循證護理--PICC-異位的原因分析與護理

1、PICCPICC異位的原因分析異位的原因分析與護理對策與護理對策循證護理循證護理 EBNEBN的實踐過程的實踐過程選題選題1.1.為什么會出現(xiàn)為什么會出現(xiàn)PICCPICC導(dǎo)管異位？導(dǎo)管異位？2.2.針對此現(xiàn)象，護理工作者應(yīng)針對此現(xiàn)象，護理工作者應(yīng) 如何應(yīng)對？如何應(yīng)對？EBNEBN的實踐過程的實踐過程尋求證據(jù)尋求證據(jù)確定關(guān)鍵詞、制定檢索戰(zhàn)略確定關(guān)鍵詞、制定檢索戰(zhàn)略 關(guān)鍵詞關(guān)鍵詞: : peripherally inserted central peripherally inserted central catheter catheter ； malposition malposition； PI

2、CC PICC；原因分析；護理；原因分析；護理確定檢索數(shù)據(jù)庫確定檢索數(shù)據(jù)庫 數(shù)據(jù)庫：數(shù)據(jù)庫：Cochrane,EMbase,PubMedCochrane,EMbase,PubMed、OVIDOVID、 ProQuest ProQuest等等 CNKI CNKI、萬方、維普等、萬方、維普等檢索結(jié)果：共檢索結(jié)果：共3131條，篩選出條，篩選出4 4篇隊列研究（外文）篇隊列研究（外文） 共共2929條，篩選出條，篩選出1414篇隊列研究（中文）篇隊列研究（中文）The retrieval resultsThe retrieval resultsReferences:References:1. Son

3、g, L. and H. Li, Malposition of peripherally inserted 1. Song, L. and H. Li, Malposition of peripherally inserted central catheter: Experience from 3,012 patients with cancer. central catheter: Experience from 3,012 patients with cancer. Exp Ther Med, 2013. 6(4): p. 891-893Exp Ther Med, 2013. 6(4):

4、p. 891-8932.2.Zhang, Y., et al., Persistent hiccup caused by peripherally Zhang, Y., et al., Persistent hiccup caused by peripherally inserted central catheter migration. J Anesth, 2011. 25(4): p. inserted central catheter migration. J Anesth, 2011. 25(4): p. 625-6.625-6.3. Lambeth, L., et al., Peri

5、pherally inserted central catheter 3. Lambeth, L., et al., Peripherally inserted central catheter tip malposition caused by power contrast medium injection. J tip malposition caused by power contrast medium injection. J Vasc Interv Radiol, 2012. 23(7): p. 981-3.Vasc Interv Radiol, 2012. 23(7): p. 98

6、1-3.4.4.Trerotola, S.O., et al., Analysis of tip malposition and Trerotola, S.O., et al., Analysis of tip malposition and correction in peripherally inserted central catheters placed at correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. J Vasc Interv

7、 Radiol, 2007. bedside by a dedicated nursing team. J Vasc Interv Radiol, 2007. 18(4): p. 513-8.18(4): p. 513-8.檢索結(jié)果檢索結(jié)果References:References: 1. 1.諶永毅等諶永毅等, 1490, 1490例腫瘤化療患者留置例腫瘤化療患者留置PICCPICC主要并發(fā)癥發(fā)生的原因分析主要并發(fā)癥發(fā)生的原因分析. . 中國現(xiàn)代醫(yī)學(xué)雜志中國現(xiàn)代醫(yī)學(xué)雜志, 2012(36): , 2012(36): 第第93-9793-97頁頁. .2.2.趙銳祎趙銳祎, , 謝彩琴與曹素娟

