本文關鍵詞： 外周置入中心靜脈導管(PICC) 非治療期間 輸液接頭 更換 適宜時間　出處：《山東大學》2014年碩士論文　論文類型：學位論文

【摘要】：研究背景 外周置入中心靜脈技術(peripherally inserted central catheter, PICC)在1992年由德國醫(yī)生Forssmaon首次使用,因其方便、有效、安全的特點而被廣泛應用于臨床,并于上世紀末傳入我國。PICC是血管內導管的一種,是指經外周靜脈(貴要靜脈、肘正中靜脈、頭靜脈)穿刺置管,其尖端位置達上腔靜脈的下1/3,靠近上腔靜脈與右心房入口處的深靜脈置管術。適應癥廣,如：(1)強刺激性藥物如多療程化療；(2)胃腸外營養(yǎng)(TPN)；(3)長期靜脈輸液；(4)早產兒或極低體重兒(1.5kg)；(5)家庭靜脈治療。PICC具有頭皮鋼針和留置針無法比擬的優(yōu)勢,如留置時間可長達1年,減輕了患者反復穿刺的痛苦；導管開口端在上腔靜脈,藥物直接輸入中心靜脈,徹底杜絕藥物滲出或因滲出導致的靜脈炎和局部組織壞死,因此,2005年以后在三級醫(yī)院被迅速開展,且技術日益成熟,適應癥不斷擴大。美國CDC(疾病控制中心)2011強調：“導管置入后的導管維護應成為輸液質量控制和改進的關注重點�！盋DC認為PICC外接口是導致導管內微生物定植的一個重要原因,尤其是長期留置的導管,需要型號合適的輸液接頭封閉導管外接口,在患者治療期間,一般每周更換一次輸液接頭,而非治療期間輸液接頭間隔多長時間更換一次,既能將導管相關性感染控制到最低,又能節(jié)約醫(yī)療資源及減輕患者經濟負擔,2011版美國靜脈輸液護理學會未明確指出,國內亦無專項研究,護理同仁則自訂標準,廖春蘭等每15～30天更換一次輸液接頭,潘建亞每7-10天更換一次,涂偉妹等則每2周更換一次輸液接頭,但均未提供循證依據。循證實踐是將最佳的證據(研究)結合病人利益及醫(yī)療工作者的判斷,以求獲得更安全、更高質量的結果。我們的研究就是為非治療期間PICC患者尋找最佳更換輸液接頭的適宜時間提供循證依據。 研究目的 探索PICC置管患者在非治療期間更換輸液接頭的適宜時間,為臨床護理工作提供循證依據；分析引起導管相關并發(fā)癥的影響因素；探討如何做好非治療期間PICC帶管患者的維護,降低PICC患者并發(fā)癥的發(fā)生率。 資料與方法 樣本一本研究共收集了2013年7月至2013年12月在某醫(yī)院PICC護理門診維護的326例非治療期間的患者使用不同天數后更換的輸液正壓接頭,PICC在體內保留時間可長達一年,需要每周對導管維護一次,非治療期間患者更換輸液接頭基本和導管維護同步,所以將收集病例分為一周組(6-8天)、兩周組(13-15天)、三周組(20-22天),前后允許誤差一天,進行細菌培養(yǎng),觀察菌落計數和細菌分類,從導管相關性感染的發(fā)生率、經濟效益和患者對非治療期間導管維護的滿意度等方面進行分析。 樣本二兩組均選取在某醫(yī)院PICC護理門診維護的非治療期間的患者,2013年1月至2013年6月在PICC導管末端使用肝素帽的287例患者作為對照組,2013年7月至2013年12月在PICC導管末端使用無針正壓輸液接頭的患者326例作為實驗組。兩組患者的年齡、病情無統(tǒng)計學意義,采用的封管液、沖封管方法及維護的操作流程均一致,從兩組病例導致醫(yī)護人員發(fā)生針刺傷的情況以及兩組病例發(fā)生導管相關并發(fā)癥的情況進行分析。 主要結果 樣本一三組患者輸液接頭細菌培養(yǎng)結果的比較,一周組和兩周組的細菌培養(yǎng)結果菌落計數均為0,示無菌生長,三周組的細菌培養(yǎng)結果其菌落計數有5例15cfu/ml,表示有微生物生長,經比較差別有顯著意義。三組患者導管相關性感染發(fā)生率和類型的比較,一周組與兩周組均有1例患者發(fā)生導管相關性感染,三周組共有6例患者發(fā)生導管相關性感染,經比較p0.05,差別有顯著意義,故一周組和兩周組導管相關性感染總發(fā)生率明顯少于三周組；一周組與兩周組均無導管病原菌定植,三周組有5例導管病原菌定植,經比較差別有顯著意義,故一周組和兩周組導管病原菌定植明顯少于三周組；三組患者發(fā)生出口部位感染、隧道感染、導管相關血流感染的發(fā)生率,經比較差別無顯著意義。經過對三組患者輸液接頭細菌培養(yǎng)結果和導管相關性感染發(fā)生率及類型的比較,三周組雖然能為部分患者減輕經濟負擔,但容易造成導管病原菌定植,存在著安全隱患,不建議推廣使用,因此只對一周組和兩周組患者在非治療期間更換輸液接頭所花費用作比較P0.05,差別有顯著意義,兩周組明顯少于一周組。三組患者對非治療期間導管維護的滿意度分別為91.45%、97.58%、89.41%,經比較P0.05,兩周組滿意度明顯高于一周組和三周組。 樣本二兩組病例導致護士發(fā)生針刺傷的比較,實驗組采用的是無針輸液裝置,沒有針刺傷的發(fā)生,對照組有8名護士發(fā)生了針刺傷,與實驗組比較P0.01差別有顯著意義,實驗組明顯低于對照組；兩組患者非治療期間并發(fā)癥發(fā)生率的比較,試驗組總發(fā)生率為5.21%,對照組發(fā)生率為6.62%,P0.05差別無顯著意義,但實驗組導管堵塞的發(fā)生率與對照組相比χ2=3.86,p0.05差別有顯著意義,實驗組明顯低于對照組。 結論與建議 PICC可以安全的應用于各類惡性腫瘤病人的化療、中長期靜脈輸液、腸外營養(yǎng)及抗菌藥物治療等。其患者在非治療期間兩周更換一次輸液接頭,既能將導管相關性感染控制到最低,保證患者安全,又能減輕患者經濟負擔、提高患者滿意度,值得在臨床中推廣使用；無針正壓接頭在避免針刺傷、減少血源性感染及防止血液回流、減少導管堵塞等方面療效明顯,深受醫(yī)務人員和患者的歡迎。
[Abstract]:Research background
