穿刺相关课件.ppt

体位：多选用右侧，仰卧位、头自然偏向一侧手臂贴近躯干、头低位、肩部放松 穿刺方法：从锁骨中内1/3的交界处，锁骨下缘约1~1.5cm（相当于第二肋骨上缘）进针。针尖指向胸骨上窝，针体穿刺与胸壁皮肤的夹角小于10°，如果以此方向进针已达4~5cm仍无回血时，不可再向前推进，应徐徐向后退针并边退边抽，仍无回血，可将针尖撤到皮下而后再改变方向。缓慢向前推进，边进针边回抽，直到有暗红色血为止。 下腔静脉病变（血栓、滤网） 局部感染 心肺复苏术后 腹腔内压增加 股静脉的解剖：股静脉位于股鞘内，紧靠股动脉内侧。股静脉的体表投影位置为腹股沟韧带中、内1/3交点下方约2.5cm处。 穿刺点：病人仰卧，大腿稍外展，在腹股沟韧带中、内1/3交点下方约2.5cm处触及股动脉搏动的内侧 进针：向内上方呈45°角，进入2.5~4cm 血栓并发症 机械并发症：误穿动脉、气胸、血胸、血气胸、出血、动静脉瘘、胸导管损伤、神经损伤 感染并发症： 穿刺部位感染：红肿、硬结、脓性分泌物 导管细菌定植：导管培养（+），外周血培养 （-） 导管相关性血行感染：外周血和导管培养出相 同细菌 穿刺入路 优点 缺点 颈内静脉 一旦出血可快速发现，并且易于按压止血 ；气胸发生率相对较低； 导管不易移位 容易误穿颈内动脉； 仍有一定气胸发生率 锁骨下静脉 病人舒适 容易并发气胸，插管病人不宜使用； 一旦出血不易按压止血；病人年龄《2岁不宜使用 导管移位发生率高 股静脉 容易定位； 无气胸发生可能； 推荐于急诊使用； 极少发生不良并发症 DVT； 穿刺点容易感染； 对于长期制动、卧床患者不建议使用 Arterial puncture Usually obvious but may be missed in a patient who is hypoxic or hypotensive. If unsure, connect a length of manometer tubing to the needle / catheter and look for blood flow which goes higher than 30cm vertically or is strongly pulsatile. Withdraw the needle and apply firm direct pressure to the site for at least 10 minutes or longer if there is continuing bleeding. If there is minimal swelling then retry or change to a different route If air is easily aspirated into the syringe (note that this may also occur if the needle is not firmly attached to the syringe) or the patient starts to become breathless. Abandon the procedure at that site. Obtain a chest radiograph and insert an intercostal drain if confirmed. If central access is absolutely necessary then try another route ON THE SAME SIDE or either femoral vein. DO NOT attempt either the subclavian or jugular on the other side in case bilateral pneumothoraces are produced. Usually from the catheter or wire being inserted too far (into the right ventricle). The average length of catheter needed for an adult internal jugular or subclavian approach is 15cm. Withdraw the wire or catheter if further than this. This can occur, especially in the hypovolaemic patient, if the needle or cannu