8、謝彩琴與曹素娟, 25, 25例例PICCPICC異位的原因分析與護理對策異位的原因分析與護理對策. . 中華護理雜志中華護理雜志, 2009(06): , 2009(06): 第第526-526-528528頁頁. .3.3.趙銳祎趙銳祎, , 謝彩琴與曹素娟謝彩琴與曹素娟. 25. 25例例PICCPICC異位的原因分析與護理對策異位的原因分析與護理對策. in . in 全國靜脈治療護理學(xué)術(shù)交流會全國靜脈治療護理學(xué)術(shù)交流會議議. 2008. . 2008. 中國北京中國北京. .4.4.劉瑞芳與潘佳佳劉瑞芳與潘佳佳, 26, 26例例PICCPICC導(dǎo)管異位的原因及對策導(dǎo)管異位的原因及對

9、策. . 中國醫(yī)藥科學(xué)中國醫(yī)藥科學(xué), 2011(19): , 2011(19): 第第66-6766-67頁頁. .5.5.成芳等成芳等, 9, 9例腫瘤患者例腫瘤患者PICCPICC靜脈血栓形成原因分析及護理靜脈血栓形成原因分析及護理. . 護理學(xué)報護理學(xué)報, 2010(12): , 2010(12): 第第65-6665-66頁頁. .6.6.朱鳳英與吳春麗朱鳳英與吳春麗, PICC, PICC常見問題的原因分析及對策常見問題的原因分析及對策. . 中國衛(wèi)生產(chǎn)業(yè)中國衛(wèi)生產(chǎn)業(yè), 2011(Z1): , 2011(Z1): 第第81-8281-82頁頁. .7.7.冒小平與張?zhí)m鳳冒小平與張?zhí)m鳳

10、, PICC, PICC穿刺置管時常見并發(fā)癥原因分析與對策穿刺置管時常見并發(fā)癥原因分析與對策. . 實用臨床醫(yī)藥雜志實用臨床醫(yī)藥雜志, 2011(16): , 2011(16): 第第15-1615-16頁頁. .8.8.白璐華與韋顯梅白璐華與韋顯梅, PICC, PICC導(dǎo)管異位的原因分析及護理對策導(dǎo)管異位的原因分析及護理對策. . 中國臨床護理中國臨床護理, 2013(03): , 2013(03): 第第198-200198-200頁頁. .9.9.吳坤與蔡永蘭吳坤與蔡永蘭, PICC, PICC靜脈血栓形成原因分析及護理靜脈血栓形成原因分析及護理. . 中國社區(qū)醫(yī)師中國社區(qū)醫(yī)師( (醫(yī)

11、學(xué)專業(yè)醫(yī)學(xué)專業(yè)), 2012(02): ), 2012(02): 第第353-353-354354頁頁. .10.10.張柳柳張柳柳, , 吳春麗與鄭曉莉吳春麗與鄭曉莉, PICC, PICC置管并發(fā)癥的原因分析及防治置管并發(fā)癥的原因分析及防治. . 臨床護理雜志臨床護理雜志, 2007(06): , 2007(06): 第第23-2423-24頁頁. .11.11.郭曉艷等郭曉艷等, PICC, PICC置管后自發(fā)異位的原因分析及護理對策置管后自發(fā)異位的原因分析及護理對策. . 內(nèi)蒙古中醫(yī)藥內(nèi)蒙古中醫(yī)藥, 2012(19): , 2012(19): 第第173173頁頁. .12.12.黃琪

12、與李晨黃琪與李晨, PICC, PICC置管異位的原因分析及護理體會置管異位的原因分析及護理體會. . 內(nèi)蒙古中醫(yī)藥內(nèi)蒙古中醫(yī)藥, 2013(10): , 2013(10): 第第152-153152-153頁頁. .13.13.林嘉旋林嘉旋, , 黃水英與黃群愛黃水英與黃群愛, , 乳腺癌患者乳腺癌患者PICCPICC發(fā)生異位的正位處理發(fā)生異位的正位處理. . 護士進(jìn)修雜志護士進(jìn)修雜志, 2011(06): , 2011(06): 第第544-545544-545頁頁. .14.14.任靜任靜, , 腫瘤患者腫瘤患者PICCPICC置管術(shù)后并發(fā)癥產(chǎn)生的原因及預(yù)防置管術(shù)后并發(fā)癥產(chǎn)生的原因及預(yù)防

