應(yīng)用超聲穿刺PICC技術(shù)

1、BAS Confidential and Proprietary. For Internal Educational Purposes OnlyPort Introduction Information超聲導(dǎo)引結(jié)合改良塞丁超聲導(dǎo)引結(jié)合改良塞丁格技術(shù)放置格技術(shù)放置PICC周娟巴德血管通道部BAS Confidential and Proprietary. For Internal Educational Purposes Only視銳5 超聲導(dǎo)引系統(tǒng) 置管專(zhuān)用超聲導(dǎo)引與改良塞丁格技術(shù)相結(jié)合-國(guó)際上廣泛應(yīng)用的穿刺技術(shù)國(guó)際上廣泛應(yīng)用的穿刺技術(shù) 對(duì)血管進(jìn)行直觀直觀的選擇與評(píng)估穿刺成功率穿刺成功率大大提

2、高 MST微血管鞘的應(yīng)用減小組織損傷減小組織損傷上臂置管上臂置管有助于機(jī)械性靜脈炎等并發(fā)癥發(fā)生率的降低 患者置管后的舒適度舒適度大大提高縮短護(hù)理時(shí)間成本BAS Confidential and Proprietary. For Internal Educational Purposes Only 經(jīng)皮穿刺插入導(dǎo)管的方法，由瑞典一位名叫塞丁格的放射科醫(yī)師發(fā)明BAS Confidential and Proprietary. For Internal Educational Purposes Only 用標(biāo)準(zhǔn)的套管針或小號(hào)針頭進(jìn)行靜脈穿刺。 通過(guò)穿刺針或套管送入導(dǎo)絲。 保留導(dǎo)絲將穿刺針或套管拔出。

3、 擴(kuò)張器插管器組件沿導(dǎo)絲送入，必要時(shí)可皮膚切開(kāi)，擴(kuò)大穿刺部位。 拔出導(dǎo)絲及擴(kuò)張器針芯。 通過(guò)擴(kuò)張器置入PICC到預(yù)測(cè)量的長(zhǎng)度。BAS Confidential and Proprietary. For Internal Educational Purposes Only血管鞘配置血管鞘配置 a、導(dǎo)絲、導(dǎo)絲35cm b、21G的鋼針的鋼針 c、20G的套管針的套管針 d、皮膚擴(kuò)張器、皮膚擴(kuò)張器 e、解剖刀、解剖刀BAS Confidential and Proprietary. For Internal Educational Purposes Only直接穿刺直接穿刺 使用14G的針直接由肘窩

4、處穿刺，屬于盲目穿刺方式 操作簡(jiǎn)單方便省時(shí) 必須選擇非常大的血管,成功率低 外露導(dǎo)管固定與肘窩影響病人活動(dòng)、增加合并癥細(xì)針導(dǎo)引細(xì)針導(dǎo)引 改良后塞丁格爾技術(shù)： 使用20-21G針穿刺，使用導(dǎo)絲及擴(kuò)張器漸推進(jìn)送入導(dǎo)管， 操作過(guò)程較直接穿刺法復(fù)雜，成功率較高 少量的局部麻醉劑應(yīng)用 困難穿刺、并發(fā)癥降低BAS Confidential and Proprietary. For Internal Educational Purposes Only改良塞丁格技術(shù) 熟悉改良塞丁格技術(shù)的應(yīng)用是開(kāi)展超聲引導(dǎo)下置管的基礎(chǔ) 非B超應(yīng)用時(shí)，可提高成功率，解決部分困難穿刺 減少穿刺者壓力BAS Confidential

5、 and Proprietary. For Internal Educational Purposes Only 超聲系統(tǒng)的工作原理 人耳可聽(tīng)到的聲波 20-20,000Hz 超聲波是一組高頻率的聲波 1-30MHz 科學(xué)家將電波通過(guò)晶體的高速震動(dòng)轉(zhuǎn)換成高頻率的超聲波。 當(dāng)這種聲波進(jìn)入人體后撞擊到不同的器官組織界面時(shí)便產(chǎn)生反射聲波并回收到晶體內(nèi)。 電腦通過(guò)對(duì)回收聲波的測(cè)量和分析，同時(shí)將數(shù)據(jù)轉(zhuǎn)換成圖像顯示在熒光屏幕上。BAS Confidential and Proprietary. For Internal Educational Purposes Only超聲波發(fā)射與接收BAS Confid

