Clinical data of 1
1. 1 General information Since September 2007, 50 patients hospitalized in xinqiao hospital Tumor Ward III of the Third Military Medical University have received PICC catheter chemotherapy, including 28 males and 22 females. Age 13 ~ 65 years old. The intubation time was 7 ~ 130 days, and the average intubation time was 58.5 days. The success rate of one-time catheterization was 98% in 50 cases, 1 case was blocked after successful puncture and then extubated. The patient and his family refused to have a second catheterization. The failure rate is 2%.
1.2 The equipment adopts blue PICC catheter produced by Bader Company of the United States, with a length of 60cm and a lumen volume of 1ml. Before intubation, the treatment room should be disinfected by ultraviolet rays, with sufficient light and ready for puncture. PICC puncture kit, sterile gloves, iodine, ethanol, medical cotton swab, tape measure, tourniquet, sterile heparin saline, clover infusion connector, 20ml syringe, intravenous puncture kit and 3M transparent membrane.
2 preoperative preparation
(1) Do a good job in psychological care of patients, let them know the purpose, process, postoperative precautions and possible complications of the operation, make them psychologically prepared, and let them sign the consent form for intubation. (2) Assist the patient to set the position, and select appropriate blood vessels and catheters (4F, 5F). (3) Measure the length of the vein. (4)PICC puncture kit, diluted heparin solution and normal saline.
3 test tube placement steps
(1) To determine the puncture point of vein and intubation, thick and straight vein with few venous valves is preferred, followed by median elbow vein and cephalic vein. The patient lay on his back, arms abduction, 90 degrees to the trunk, and measured and positioned. The subclavian vein was measured from the point before puncture to the sternal notch, and then subtracted by 2cm[2]. (2) Establish sterile area, disinfect puncture point, pre-flush catheter with normal saline, and trim the length of catheter. (3) Tie the tourniquet, and insert the needle at 15 ~ 30. Once the blood returns, immediately push down the catheter needle to an angle of 3 ~ 6mm, send it to the external intubation, fix the guide tube with the fingers of the left hand, press the middle finger on the blood vessel at the catheter tip, loosen the tourniquet, pull out the puncture needle, clamp the catheter tip with tweezers, and gradually send the catheter to a predetermined length, exit the guide tube, and use. (4) After successful intubation, apply local pressure for 20min, and instruct the intubated limbs to avoid strenuous activities to prevent bleeding.
4 record after placing the test tube
Name and date of PICC placement, PICC type, catheter model, catheter tip position, insertion length and exposure length, name of puncture vein, and whether the puncture process is smooth and fixed.
5 nursing
(1) Nursing before catheterization. Before catheterization, the surgical nurse should explain the importance of catheterization, the possible situations during the operation and the main points that need the cooperation of patients, obtain the understanding and support of patients and their families, and sign a puncture consent form with them. To understand the coagulation function and platelet value of patients; Measure the length of the pipe carefully. During the operation, strict aseptic operation and corresponding psychological care were carried out. (2) Nursing in catheterization. Pay attention to keep warm when catheterization. When the catheter enters the shoulder, let the patient's head turn to the puncture side and chin rest on the shoulder to prevent the catheter from entering the internal jugular vein. If it is difficult to convey the catheter, you can pull it back slightly, adjust the puncture needle slightly before conveying the catheter, or push 0.9% sodium chloride injection while conveying the catheter. In case of resistance, the catheter cannot be forcibly transported. Ask the patient to adjust the body position properly so that the upper limbs are perpendicular to the trunk, or pause for a period of time before delivering the catheter. If it is not possible, put it into the contralateral vein. (3) Nursing after catheterization. Placing a piece of gauze with the size of about 2cm×2cm at the puncture point, and then sticking a transparent film, on the one hand, can play the role of pressure hemostasis, on the other hand, it is beneficial to observe the bleeding situation. Under normal circumstances, replace the film every 24 hours and then once a week. If there is bleeding, pollution or humidity, please replace it at any time. When replacing, pay attention to uncovering the film from bottom to top, do not touch the skin in the film-covered area with your hands, and strictly carry out aseptic operation. Closely observe the puncture point for bleeding and edema, and touch the puncture point for pain and induration. If you have pain and induration, you can use hirudoid for external application, and the effect is better. If the amount of bleeding is small, the patch can be replaced directly. If the amount of bleeding is large, elastic bandage can be used to wrap the patch or gel sponge can be placed at the puncture point to stop bleeding. Observe and record the scale of the catheter every day to see if the catheter is discounted. If part of the catheter falls off, local fixation can be used, and the fallen catheter must not be sent into blood vessels to prevent infection. Observe the infusion speed every time. If the dripping speed is not smooth, the pipe may be blocked. After daily infusion, seal the pipe with 20ml physiological saline pulse.