13、. . 求醫(yī)問藥求醫(yī)問藥( (下半月下半月), 2012(12): ), 2012(12): 第第43-4443-44頁頁. .根據(jù)數(shù)據(jù)庫檢索策略檢索文獻(xiàn)，對文獻(xiàn)進(jìn)行根據(jù)數(shù)據(jù)庫檢索策略檢索文獻(xiàn)，對文獻(xiàn)進(jìn)行篩選，從得到的文獻(xiàn)中選出篩選，從得到的文獻(xiàn)中選出2 2篇為例進(jìn)行評價篇為例進(jìn)行評價Song,L.and H.Li,Malposition of Song,L.and H.Li,Malposition of peripherally inserted central catheter: peripherally inserted central catheter: Experience from

14、 3,012 patients with Experience from 3,012 patients with cancer. Exp Ther Med, 2013. 6(4): p. cancer. Exp Ther Med, 2013. 6(4): p. 891-893.891-893.趙銳祎趙銳祎, ,謝彩琴謝彩琴, ,曹素娟曹素娟. 25. 25例例PICCPICC異位的原異位的原 因分析與護理對策因分析與護理對策J. J. 中華護理雜志，中華護理雜志，2009,2009, 06:526-528 06:526-528EBNEBN的實踐過程的實踐過程評價證據(jù)評價證據(jù)Authentici

15、tyAuthenticityApplicabilityApplicabilityImportanceImportanceNewcastleNewcastleOttawa scale NOSOttawa scale NOSThe main contentThe main contentObjective:Objective:TheThe aim of this study was to observe and aim of this study was to observe and analyze the causes of misplacement of peripherally insert

16、ed analyze the causes of misplacement of peripherally inserted central catheters (PICCs) in patients with cancer. central catheters (PICCs) in patients with cancer. Methods:Methods:A A total of 3,012 patients who underwent insertion total of 3,012 patients who underwent insertion of a PICC were revi

17、ewed from August 2000 to March 2012. of a PICC were reviewed from August 2000 to March 2012. ThelocationsThelocations of the tube tips were recorded by chest X of the tube tips were recorded by chest X ray ray examination.examination.Results:Results:MalpositionMalposition of the PICC was observed in

18、 237 of the PICC was observed in 237 cases (7.87%), with the most frequently occurring site of cases (7.87%), with the most frequently occurring site of misplacement being the jugular vein, followed by the misplacement being the jugular vein, followed by the axillaryaxillary vein. vein. Discussion:D

19、iscussion: In order to ensure the safe usage of In order to ensure the safe usage of PICCs, strict placement guidelines, skilled and experienced PICCs, strict placement guidelines, skilled and experienced healthcare professionals and the cooperation of the patient healthcare professionals and the co

20、operation of the patient is necessary. is necessary. AuthenticityAuthenticityThe truth of its researchThe truth of its research：total of 3,012 total of 3,012 patients who underwent insertion of a PICC were patients who underwent insertion of a PICC were reviewed from August 2000 to March 2012. The l

21、ocations reviewed from August 2000 to March 2012. The locations of the tube tips were recorded by chest Xof the tube tips were recorded by chest X ray ray examination.examination.Whether the object of study is rep- Whether the object of study is rep- resentativeresentative of the target population:

22、of the target population: yes ,1,590 adult males, 1,121 adult females and 301 yes ,1,590 adult males, 1,121 adult females and 301 children; age range:1children; age range:1 94 years; median age: 52 years94 years; median age: 52 yearsStrength of Demonstration:Strength of Demonstration: It is also a I

23、t is also a retrospective cohort study ,the feasibility is good.retrospective cohort study ,the feasibility is good.Follow-up time:Follow-up time: August 2000 to March 2012.August 2000 to March 2012.Correction:Correction:lacklackWhether the sequenceis reasonable:Whether the sequenceis reasonable: Re

24、asonable ReasonableFactor:Factor: clinical skill, experience,location, depth clinical skill, experience,location, depthResult:Result: malposition of peripherally inserted central malposition of peripherally inserted central cathetercatheterConsistent with epidemiological regularity:Consistent with e

