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首页 静脉穿刺

静脉穿刺

静脉穿刺

yoyo
2009-04-21 0人阅读 举报 0 0 暂无简介

简介:本文档为《静脉穿刺pdf》,可适用于自然科学领域

Thenewenglandjournalofmedicinenengljmedwwwnejmorgnovember,evideosinclinicalmedicinePeripheralIntravenousCannulationRafaelOrtega,MD,PavanSekhar,MD,MichaelSong,MD,ChristopherJHansen,BA,andLaurenPetersonFromtheDepartmentofAnesthesiology,BostonMedicalCenter,BostonAddressreprintrequeststoDrOrtegaattheDepartmentofAnesthesiology,BostonMedicalCenter,ENewtonSt,Boston,MA,oratrortegabueduNEnglJMed:eCopyright©MassachusettsMedicalSocietyFigureBasilicandCephalicVeinsoftheUpperExtremitiesIntroductionObtainingperipheralintravenousaccessisanessentialskillforallphysiciansAlthoughitisconsideredoneofthesimplestinvasiveprocedures,masteringthispotentiallylifesavinginterventionrequiresrefinedskillsandexperienceIndicationsPeripheralintravenouscatheterizationisrequiredinabroadrangeofclinicalapplications,includingintravenousdrugadministration,intravenoushydration,andtransfusionsofbloodorbloodcomponents,aswellasduringsurgery,duringemergencycare,andinothersituationsinwhichdirectaccesstothebloodstreamisneededContraindicationsRelativecontraindicationstoinsertionofaperipheralcatheterataspecificsiteinthebodymayincludeinfection,phlebitis,sclerosedveins,previousintravenousinfiltration,burnsortraumaticinjuryproximaltotheinsertionsite,arteriovenousfistulainanextremity,andsurgicalproceduresaffectinganextremityOthersituationsmayprecludeobtainingperipheralintravenousaccessForinstance,extremedehydrationorshockmayrendercannulationofcollapsedperipheralveinsimpossibleWhenaccesstoperipheralveinsisimpossibleandinsituationsinwhichaccessingperipheralveinsmaytaketoolong,insertionofacentralvenousorintraosseouscatheterorperipheralvenouscutdownmayberequiredAnatomyAdetailedunderstandingofthevenoussystemsoftheupperandlowerextremitieswillfacilitatesuccessfulcannulationTheupperextremitieshavetwoprimaryvenoussystems:thecephalicandthebasilicveins(Fig)ThevenoussystemofthelowerextremitiesconsistsofthegreaterandlessersaphenousveinsSiteSelectionThechoiceofasiteforintravenouscannulationdependsonmanyfactors,includingtheintendeduseofthecatheter,accessibilityoftheveingiventhepositionofthepatient,thepatient’sageandcomfort,andtheurgencyofthesituationIngeneral,upperextremityveinsarepreferred,sincetheyaremoredurableandareassociatedwithfewercomplicationsthanarelowerextremityveinsThepreferredcannulationsitesaretheveinsoftheforearmThemediancubitalvein,whichcrossestheantecubitalfossa,isfrequentlycannulatedinurgentsituCopyright©MassachusettsMedicalSocietyAllrightsreservedDownloadedfromwwwnejmorgatCATHOLICHEALTHCAREWESTonMarch,peripheralintravenouscannulationnengljmedwwwnejmorgnovember,ations,becauseitaccommodateslargeborecathetersandmaybeeasiertocannulatethanotherveinsintheforearmHowever,cautioniswarrantedtoavoidinadvertentcannulationofthebrachialartery,whichusuallyliesjustmedialtothemediancubitalveinThesameappliesfortheradialandulnararteriesatthelevelofthewristcarefulpalpationtoidentifyarterialpulsationsshouldminimizethepossibilityofthiscomplicationWhenupperextremityveinsareinaccessible,thedorsalveinsofthefootorthesaphenousveinsofthelowerextremitymaybeusedCannulationintheseveinsisassociatedwithahigherincidenceofthrombosisandembolismHowever,thisriskislowerinchildrenandinfantsthaninadultstherefore,theveinsofthelegsandfeetareanacceptablealternativewhencannulationoftheupperextremitieshasfailedinachildorinfantOtheralternativeintravenouscannulationsitesincludethescalpveins,usedinneonatesandyounginfants,andtheexternaljugularveinEquipmentGathertheequipmentandhaveitreadyatthebedsidebeforebeginningtheprocedureYouwillneedgloves,eyeprotection,anonlatextourniquet,chlorhexidinebasedantisepticsolution,sterilebygauze,asalineflush,atransparentocclusivedressingandtape,acatheterofanappropriatesize,rangingfromtogauge,anintravenousfluidbagwithtubing,andasharpscontainerAlocalortopicalanestheticmayberequiredifthecatheterisgaugeorgreaterCatheterTypeandSizeTherearemanycatheters,varyinginstyle,length,andsafetymechanisms(Fig)DifferentsafetymechanismshavebeendevelopedtominimizethepossibilityofinadvertentneedlesticksNeedlesshouldalwaysbediscardedappropriatelyinasharpscontainerThesizeofthecatheterusedwilldependontheclinicalsituationThesmallesteffectivecathetershouldbeused,becausesmallcathetersallowforlessresistancetobloodflowaroundthecannulaandareassociatedwithfewercomplicationsLargecatheters,suchasandgaugecatheters,areusedinacutesituationsforfluidresuscitationOthervariablesthatmayinfluencethesizeofthecatheterusedincludeagerelatedvesselsize,theneedforpressurizedbolusesforadministrationofcontrastmaterialormedication,andtheviscosityofthefluidtobeinfusedPreparationExplaintheproceduretothepatientandaddressanyspecificquestionsorconcernsDiscusspotentialcomplicationssuchasbleeding,bruising,andinfectionYoumustfollowstandardprecautionswhenplacingaperipheralvenouscatheterPositioningWhentheselectedsiteisinanupperextremity,thepatientshouldbeplacedinthesupineposition,withthearmsupportedAcomfortablepositionforthepractitionerandproperlightingareimportantforsuccessfulintravenouscannulationProcedureTiethetourniquetwithahalfknottocmabovethetargetedinsertionsitePlacethetourniquetflatagainsttheskinandbringthetourniquetendstogether,FigureDifferentTypesofCathetersCopyright©MassachusettsMedicalSocietyAllrightsreservedDownloadedfromwwwnejmorgatCATHOLICHEALTHCAREWESTonMarch,nengljmedwwwnejmorgnovember,ThenewenglandjournalofmedicineoverlappingoneanotherStretchtheendsofthetourniquet,andwithonefinger,tuckthetoptailbeneaththebottom,directingtheendawayfromthepuncturesiteWhenevaluatingaveinforcannulation,inspectandpalpatetheavailableveinsGentlytilttheextremityoradjusttheangleofthelighttorevealbetterthecontoursofthevesselTopalpateavein,placeoneortwofingertipsovertheselectedveinandgentlyapplypressureReleasethepressuretowatchandfeelthereboundoftheveinonrefillingOnceyouhaveselectedthevein,cleanthesitewithachlorhexidinebasedantisepticsolution,usingabackandforthmotionAllowtheareatodrycompletelyDonotrepalpatetheareaIfalargergaugecatheterisused,thesitemaybeanesthetizedwithalocalinjection,topicalcream,orethyleneglycolcryoanesthesiaTopreparethecatheter,inspectthemetalneedleandplasticcannulaforanydamageorcontaminantsSpinthehuboftheplasticcannulatoverifythatitmoveseasilyoffthemetalneedleDonotmovethetipofthecannulaoverthebevelofthemetalneedle,sincethiscoulddamagetheendofthecannulaSuperficialveinsaredisplacedeasilyandneedtobestabilizedUseyournondominanthandtoapplytractiontotheskindistaltothevenipuncturesiteIfthecatheterisplacedinthedorsumofthehand,graspthepatient’shandwithyournondominanthand,fingersbeneaththepalmPulldownwardtoflexthewristanduseyourthumbtokeeptheskintaut(Fig)Ifaforearmveinisselected,useyournondominanthandtoencirclethepatient’sarm,placeyourthumbontheskindistaltothevenipuncturesite,andpulldownAlwaysmaintainafirmgriponthepatient’shandthroughouttheprocedureWithyourdominanthand,insertthecatheterwiththemetalneedlebevelup,atatodegreeanglethroughtheskinandintothevein(Fig)TheangleusedtoapproachtheveinisdependentonthedepthoftheveinAlesserangleisrequiredforsuperficialveinsDonotinsertthecathetertoodeeply,becauseoftheriskofpenetratingthefarwalloftheveinWhenthecatheterenterstheveinlumen,watchfortheinitial“flashback”ofblood,whichwillslowlyfillthecatheterchamberOncethemetalneedleandplasticcannulaareinthelumen,lowerthecathetersothatitisalmostparalleltotheskinHoldtheendofthecatheterwiththethumbandindexfingerofyourdominanthandMaintaintensionontheveinandtheskin,stabilizetheneedle,andcarefullyadvancethecatheterintotheveinWhenthecatheterhasenteredtheveinlumencompletely,removethetourniquetTopreventbloodlossfromtheopenplasticcannulahubwhenthemetalneedleisremoved,placedirectpressureovertheveinproximaltotheendofthecatheterandplaceagauzepadbeneaththecannulahubRemovethemetalneedlefromtheplasticcannulaandplaceitinthesharpscontainerNeverattempttoreinsertthemetalneedleintotheplasticcannulaDoingsomayshearofftheplasticcannula,releasingitintothebloodstream,resultinginapossibleembolusMakesurethetourniquethasbeenreleased,andconfirmthatthecannulaispatentbyflushingitwithnormalsalineThevolumeuseddependsonthesizeoftheveinandthegaugeofthecatheterCheckthatthereisnoswelling,redness,leakage,ordiscomfortaroundtheinsertionsiteAttachtheintravenousfluidtubingtothecannulaandstartthefluidinfusionIdeally,youshouldsecurethecannulawithatransparentocclusivedressingplacedoverthecannulahubConfirmthatthehubofthecannulaisclearlyvisiblethroughthedressingtofacilitatemonitoringAftersecuringthecannulawithtape,looptheintravenoustubingandsecureitFigureKeepingtheSkinTautbeforeInsertionFigureInsertingtheCatheterCopyright©MassachusettsMedicalSocietyAllrightsreservedDownloadedfromwwwnejmorgatCATHOLICHEALTHCAREWESTonMarch,nengljmedwwwnejmorgnovember,peripheralintravenouscannulationawayfromtheinsertionsiteLoopingthetubingmaypreventaccidentaldisplacementofthecannula,decreasetheneedforcannulamanipulation,andlowertheriskofvenouscontaminationorirritationItisrecommendedtowritethedateofinsertiononthedressingtofacilitatedetermininghowlongthecannulahasbeeninplaceToreducetheriskofinfection,continuetoreviewtheindicationsforperipheralintravenouscatheterization,andremovethecannulaassoonaspossibleTroubleshootingWhenaveinisdifficulttoseeortoidentifyonpalpation,severalmethodscanbeusedtoincreaseitsdilatationTheseincludeloweringthearmbelowheartlevel,gentlytappingonthevein,instructingthepatienttoopenandclosehisorherfistrepeatedly,andapplyingawarmcompresstotheselectedsitetoincreasevasodilatationTransilluminationorultrasonographymayalsobeusedtohelplocateaveinBloodmightflashbackintothechamberifthetipoftheneedlehasenteredthevessellumenbutthecannulaitselfhasnotyetenteredthelumenThisproblemcanbeavoidedbyreducingtheangleofthecatheterandadvancingtheneedleafewmoremillimetersintotheveinAvalvewithintheveinmaypreventadvancementofaninsertedcatheterIfthisoccurs,holdthecannulahubinplace,removethetourniquet,andconnecttheintravenoustubingtothecannulaRunningfluidintotheveinmayopenthevalveandallowthecannulatobecompletelyinsertedOccasionally,itispossibletoadvancethecatheterwhenitisoutsidetheveinorwhenthecatheterhasperforatedthevein’soppositewallEithersituationcancausepainandswellingattheinsertionsitebecausetheintravenousfluidsareadministeredintosubcutaneoustissue(Fig)Whenthisoccurs,thecannulashouldbewithdrawncompletely,andanothercannulaplacedatanalternativesiteWhenacannulationattemptisunsuccessful,thesubsequentattemptsshouldbeperformedinaveinproximaltotheinitialpuncturesiteComplicationsThemostcommoncomplicationsarisingfromintravenouscannulationarepain,bruising,bacterialinfection,extravasation,phlebitis,thrombosis,embolism,andnervedamagePropersteriletechniqueandselectionoftheappropriatecathetersizemayavertthesecomplicationsEnsureproperandadequatefluidadministrationorflushthesitewithsalinetopreventthemoreseriouscomplicationsofthrombosisandembolismSummaryThechancesofsuccessfulperipheralintravenouscannulationincreasewithmeticulousattentiontopropertechnique,theuseofproperequipment,familiaritywithanatomy,andaknowledgeofavarietyofapproachestoaccessingperipheralveinsReferencesBenumofJL,edClinicalproceduresinanesthesiaandintensivecarePhiladelphia:JBLippincott,CostantinoTG,ParikhAK,SatzWA,FojtikJPUltrasonographyguidedperipheralintravenousaccessversustraditionalapproachesinpatientswithdifficultintravenousaccessAnnEmergMed:TagalakisV,KahnSR,LibmanM,BlosteinMTheepidemiologyofperipheralveininfusionthrombophlebitis:acriticalreviewAmJMed:Copyright©MassachusettsMedicalSocietyFigureSwellingonAdministrationofFluidsintoSubcutaneousTissueCopyright©MassachusettsMedicalSocietyAllrightsreservedDownloadedfromwwwnejmorgatCATHOLICHEALTHCAREWESTonMarch,

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