6、ential and Proprietary. For Internal Educational Purposes Only如何在超聲波下找血管？1、正常的血管內(nèi)的血液無(wú)回聲，在英光屏上圖像呈現(xiàn) 黑色；2、血管的輪廓經(jīng)過(guò)圖像銳化處理，與周?chē)M織邊界更清晰。3、尋找“黑洞” BAS Confidential and Proprietary. For Internal Educational Purposes Only血管的橫斷圖 vs. 縱向圖BAS Confidential and Proprietary. For Internal Educational Purposes Only區(qū)分動(dòng)靜脈

7、區(qū)分動(dòng)靜脈 尋找 血管 靜脈容易被壓癟 受壓迫時(shí)沒(méi)有脈沖現(xiàn)象 動(dòng)脈有彈性，不易被壓癟，有脈沖現(xiàn)象BAS Confidential and Proprietary. For Internal Educational Purposes Only 在這幅圖中你能看見(jiàn)什么結(jié)構(gòu)? 靜脈靜脈 動(dòng)脈動(dòng)脈 神經(jīng)神經(jīng)BAS Confidential and Proprietary. For Internal Educational Purposes Only手提式超聲顯示屏專(zhuān)為最輕松地獲得血管通專(zhuān)為最輕松地獲得血管通路而設(shè)計(jì)路而設(shè)計(jì)直觀的、單一功能的操作直觀的、單一功能的操作按鍵按鍵屏幕圖示清晰易懂屏幕圖示清晰

8、易懂BAS Confidential and Proprietary. For Internal Educational Purposes Only清晰的屏幕顯示BAS Confidential and Proprietary. For Internal Educational Purposes Only探頭和顯示屏按鈕開(kāi)/關(guān)/重置增加和減少增益深度凍結(jié)圖像 按5秒打印或保存圖像可以實(shí)現(xiàn)在無(wú)菌區(qū)獨(dú)立操作BAS Confidential and Proprietary. For Internal Educational Purposes Only探頭應(yīng)用探頭應(yīng)用 最少量的導(dǎo)電糊讓探頭可以在皮膚上

9、滑動(dòng)并獲得適當(dāng)?shù)膫鲗?dǎo)。 單一探頭，多種深度掃描 保持探頭與皮膚垂直，輕輕的貼著皮膚，以得到最佳的影像. 確定血管在屏幕的中央，獲取血管深度。BAS Confidential and Proprietary. For Internal Educational Purposes Only探頭方向標(biāo)記深度標(biāo)記 0.5 cm中心標(biāo)記導(dǎo)管尺寸圖標(biāo)適合的導(dǎo)管尺寸血管深度 -中心深度標(biāo)記點(diǎn)BAS Confidential and Proprietary. For Internal Educational Purposes Only導(dǎo)針器導(dǎo)針器-專(zhuān)利設(shè)計(jì)專(zhuān)利設(shè)計(jì)BAS Confidential and Pro

10、prietary. For Internal Educational Purposes Only導(dǎo)針器的優(yōu)點(diǎn)導(dǎo)針器的優(yōu)點(diǎn)1 cm2 cmBAS Confidential and Proprietary. For Internal Educational Purposes Only無(wú)菌導(dǎo)電糊、無(wú)菌罩無(wú)菌導(dǎo)電糊、無(wú)菌罩BAS Confidential and Proprietary. For Internal Educational Purposes Only步驟： 病人的評(píng)估 向病人說(shuō)明與解釋 用物準(zhǔn)備（含超聲儀器設(shè)定與準(zhǔn)備） 工作人員準(zhǔn)備 皮膚消毒 評(píng)估血管 超聲波導(dǎo)引器 PICC導(dǎo)管準(zhǔn)備 X

11、光確認(rèn)PICC導(dǎo)管末端位置BAS Confidential and Proprietary. For Internal Educational Purposes Only向病人說(shuō)明與解釋BAS Confidential and Proprietary. For Internal Educational Purposes Only評(píng)估血管評(píng)估血管動(dòng)脈:血管當(dāng)受到探頭的壓迫時(shí)，會(huì)顯示 有脈沖現(xiàn)象，而不會(huì)完全被壓扁靜脈:血管當(dāng)受到探頭的壓迫時(shí)會(huì)完全變扁，且無(wú)脈沖現(xiàn)象首選右側(cè)貴要靜脈BAS Confidential and Proprietary. For Internal Educational P

12、urposes OnlyPICC套件PICC穿刺包MST套件導(dǎo)針器套件無(wú)粉手套10*12透明貼膜消毒物品生理鹽水BAS Confidential and Proprietary. For Internal Educational Purposes Only準(zhǔn)備工作準(zhǔn)備工作六六步步洗洗手手法法BAS Confidential and Proprietary. For Internal Educational Purposes Only工作人工作人員準(zhǔn)備員準(zhǔn)備 完整的訓(xùn)練 熟練的靜脈注射技術(shù) 采用最大范圍的覆蓋以預(yù)防導(dǎo)管相關(guān)感染(CDC, 2002) BAS Confidential and Pr