25、pidemiological regularity: a retrospective cohort study a retrospective cohort study Reflect the consistency:Reflect the consistency: There have been amount of cohort studies There have been amount of cohort studies and case control studies and case control studies involved aboutinvolved about ectop

26、ic and vein selection of PICC ectopic and vein selection of PICCApplicabilityApplicabilityTo guide the prevention policy:To guide the prevention policy: 1.a suitable vein and a suitable1.a suitable vein and a suitable catheter catheter 2.appropriate movements 2.appropriate movements 3.the position o

27、f the patient 3.the position of the patientImportanceImportanceW With such frequent application in ith such frequent application in clinical practice, an increasing number clinical practice, an increasing number of catheter complications of catheter complications have been observed . have been obser

28、ved .M Malpositionedalpositioned catheters result in catheters result in discomfort and pain to the patients, and discomfort and pain to the patients, and also induce serious consequences, such also induce serious consequences, such as loss of usage.as loss of usage.C Catheter atheter ectopiaectopia

29、 can significantly can significantly increase the other complications of PICC increase the other complications of PICC NewcastleOttawa scale NOSNewcastleOttawa scale NOS欄目欄目條目條目評價標(biāo)準(zhǔn)評價標(biāo)準(zhǔn)研究對象選擇1.暴露組的代表性12.非暴露組的代表性13.暴露因素確定14.肯定研究起始時尚無要觀察的結(jié)局指標(biāo)1組織間可比性1.研究控制了重要的混雜因素02.研究控制了任何其他的混雜因素0結(jié)果測量1.結(jié)局指標(biāo)的評價12.隨訪時間足

30、夠長13.暴露組和非暴露組隨訪的完整性1NOSNOS得分為得分為7 7分，其中研究并未控制混雜因素（年齡、病情等），該兩項為分，其中研究并未控制混雜因素（年齡、病情等），該兩項為0 0分。分。EBNEBN的實踐過程的實踐過程評價證據(jù)評價證據(jù)2525例例PICCPICC異位的原因分析與護理對策異位的原因分析與護理對策真實性真實性重要性重要性適用性適用性NOS質(zhì)量評價法質(zhì)量評價法主要內(nèi)容主要內(nèi)容目的目的: :探索探索PICCPICC異位的原因與護理對策。異位的原因與護理對策。方法方法: :通過回顧性分析通過回顧性分析, ,對對2525例例PICCPICC異位的發(fā)生部位異位的發(fā)生部位 置管途徑、處理

31、方法及結(jié)果進(jìn)行研究、總結(jié)。置管途徑、處理方法及結(jié)果進(jìn)行研究、總結(jié)。結(jié)果結(jié)果: :PICCPICC異位與靜脈選擇、置管長度的外測量方異位與靜脈選擇、置管長度的外測量方 法、患者局部血管解剖變異、穿刺時患者體法、患者局部血管解剖變異、穿刺時患者體 位、操作者送管技巧等因素有關(guān)。位、操作者送管技巧等因素有關(guān)。結(jié)論結(jié)論: :為了減少為了減少PICCPICC異位的發(fā)生，置管部位宜選擇異位的發(fā)生，置管部位宜選擇右右 上肢、貴要靜脈；傳統(tǒng)外測量方法與送管時上肢、貴要靜脈；傳統(tǒng)外測量方法與送管時患患 者體位有待改進(jìn)；多數(shù)者體位有待改進(jìn)；多數(shù)PICCPICC異位可以通過各異位可以通過各種種 方法糾正。方法糾正。