Peripherally inserted central venous Technology (peripherally inserted central catheter, PICC) in 1992 by the German doctor Forssmaon used for the first time, because of its convenient, effective, safe characteristics and has been widely used in clinical, and at the end of last century into China.PICC is an intravascular catheter, refers to the Zhou Jingmai (to you vein, median cubital vein, cephalic vein puncture, 1/3) under the tip of the superior vena cava, superior vena cava and the right atrium near the entrance of the deep venous catheterization. Wide indications, such as: (1) strong irritant drugs such as Cheng Hualiao therapy; (2) parenteral nutrition (TPN); (3) long-term intravenous infusion; (4) premature infants or very low birth weight infants (1.5kg); (5) the family intravenous treatment of.PICC with scalp needle and indwelling needle incomparable advantages, such as the indwelling time of up to 1 years, reduced the patient repeatedly puncture pain; the open end of the upper cavity catheter static Vein drug directly into the central vein, completely eliminate drug exudation or phlebitis caused by leakage and local tissue necrosis, therefore, after 2005 in three hospitals were carried out quickly, and the technology matures, indications continue to expand. The United States CDC (Center for Disease Control) 2011 stressed: "after catheter catheter maintenance should be the focus of the infusion quality control and improvement." CDC said PICC interface is an important cause of microbial colonization within the duct, especially long-term catheter indwelling, need transfusion joint type the appropriate closed pipe interface in patients during treatment, generally replaced once a week instead of transfusion joint treatment during infusion how long does it take to change a joint interval, which can be catheter-related infection control to a minimum, and can save medical resources and reduce the economic burden of the patients, the 2011 edition of the American venous transfusion nursing Not clear that the domestic society, no specific research on the nursing staff is defined standard, Liao Chunlan every 15 to 30 days to replace a transfusion, Pan Jianya replaced once every 7-10 days, Tu Wei sister every 2 weeks to replace a transfusion, but did not provide evidence based practice is confirmed. The best evidence (Study) with the interest of patients and medical workers judgment, in order to obtain safer, higher quality results. Our study is to provide evidence for appropriate time during treatment of patients with PICC to find the best replacement transfusion joint.
research objective
To explore the suitable time of patients with PICC catheter replacement transfusion in non treatment period, and provide evidence for clinical nursing work; influencing factors of catheter-related complications; to explore how to do non during the treatment of patients with PICC catheter maintenance, reduce the incidence of complications in patients with PICC.
