穿刺相關(guān)課件

1、深靜脈穿刺什么是深靜脈穿刺？指經(jīng)體表將導(dǎo)管或監(jiān)測(cè)探頭 置入上、下腔靜脈及右心房、肺動(dòng)脈內(nèi)的一種有創(chuàng)的操作技術(shù)。適應(yīng)癥及用途監(jiān)測(cè)中心靜脈壓衡量右心泵功能及時(shí)應(yīng)用急救藥物、輸血、輸液經(jīng)導(dǎo)管安裝臨時(shí)起搏器漂浮導(dǎo)管(PCWP)長(zhǎng)時(shí)間靜脈營(yíng)養(yǎng)(TPN)相對(duì)禁忌癥Anticoagulation or thrombolytic therapyBleeding disordersCombative patientsDistorted local anatomyVasculitis Cellulitis, burns, severe dermatitis at site物品準(zhǔn)備做穿刺前準(zhǔn)備好物品和液體穿刺包，靜

2、脈靜脈導(dǎo)管無(wú)菌紗布、無(wú)菌手套、5ml一次性注射器兩個(gè)，鋪巾、中心靜脈穿刺包（內(nèi)有導(dǎo)絲、中心靜脈導(dǎo)管、擴(kuò)皮器等）薄膜敷貼等0.9%NS和利多卡因各一支在檢查的過(guò)程中，使物品都處于備用狀態(tài)穿刺的基本原則確定深靜脈置管是否有必要簽署同意書(shū)掌握解剖知識(shí)熟練使用穿刺用品取得病人配合嚴(yán)格無(wú)菌操作穿刺過(guò)程中總有一個(gè)手持導(dǎo)絲敢于請(qǐng)示上級(jí)（敢于放棄）穿刺時(shí)請(qǐng)保持穿刺針負(fù)壓重新定位時(shí)須將針尖退至皮下術(shù)后胸片再次定位Seldinger technique粗針定位Use introducing needle to locate vein導(dǎo)絲順針而入Wire is threaded through the needle

3、移開(kāi)粗針 Needle is removed擴(kuò)皮 Skin and vessel are dilated順導(dǎo)絲置入導(dǎo)管Catheter is placed over the wire移開(kāi)導(dǎo)絲Wire is removed固定導(dǎo)管Catheter is secured in place頸內(nèi)靜脈穿刺術(shù)解剖學(xué)關(guān)系體表標(biāo)志穿刺方法禁忌癥頸內(nèi)靜脈穿刺禁忌癥上腔靜脈血栓形成氣管切開(kāi)術(shù)后一側(cè)穿刺失敗后對(duì)側(cè)穿刺解剖學(xué)關(guān)系體表定位中路定位及操作體位：病人仰臥，頭低位，右肩部墊起，頭后仰使頸部充分伸展，面部略轉(zhuǎn)向?qū)?cè)。穿刺點(diǎn)與進(jìn)針：鎖骨與胸鎖乳突肌的鎖骨頭和胸骨頭所形成的三角區(qū)的頂點(diǎn)，頸內(nèi)靜脈正好位于此三角形的中

4、心位置，該點(diǎn)距鎖骨上緣約35cm，進(jìn)針時(shí)針干與皮膚呈30角，與中線平行直接指向足端。如果穿刺未成功，將針尖退至皮下，再向外傾斜10左右，指向胸鎖乳突肌鎖骨頭的內(nèi)側(cè)后緣，常能成功。一般選用中路穿刺。因?yàn)榇它c(diǎn)可直接觸及頸總動(dòng)脈，可以避開(kāi)頸總動(dòng)脈，誤傷動(dòng)脈的機(jī)會(huì)較少。另外此處頸內(nèi)靜脈較淺，穿刺成功率高。體表定位鎖骨下靜脈穿刺術(shù)根據(jù)穿刺點(diǎn)與鎖骨關(guān)系分為鎖骨上入路及鎖骨下入路鎖骨下靜脈穿刺禁忌癥呼吸衰竭肺大皰高PEEP凝血功能異常上腔靜脈血栓胸部外傷解剖解剖解剖特點(diǎn)1.起自腋靜脈，跨第一肋骨上方，經(jīng)鎖骨中斷的后方，在胸鎖關(guān)節(jié)后與頸內(nèi)靜脈匯合無(wú)名靜脈，入胸腔，后與對(duì)側(cè)的無(wú)名靜脈匯合上腔靜脈；2.鎖骨下靜脈