32、真實性真實性1.1.其研究是否具有真實性其研究是否具有真實性 導(dǎo)管異位是導(dǎo)管異位是PICCPICC的常見問題，發(fā)生率約的常見問題，發(fā)生率約6.76.7。我科于。我科于20032003年年5 5月至月至2008 2008 年年7 7月共進(jìn)行月共進(jìn)行PICCPICC置管置管361361例，發(fā)生導(dǎo)管異位例，發(fā)生導(dǎo)管異位2525例（例（6 69292）。）。2.2.研究對象是否能代表所研究的目標(biāo)人群研究對象是否能代表所研究的目標(biāo)人群 可以，本組可以，本組361361例例PICCPICC置管患者發(fā)生置管患者發(fā)生PICCPICC異位異位2525例。例。2525例中，男例中，男1616例，女例，女9 9例；

33、年例；年 齡齡15158484歲，平均歲，平均39.539.5歲；白血病歲；白血病9 9例，淋巴瘤例，淋巴瘤1111例，多發(fā)性骨髓瘤例，多發(fā)性骨髓瘤3 3例，其他例，其他2 2例。例。3.3.研究方法論證強度研究方法論證強度 通過回顧性隊列研究，通過回顧性隊列研究，2525例例PICCPICC異位的發(fā)生部位、置管途徑、處理方法，可行性異位的發(fā)生部位、置管途徑、處理方法，可行性較好。較好。 4.4.隨訪時間是否足夠？隨訪是否完整？隨訪時間是否足夠？隨訪是否完整？ 我科于我科于20032003年年5 5月至月至20082008年年7 7月共進(jìn)行月共進(jìn)行PICCPICC置管置管361361例，發(fā)生導(dǎo)

34、管異位例，發(fā)生導(dǎo)管異位2525例，本例，本文提及了隊列的開始時間及終止時間，隨訪時間足夠。文提及了隊列的開始時間及終止時間，隨訪時間足夠。5.5.是否對影響結(jié)局的重要因素進(jìn)行了統(tǒng)計學(xué)的校正是否對影響結(jié)局的重要因素進(jìn)行了統(tǒng)計學(xué)的校正 否，本研究并沒有對混雜因素進(jìn)行校正否，本研究并沒有對混雜因素進(jìn)行校正6.6.病因?qū)W研究因果效應(yīng)的先后順序是否合理病因?qū)W研究因果效應(yīng)的先后順序是否合理 合理，因：靜脈選擇、置管長度的外測量方法、患者局部血管解剖變合理，因：靜脈選擇、置管長度的外測量方法、患者局部血管解剖變異、穿刺時患者體位、操作者送管技巧等因素。果：異、穿刺時患者體位、操作者送管技巧等因素。果：PIC

35、CPICC異位異位7.7.病因?qū)W研究的結(jié)果是否符合流行病學(xué)的規(guī)律病因?qū)W研究的結(jié)果是否符合流行病學(xué)的規(guī)律 符合，屬于歷史性隊列研究符合，屬于歷史性隊列研究8.8.病因致病的因果關(guān)系是否在不同的研究中反映出病因致病的因果關(guān)系是否在不同的研究中反映出一致性一致性 是。已有多個隊列研究、病例對照研究涉及是。已有多個隊列研究、病例對照研究涉及PICCPICC異位與靜脈選擇、置異位與靜脈選擇、置管長度的外測量方法、患者局部血管解剖變異、穿刺時患者體位、操管長度的外測量方法、患者局部血管解剖變異、穿刺時患者體位、操作者送管技巧等因素有關(guān)，結(jié)果都是肯定的。作者送管技巧等因素有關(guān)，結(jié)果都是肯定的。重要性重要性 導(dǎo)管異位可明顯增加導(dǎo)管異位可明顯增加PICCPICC其他并發(fā)癥其他并發(fā)癥的發(fā)生，如液體滲漏、肢體腫脹、疼的發(fā)生，如液體滲漏、肢體腫脹、疼痛等，也可發(fā)生一些特殊的危險，如痛等，也可發(fā)生一些特殊的危險，如椎體旁積液、房顫等，常常導(dǎo)致不能椎體旁積液、房顫等，常常導(dǎo)致不能完成治療而拔除導(dǎo)管，有時需要重新完成治療而拔除導(dǎo)管，有時需要重新置管。置管。 適用性適用性作為指導(dǎo)防治政策作為指導(dǎo)防治政策: :PICC