Information and methods
Samples were collected in this study from July 2013 to December 2013 the infusion in 326 cases of non treatment during the hospital PICC nursing outpatient maintenance of patients using different days after the replacement of the positive pressure joint, the retention time of PICC in the body for up to a year, a week of catheter maintenance time during treatment of patients with non replacement transfusion joint and catheter to maintain synchronization, so the collected cases were divided into one week group (6-8 days), two weeks group (13-15 days), three weeks group (20-22 days), before and after the allowable error of one day, bacterial culture, observation of colony counting and classification of bacteria, the incidence of catheter-related infections, and economic benefits were analyzed the catheter maintenance during treatment satisfaction.
Samples of the 22 groups were selected during treatment in non PICC nursing outpatient maintenance of hospital patients, 287 cases from January 2013 to June 2013 in the end of the heparin cap PICC catheter patients as the control group, from July 2013 to December 2013 at the PICC end of the catheter using a needleless positive pressure infusion connector of 326 patients as the experimental group. The two groups of patients with age the condition, no significant tube sealing liquid with the uniform flush sealed tube method and operation process of maintenance, from two cases lead to analyze the medical staff of needle and two cases with catheter-related complications.
Main results
A sample of 13 patients the results of bacterial culture joint infusion, one week group and two week group of bacterial culture results of colony count was 0, in three weeks of sterile growth, the colony counting of bacterial culture results of 5 cases of 15cfu/ml, said that the growth of microorganisms, the difference was significant. Comparing the incidence and the type of the three groups of patients with catheter-related infection and catheter-related infection have a week group and two week group of 1 patients, three weeks group there were 6 cases of patients with catheter-related infection, compared with P0.05, the difference was significant, so one week group and two week group the total incidence of catheter-related infection was less than three week group; group of one week and two weeks no differences between the three groups catheter bacterial colonization, three weeks group with 5 cases of catheter colonization, the difference was significant, so the colonization in a week and two week group was significantly less than the three weeks group catheter pathogen; three groups The occurrence of exit site infection, tunnel infection, the incidence of catheter-related bloodstream infections, compared with no significant difference. After the three groups of patients with transfusion compared the incidence and type of bacterial culture results and catheter-related infection, three weeks group can reduce the economic burden for patients, but is likely to cause catheter bacterial colonization, there are security risks, is not recommended, therefore only for a week and two week group of patients during treatment in non transfusion joint replacement cost compared to P0.05, the difference was significant, two weeks was significantly less than a week group. The three groups of patients during treatment of catheter maintenance satisfaction respectively. 91.45%, 97.58%, 89.41%, compared with P0.05, two weeks group satisfaction was significantly higher than the one week group and three week group.
A sample of 22 cases occurred causing nurses needlestick injury, experimental group using a needle free infusion device, no needle stick injury, the control group of 8 nurses had needlestick injuries, and experimental group P0.01 showed significant difference in the experimental group was significantly lower than the control group; the two groups of patients during the treatment of non complication the occurrence rate of the test group, the total incidence rate was 5.21%, the incidence of the control group was 6.62% P0.05, there was no significant difference in the experimental group, but the incidence of catheter blockage compared with the control group was 2=3.86, there was significant difference between P0.05, the experimental group was significantly lower than the control group.
Conclusions and suggestions
PICC can be safely used in patients with malignant tumor of the chemotherapy, long-term intravenous infusion, parenteral nutrition and antibiotics therapy. The patients in the non treatment during the two weeks to replace a transfusion joint can be catheter-related infection control to a minimum, to ensure the safety of patients, but also can reduce the economic burden of patients, improve patient satisfaction, is worth popularizing in clinical use; needleless positive pressure connector to avoid needlestick injury, reduce blood borne infection and prevent the backflow of blood, reduce catheter blockage and obvious curative effect, by the medical staff and patients welcome.

【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R472

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