非治疗期间PICC患者更换输液接头适宜时间的研究

发布时间：2018-01-22 01:10

本文关键词： 外周置入中心静脉导管(PICC) 非治疗期间输液接头更换适宜时间　出处：《山东大学》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景外周置入中心静脉技术(peripherally inserted central catheter, PICC)在1992年由德国医生Forssmaon首次使用,因其方便、有效、安全的特点而被广泛应用于临床,并于上世纪末传入我国。PICC是血管内导管的一种,是指经外周静脉(贵要静脉、肘正中静脉、头静脉)穿刺置管,其尖端位置达上腔静脉的下1/3,靠近上腔静脉与右心房入口处的深静脉置管术。适应症广,如：(1)强刺激性药物如多疗程化疗；(2)胃肠外营养(TPN)；(3)长期静脉输液；(4)早产儿或极低体重儿(1.5kg)；(5)家庭静脉治疗。PICC具有头皮钢针和留置针无法比拟的优势,如留置时间可长达1年,减轻了患者反复穿刺的痛苦；导管开口端在上腔静脉,药物直接输入中心静脉,彻底杜绝药物渗出或因渗出导致的静脉炎和局部组织坏死,因此,2005年以后在三级医院被迅速开展,且技术日益成熟,适应症不断扩大。美国CDC(疾病控制中心)2011强调：“导管置入后的导管维护应成为输液质量控制和改进的关注重点。”CDC认为PICC外接口是导致导管内微生物定植的一个重要原因,尤其是长期留置的导管,需要型号合适的输液接头封闭导管外接口,在患者治疗期间,一般每周更换一次输液接头,而非治疗期间输液接头间隔多长时间更换一次,既能将导管相关性感染控制到最低,又能节约医疗资源及减轻患者经济负担,2011版美国静脉输液护理学会未明确指出,国内亦无专项研究,护理同仁则自订标准,廖春兰等每15～30天更换一次输液接头,潘建亚每7-10天更换一次,涂伟妹等则每2周更换一次输液接头,但均未提供循证依据。循证实践是将最佳的证据(研究)结合病人利益及医疗工作者的判断,以求获得更安全、更高质量的结果。我们的研究就是为非治疗期间PICC患者寻找最佳更换输液接头的适宜时间提供循证依据。研究目的探索PICC置管患者在非治疗期间更换输液接头的适宜时间,为临床护理工作提供循证依据；分析引起导管相关并发症的影响因素；探讨如何做好非治疗期间PICC带管患者的维护,降低PICC患者并发症的发生率。资料与方法样本一本研究共收集了2013年7月至2013年12月在某医院PICC护理门诊维护的326例非治疗期间的患者使用不同天数后更换的输液正压接头,PICC在体内保留时间可长达一年,需要每周对导管维护一次,非治疗期间患者更换输液接头基本和导管维护同步,所以将收集病例分为一周组(6-8天)、两周组(13-15天)、三周组(20-22天),前后允许误差一天,进行细菌培养,观察菌落计数和细菌分类,从导管相关性感染的发生率、经济效益和患者对非治疗期间导管维护的满意度等方面进行分析。样本二两组均选取在某医院PICC护理门诊维护的非治疗期间的患者,2013年1月至2013年6月在PICC导管末端使用肝素帽的287例患者作为对照组,2013年7月至2013年12月在PICC导管末端使用无针正压输液接头的患者326例作为实验组。两组患者的年龄、病情无统计学意义,采用的封管液、冲封管方法及维护的操作流程均一致,从两组病例导致医护人员发生针刺伤的情况以及两组病例发生导管相关并发症的情况进行分析。主要结果样本一三组患者输液接头细菌培养结果的比较,一周组和两周组的细菌培养结果菌落计数均为0,示无菌生长,三周组的细菌培养结果其菌落计数有5例15cfu/ml,表示有微生物生长,经比较差别有显著意义。三组患者导管相关性感染发生率和类型的比较,一周组与两周组均有1例患者发生导管相关性感染,三周组共有6例患者发生导管相关性感染,经比较p0.05,差别有显著意义,故一周组和两周组导管相关性感染总发生率明显少于三周组；一周组与两周组均无导管病原菌定植,三周组有5例导管病原菌定植,经比较差别有显著意义,故一周组和两周组导管病原菌定植明显少于三周组；三组患者发生出口部位感染、隧道感染、导管相关血流感染的发生率,经比较差别无显著意义。经过对三组患者输液接头细菌培养结果和导管相关性感染发生率及类型的比较,三周组虽然能为部分患者减轻经济负担,但容易造成导管病原菌定植,存在着安全隐患,不建议推广使用,因此只对一周组和两周组患者在非治疗期间更换输液接头所花费用作比较P0.05,差别有显著意义,两周组明显少于一周组。三组患者对非治疗期间导管维护的满意度分别为91.45%、97.58%、89.41%,经比较P0.05,两周组满意度明显高于一周组和三周组。样本二两组病例导致护士发生针刺伤的比较,实验组采用的是无针输液装置,没有针刺伤的发生,对照组有8名护士发生了针刺伤,与实验组比较P0.01差别有显著意义,实验组明显低于对照组；两组患者非治疗期间并发症发生率的比较,试验组总发生率为5.21%,对照组发生率为6.62%,P0.05差别无显著意义,但实验组导管堵塞的发生率与对照组相比χ2=3.86,p0.05差别有显著意义,实验组明显低于对照组。结论与建议 PICC可以安全的应用于各类恶性肿瘤病人的化疗、中长期静脉输液、肠外营养及抗菌药物治疗等。其患者在非治疗期间两周更换一次输液接头,既能将导管相关性感染控制到最低,保证患者安全,又能减轻患者经济负担、提高患者满意度,值得在临床中推广使用；无针正压接头在避免针刺伤、减少血源性感染及防止血液回流、减少导管堵塞等方面疗效明显,深受医务人员和患者的欢迎。
[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.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R472

【参考文献】