射”标识Product FeaturesProduct Features产品特征产品特征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单腔和双腔三腔导管三腔导管 MC-PP-349BAS Confidential and Proprietary.For Internal Educational Purposes Only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