5、后方膈前角肌與鎖骨下動(dòng)脈伴行，鎖骨下靜脈在前，鎖骨下動(dòng)脈在后；3.胸骨頂在鎖骨下靜脈后方約5mm處 誤傷胸膜是經(jīng)皮鎖骨下靜脈穿刺可能遇到的最大危險(xiǎn)。解剖特點(diǎn)鎖骨下靜脈解剖標(biāo)志清楚，位置較淺表，粗大(內(nèi)徑12cm)，成人粗如拇指，血流快，經(jīng)常處于充盈狀態(tài)，故易于穿刺。鎖骨下靜脈插管不影響氣管插管及人工呼吸；置管后不影響病人活動(dòng)，便于護(hù)理。股靜脈穿刺禁忌癥下腔靜脈病變（血栓、濾網(wǎng)）局部感染心肺復(fù)蘇術(shù)后腹腔內(nèi)壓增加股靜脈穿刺置管術(shù)股靜脈的解剖：股靜脈位于股鞘內(nèi)，緊靠股動(dòng)脈內(nèi)側(cè)。股靜脈的體表投影位置為腹股溝韌帶中、內(nèi)1/3交點(diǎn)下方約2.5cm處。體位及穿刺點(diǎn)穿刺點(diǎn)：病人仰臥，大腿稍外展，在腹股溝韌帶中

6、、內(nèi)1/3交點(diǎn)下方約2.5cm處觸及股動(dòng)脈搏動(dòng)的內(nèi)側(cè)進(jìn)針：向內(nèi)上方呈45角，進(jìn)入2.54cm并發(fā)癥血栓并發(fā)癥機(jī)械并發(fā)癥：誤穿動(dòng)脈、氣胸、血胸、血?dú)庑亍⒊鲅?、?dòng)靜脈瘺、胸導(dǎo)管損傷、神經(jīng)損傷感染并發(fā)癥： 穿刺部位感染：紅腫、硬結(jié)、膿性分泌物 導(dǎo)管細(xì)菌定植：導(dǎo)管培養(yǎng)（+），外周血培養(yǎng) （-） 導(dǎo)管相關(guān)性血行感染：外周血和導(dǎo)管培養(yǎng)出相 同細(xì)菌各種入路穿刺方法比較穿刺入路優(yōu)點(diǎn)缺點(diǎn)頸內(nèi)靜脈一旦出血可快速發(fā)現(xiàn)，并且易于按壓止血；氣胸發(fā)生率相對(duì)較低；導(dǎo)管不易移位容易誤穿頸內(nèi)動(dòng)脈；仍有一定氣胸發(fā)生率鎖骨下靜脈病人舒適容易并發(fā)氣胸，插管病人不宜使用；一旦出血不易按壓止血；病人年齡2歲不宜使用導(dǎo)管移位發(fā)生率高股靜脈

7、容易定位；無(wú)氣胸發(fā)生可能；推薦于急診使用；極少發(fā)生不良并發(fā)癥DVT；穿刺點(diǎn)容易感染；對(duì)于長(zhǎng)期制動(dòng)、臥床患者不建議使用Practical problems common to most techniques of insertionArterial punctureUsually obvious but may be missed in a patient who is hypoxic or hypotensive. If unsure, connect a length of manometer tubing to the needle / catheter and look for bloo

8、d flow which goes higher than 30cm vertically or is strongly pulsatile. Withdraw the needle and apply firm direct pressure to the site for at least 10 minutes or longer if there is continuing bleeding. If there is minimal swelling then retry or change to a different routeSuspected pneumothoraxIf air

9、 is easily aspirated into the syringe (note that this may also occur if the needle is not firmly attached to the syringe) or the patient starts to become breathless. Abandon the procedure at that site. Obtain a chest radiograph and insert an intercostal drain if confirmed. If central access is absol

10、utely necessary then try another route ON THE SAME SIDE or either femoral vein. DO NOT attempt either the subclavian or jugular on the other side in case bilateral pneumothoraces are produced.Arrhythmias during the procedureUsually from the catheter or wire being inserted too far (into the right ven

11、tricle). The average length of catheter needed for an adult internal jugular or subclavian approach is 15cm. Withdraw the wire or catheter if further than this.Air embolusThis can occur, especially in the hypovolaemic patient, if the needle or cannula is left in the vein whilst open to the air. It i

12、s easily prevented by ensuring that the patient is positioned head down (for jugular and subclavian routes) and that the guidewire or catheter is passed down the needle promptly.The wire will not thread down the needleCheck that the needle is still in the vein. Flush it with saline. Try angling the

13、needle so the end of it lies more along the plane of the vessel. Carefully rotate the needle in case the end lies against the vessel wall. Reattach the syringe and aspirate to check that you are still in the vein. If the wire has gone through the needle but will not pass down the vein it should be v

14、ery gently pulled back. If any resistance is felt then the needle should be pulled out with the wire still inside, and the procedure repeated. This reduces the risk of the end of the wire being cut off by the needle tip.Persistent bleeding at the of entryApply firm direct pressure with a sterile dressing. Bleeding should usually stop unless there is a coagulation abnormality. Persistent severe bleeding may require surgical explora