6 Prevention and treatment of common complications
6. 1 Nurses with catheter blockage need to master the correct tube sealing technology, which can prevent blood from entering the lumen, causing coagulation and tube blockage. Blood transfusion, plasma, fat emulsion, etc. Will increase the possibility of catheter blockage. After blood transfusion, the catheter was washed with 0.9% sodium chloride injection. Don't take a blood test through a catheter. Once the catheter is blocked, do not forcibly inject liquid, otherwise there is a risk of catheter rupture or embolism. First, check whether the catheter is discounted. After eliminating the above reasons, if it is not completely blocked, repeatedly aspirate or rinse the catheter with 0.9% sodium chloride injection to obtain the catheter. If it is still blocked by the above method, it can be sucked with a syringe containing 20 ~ 50u/ml 10ml heparin sodium solution, and then it is relaxed. With the help of negative pressure, the catheter can be reopened after suction and push. There were/kloc-0 cases of blockage in our department, and the catheter was unobstructed after the above treatment.
6.2 Phlebitis After PICC, edema, pain and phlebitis of upper limbs are easily caused by slow blood flow caused by catheter, stimulation of foreign bodies in blood vessels and vasospasm caused by patients' tension [3]. In order to reduce the occurrence of phlebitis, the choice of catheter model should be suitable for the diameter of blood vessels, and the puncture action should be gentle, which can reduce the mechanical stimulation to blood vessels and damage the intima of blood vessels. Chemical phlebitis is easily caused by infusion of highly irritating chemotherapy drugs. Before infusion, ensure that the catheter tip is in the superior vena cava. After phlebitis, raise the affected limb and apply local wet and hot compress four times a day for 20 ~ 30 min each time. If the symptoms are not relieved within 3 days, extubation should be considered. After extubation, wet and hot compress should be continued, and fluid infusion from this part should be stopped [4].
7 application experience
(1) Three-way PICC is made of medical advanced silicone material, and the catheter is very soft. No matter the puncture process or long-term catheterization, it will not damage the intima of blood vessels, nor will it cause blood vessel wall penetration, which reduces the possibility of phlebitis or thrombosis. (2)PICC chose elbow vein to intubate central vein. The elbow vein is easy to be seen or palpated, and there is no important tissue structure around it, so the surgical trauma is small. No complications such as bleeding, pneumothorax, arterial injury and air embolism occurred in this group. (3) The infused hypertonic, highly viscous and irritating drugs directly enter the central vein through PICC catheter and are quickly diluted by blood, which reduces the toxic effect of drugs on peripheral blood vessels, protects the peripheral vascular network, and solves the problems of drug extravasation and drug-induced pain [5]. (4) The iatrogenic infection caused by central vein is quite high. It is reported that the mortality rate of PICC catheter infection is 3%, and most infections are caused by bacteria on the skin of the intubation site migrating outside the catheter cavity through subcutaneous tunnels. Therefore, strict aseptic operation, cleaning, disinfection and protection of puncture site are very important. (5)PICC puncture procedure is simple and easy to master, which not only eliminates the pain of repeated venipuncture, but also greatly reduces the workload of medical care and reduces the risk of infection, and is especially suitable for multi-course chemotherapy of tumor patients. Due to the short use time and few cases in our department, there may be many long-term nursing problems that have not been discovered in time, such as catheter drift, ectopic, rupture and embolism. We will pay attention to observation and accumulate more nursing experience in future use.