13、oprietary. For Internal Educational Purposes Only皮膚皮膚消毒消毒 2% 洗必泰為優(yōu)先選用的消毒溶液(CDC, 2002) 碘伏及75%酒精BAS Confidential and Proprietary. For Internal Educational Purposes Only 建立無(wú)菌區(qū)建立無(wú)菌區(qū)BAS Confidential and Proprietary. For Internal Educational Purposes Only無(wú)菌物品的擺放無(wú)菌物品的擺放BAS Confidential and Proprietary. For

14、 Internal Educational Purposes Only 超聲探頭應(yīng)用超聲探頭應(yīng)用BAS Confidential and Proprietary. For Internal Educational Purposes Only 探頭的擺放探頭的擺放 導(dǎo)線處于無(wú)菌區(qū)域?qū)Ь€處于無(wú)菌區(qū)域BAS Confidential and Proprietary. For Internal Educational Purposes Only 選擇合適的導(dǎo)針器選擇合適的導(dǎo)針器導(dǎo)針器BAS Confidential and Proprietary. For Internal Educational P

15、urposes Only再次超聲定位，準(zhǔn)備穿刺再次超聲定位，準(zhǔn)備穿刺BAS Confidential and Proprietary. For Internal Educational Purposes Only皮下局部麻醉皮下局部麻醉 靜脈穿刺靜脈穿刺BAS Confidential and Proprietary. For Internal Educational Purposes Only在針入血管的瞬間，在針入血管的瞬間，血管會(huì)凹下去血管會(huì)凹下去BAS Confidential and Proprietary. For Internal Educational Purposes Onl

16、y靜脈穿刺靜脈穿刺 見(jiàn)回血，輕輕分離探頭見(jiàn)回血，輕輕分離探頭BAS Confidential and Proprietary. For Internal Educational Purposes Only鋼針穿刺成功后有回血鋼針穿刺成功后有回血BAS Confidential and Proprietary. For Internal Educational Purposes Only持持導(dǎo)絲導(dǎo)絲放入放入穿刺針穿刺針內(nèi)內(nèi), , 以以確確保保導(dǎo)絲導(dǎo)絲在血管在血管內(nèi)內(nèi)導(dǎo)絲在體外保留至少導(dǎo)絲在體外保留至少10-15cm10-15cmBAS Confidential and Proprietary.

17、For Internal Educational Purposes Only撤出穿刺針，擴(kuò)大穿刺點(diǎn)撤出穿刺針，擴(kuò)大穿刺點(diǎn)（酌情給與局麻）BAS Confidential and Proprietary. For Internal Educational Purposes Only沿導(dǎo)絲插入擴(kuò)張器沿導(dǎo)絲插入擴(kuò)張器/插管鞘組件插管鞘組件BAS Confidential and Proprietary. For Internal Educational Purposes Only擴(kuò)張器擴(kuò)張器/插管鞘組件沿導(dǎo)絲推入靜脈內(nèi)插管鞘組件沿導(dǎo)絲推入靜脈內(nèi)BAS Confidential and Proprie

18、tary. For Internal Educational Purposes Only撤出導(dǎo)絲及擴(kuò)張器撤出導(dǎo)絲及擴(kuò)張器BAS Confidential and Proprietary. For Internal Educational Purposes Only 從插管鞘中送入到上腔靜脈從插管鞘中送入到上腔靜脈BAS Confidential and Proprietary. For Internal Educational Purposes Only撕裂撕裂/退出穿刺鞘退出穿刺鞘BAS Confidential and Proprietary. For Internal Education

19、al Purposes Only在超聲下觀察頸內(nèi)靜脈在超聲下觀察頸內(nèi)靜脈BAS Confidential and Proprietary. For Internal Educational Purposes Only導(dǎo)管固定導(dǎo)管固定導(dǎo)管導(dǎo)管U U型擺放型擺放紗塊壓迫、覆蓋透明貼膜紗塊壓迫、覆蓋透明貼膜BAS Confidential and Proprietary. For Internal Educational Purposes OnlyBAS Confidential and Proprietary. For Internal Educational Purposes Only導(dǎo)管固定導(dǎo)管固定彈力繃帶包扎彈力繃帶包扎BAS Confidential and Proprietary. For Inte