外敷消栓散预防经外周静脉置入中心静脉导管相关性血栓的效果观察

Effect observation on external application of Xiao-shuan-san in preventing peripherally inserted central venous catheter-related thrombosis

目的分析消栓散外敷预防经外周静脉置入中心静脉导管(PICC)相关性血栓(CRT)的可行性,为减少PICC后静脉血栓的发生提供指导.方法选择2016年10月至2018年12月青岛大学附属烟台毓璜顶医院收治的PICC患者218例,按患者及家属的治疗意愿将患者分为对照组(103例)和治疗组(115例).两组患者均采用三向瓣膜式导管,在B超引导下经贵要静脉、肱静脉或头静脉穿刺置管,导管头端位于第6~8后肋间,对照组给予常规干预,包括毛巾热敷置管侧肢体穿刺点上方至肩部位置,每日3次,每次15min,置管侧上肢进行握拳松拳动作,每日4次,每次30个,连续进行1个月;治疗组在常规干预基础上给予消栓散(组成:桃仁15g、红花15g、川芎15g、赤芍15g、刘寄奴10g、黄芩10g、蒲公英30g)外敷,于PICC后2h,用蜂蜜将中药调好,贴敷范围上至置管侧腋窝,下至穿刺部位远端10cm,左右两侧至臂缘,涂抹均匀后用保鲜膜包裹,每日1次,每次贴敷4h,连续贴敷1个月.于PICC前1d和置管后30d观察两组患者凝血指标的变化、CRT发生率、并发症发生情况、腋静脉最大血液流速(Vmax),并通过问卷调查了解患者对医疗护理工作的满意度.结果两组置管前和置管后不同时间点各凝血指标比较差异均无统计学意义(均P>0.05).对照组置管后30d?CRT发生率显著高于治疗组〔15.53%(16/103)比2.61%(3/115),P<0.05〕;对照组PICC相关并发症如穿刺点渗液、静脉炎、导管堵塞、局部红肿疼痛、血流感染等发生率和总并发症发生率均明显高于治疗组〔穿刺点渗液:11.65%(12/103)比5.22%(6/115),静脉炎:10.68%(11/103)比4.35%(5/115),导管堵塞:6.80%(7/103)比1.74%(2/115),局部红肿疼痛:9.71%(10/103)比4.35%(5/115),血流感染:5.83%(6/103)比1.74%(2/115),总并发症发生率:44.66%(46/103)比17.39%(20/115),P<0.05〕;治疗组置管后30d腋静脉Vmax明显高于对照组(cm/s:15.63±3.03比11.75±1.91,P<0.05).治疗组患者对医疗护理工作的满意度明显高于对照组〔95.65%(110/115)比88.35%(91/103),P<0.05〕.结论消栓散外敷可有效减少CRT和穿刺点渗液、静脉炎、导管堵塞、局部红肿疼痛、血流感染等的发生率,提高患者对医疗护理工作的满意度,为预防PICC所致CRT和其他并发症提供了新的思路和理论依据.

Objective To analyze the feasibility of external application of Xiao-shuan-san(a powder agent for thrombus lysis or elimination)to prevent peripherally inserted central venous catheter(PICC)-related thrombosis,and to provide reasonable suggestions for reducing the incidence of venous thrombosis after PICC.Methods A total of 218 patients treated with PICC were selected from Yantai Yuhuangding Hospital Affiliated to Qingdao University from October 2016 to December 2018,and they were divided into a control group(103 cases)and a treatment group(115 cases)according to the treatment intention of patients and their families.The three way valve catheter was used in both groups.Under the guidance of B-ultrasound,the catheter was inserted through the puncture of basilic vein,the brachial vein or the cephalic vein.The end of the catheter was located between the 6th and 8th posterior intercostal area.In the control group,the patients received routine intervention,including hot towel compress upon an area from the upper part of the puncture point at the tube side upper limb to the shoulder position,three times a day and 15 minutes each time,this upper limb also performed fist clenching-loose exercise four times a day,30 times each time,and totally the hot towel compress and the fist clenching-loose exercise were continuously lasted for 1 month;while the patients in the treatment group were given external application of Xiao-shuan-san(Ingredients:peach kernel 15 g,safflower 15 g,rhizoma of chuanxiong 15 g,red peony 15 g,artemisiae anomala 10 g,scutellaria 10 g,dandelion 30 g)on the basis of routine intervention.At 2 hours after PICC,all the above Chinese medicines were mixed with honey that was externally applied onto an rectangular area with surrounding edges:upper side was the armpit at the catheter side,the lower side was 10 cm distal to the puncture site,the bilateral sides were the arm medial and lateral edges,then the external applied medicine was smeared evenly in the area,and wrapped with fresh-keeping film,once a day for 4 hours and persisting for 1 month.On 1 day before PICC and 30 days after catheterization,the changes of coagulation indexes,the incidence of catheter related thrombosis(CRT),the incidence of complications,the maximum blood flow rate(Vmax)of axillary vein were observed in the two groups,and the patients'satisfaction degree toward medical and nursing staff was realized through questionnaire survey.Results There were no statistical significant differences in coagulation indexes between the treatment group and the control group before catheterization and after it at different time-points(all P>0.05).The incidence of CRT in the control group was significantly higher than that in the treatment group[15.53%(16/103)vs.2.61%(3/115),P<0.05];the incidence of total various complications of PICC in the control group were obviously higher than those in the treatment group Exudate at puncture site:11.65%(12/103)vs.5.22%(6/115),phlebitis:10.68%(11/103)vs.4.35%(5/115),catheter blockage:6.80%(7/103)vs.1.74%(2/115),local red swelling and pain:9.71%(10/103)vs.4.35%(5/115),bloodstream infection:5.83%(6/103)vs.1.74%(2/115),total complication rate:44.66%(46/103)vs.17.39%(20/115),all P<0.05;after 30 days of catheterization,the Vmax of axillary vein in the treatment group was significantly higher than that in the control group(cm/s:15.63±3.03 vs.11.75±1.91,P<0.05);the satisfaction degree of patients toward the medical and nursing staff in the treatment group was obviously higher than that in the control group[95.65%(110/115)vs.88.35%(91/103),P<0.05].Conclusion External application of Xiao-shuan-san can effectively reduce the incidences of CRT and other complications,elevate patients'satisfaction degree in terms of medical and nursing care,and provide new ideas and theoretical basis for the prevention of CRT and other complications caused by catheterization.