基于ACE Star循证模式选择新生儿经外周静脉穿刺的中心静脉导管置管部位

Selection of PICC catheter location in neonates via evidence-based ACE Star model

目的:应用ACE Star循证模式探讨新生儿经外周静脉穿刺的中心静脉导管(peripherally inserted central venous catheter,PICC)的最佳置管部位。方法:按照ACE Star循证模式中问题确立、证据综合、转译评鉴、整合实践和效果评价5个步骤进行研究。综合荟萃分析结果、相关指南、专家建议、护理人员的临床经验以及新生儿的特点,形成最终建议,对湖南省某三甲医院行PICC的87例新生儿进行整合实践,评价患儿的并发症发生率和一次穿刺成功率等结局指标。结果:荟萃分析结果显示新生儿经下肢静脉行PICC的并发症发生率低于上肢静脉,差异有统计学意义(OR=0.83,95%CI:0.75~0.92,P<0.05)。最终的转译评鉴结果建议新生儿若无PICC置管前下肢静脉已被破坏等特殊情况,首选经下肢静脉行PICC。整合实践的结果显示,新生儿经下肢静脉行PICC的并发症总发生率为17.24%。与左下肢置管相比,右下肢置管的并发症总发生率、导管堵塞的发生率较低,差异有统计学意义(均P<0.05)。与经股静脉置管相比,经大隐静脉置管的一次穿刺成功率高且并发症总发生率、导管堵塞发生率和感染发生率较低,差异有统计学意义(均P<0.05)。结论:右下肢大隐静脉可作为新生儿PICC的最佳置管部位。

Objective:To explore the most suitable insertion site for neonatal placement of peripherally inserted central venous catheter(PICC)according to the evidence-based ACE Star model.Methods:This study was carried out according to the evidence-based ACE Star model in 5 steps,including discovery research,evidence summary,guidelines translation,practice integration,and outcome evaluation.Based on the results of Meta-analysis,relevant guidelines,expert recommendations,clinical experience of nurses,and characteristics of neonates,the final recommendation was formed.A total of 87 neonates in a tertiary neonatal intensive care unit in Hunan Province were integrated into practice of PICC to evaluate the incidence of catheter-related complications and one-attempt success rate of puncture.Results:The results of Meta-analysis showed that the incidence of complications of PICC in neonates via lower limb veins was significantly lower than that of upper limb veins(OR=0.83,95%CI 0.75 to 0.92,P<0.05).The final result of guideline translation was that PICC should be performed first through lower limb veins if the lower limb vein before PICC catheterization was not damaged.The results of integrated practice showed that the incidence of complications of PICC via lower extremity vein was 17.24%.Compared with the left lower limb catheterization,the incidence of complications and the incidence of catheter blockage of the right lower limb catheterization were significantly lower(both P<0.05).Compared with femoral vein catheterization,one-attempt success rate of puncture via the saphenous vein catheterization was higher and the incidence of complications,the incidence of catheter blockage,and the incidence of infection were lower,with significant difference(all P<0.05).Conclusion:Saphenous vein in right lower limb could be the most suitable insertion site for neonatal PICC.