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1、ICU深静脉插管技术详解简单易懂，告别国内教科书 来自美国旧金山加利福尼亚大学的培训资料，彻底告别国内不专业的文献以及教科书。深静脉插管主要适应症： . 给予药物-很多药物（升压药、化疗药、全胃肠外营养等）因为具有刺激性，不适合经浅静脉导管给药，故需要经中心静脉导管给药。 . 血液动力学检测-检测中心静脉压；. 血浆过滤、血浆置换术、血液透析、持续静脉-静脉血液滤过。次要适应症：. 浅静脉通路困难；. 容量复苏。绝对禁忌症: Cellulitis over the vein site (must pick alternative location) Peripheral IV access i
2、s adequate for the clinical needs of the patient Operator inexperience (unless supervised by an experienced practitioner) Uncooperative or combative patients Infection over catheter site Clot in the selected vein 相对禁忌症：部位选择：你的病人能够忍受相应的并发症吗？LocationAdvantagesDisadvantagesFemoral VeinFast, easy, highs
3、uccess rateDoes not interfere withintubation 0% risk of pneumothoraxHard to keep the site sterileNo CVP monitoringPrevents patient mobilizationHigher rates of thrombosis than SCVHigher rates of line infectionFemoral artery puncture more frequent than SCVInternal JugularEasy to control bleedingPneumo
4、thorax is less commonStraight shot into SVCDifficult to access if pt being intubated or withtrach or has a large neckDressings hard to maintainPoor landmarks in obese patientsCarotid puncture more frequent than SCVHigher rates of thrombosis than SCVSubclavian VeinMost comfortable for patientBony lan
5、dmarks in obesityHigher risk for pneumothoraxCompression of bleeding site difficultLong pass from skin to vein (consider in obesity)Lowest risk of thrombosisLowest risk of line infectionContraindications serious lung disease, coagulopathy解剖： The IJ vein travels with the carotid artery; the vein typi
6、cally lies anterolateral to the carotid artery. It runs under the medial portion of the upper part of the sternocleidomastoid muscle and travels under the apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle.The subclavian vein is easily
7、found in almost every patient, and a catheter in the subclavian vein is more comfortable for the patient than one placed in the internal jugular vein.As the subclavian vein crosses behind the first rib, it lies posterior to the medial third of the clavicle, and has a diameter of 1-2 cm. At this poin
8、t, the subclavian artery lies superior and posterior to the vein. As these vessels continue laterally, they both drop caudally to enter the axillary region. The right side is often preferred for line insertions as the dome of the pleura of the lung may extend above the first rib on the left, but rar
9、ely extends this far on the right. Insertion on the right also avoids the risk of damage to the thoracic duct on the left.ConsentAlways obtain consent prior to the procedure.Be sure to inform the patient of the reason for the procedure, the proposed benefits, its major risks and the potential manage
10、ment of these complications (including insertion of a chest tube, surgery or cardioversion). It is also best to walk the patient through the steps of the procedure to minimize their anxiety.Step-by-Step Procedures Guide GETTING READY FOR THE PROCEDURE: C-SOAPIMC: comfort, make sure you are comfortab
11、le with the environment. Assure there is enough room around the patient, get table in the right spot, raise bed for your comfort, get appropriate supervision in case of complications. Give patient appropriate medicines before procedure (i.e. intubated pt can get sedatives or narcotics)S: sterility.
12、This means full sterile gown, mask, eye protection, gloves and an additional sterile sheet to cover the ENTIRE patient. (sheet in kit is too small and not enough)O: oxygen. Make sure patient has sufficient oxygen supplementation before the procedure. Intubated patient should be on 100% FIO2.A: airwa
13、y. Make sure the airway is secure. This is very important for spontaneously breathing patients, as you will cover their face and put them in an awkward position. Assure that they can tolerate the position for a period of time.P: position. Patients should be placed in trendenlendburg position for all
14、 neck lines. In addition, for subclavian lines a roll should be placed between the shoulder blades to improve anatomic landmarks.I: IV access. In case there is a complication, it is always good to have peripheral IV access that is free flowing and available in case of a need to perform rescusitation
15、 or administer code medications.M: monitors. Minimum monitoring includes a continous O2 monitor and heart rate monitor. Blood pressure should also be cycled more frequently, about every 5 minutes, to assure patient safety. Have the volume turned up on the monitor so that you can hear the stability o
16、f your vitals and assign a person in the room to keep a watch on the vitals.EquipmentBefore you begin, you should be familiar with the kit. One should gather all needed materials before starting the procedure. In addition to a central venous access kit, you will need the following supplies: Insertion
