外科醫學會 消化系外科 周邊置入中央靜脈導管-台北醫學大學附設醫院初始經驗 陳嘉哲1 湯堯舜1 陳瑞杰2 黃宏昌1 陳嘉哲1 湯堯舜1 陳瑞杰2 黃宏昌1 台北醫學大學附設醫院 外科部 急外科1 消化外科2

Topic Venous access device introduction. Indication for PICC insertion. Why do we choose PICC? PICC in our hospital. Limitation and Future.

Vascular Access Devices

What Is PICC ? 1. PICC: Peripherally inserted central catheter First described in 1975 2. Long vascular access devices ( > 30cm) from peripheral veins of upper arm Tip in cavo-atrial junction (CAJ)

Indication For PICC Appropriate: Early Assessment. Right device, Right patient, Right time. Duration of infusion Infusate: osmolality (>600 mOsm/L)and pH<5 or pH > 9 (irritant) In Taiwan: TPN for four weeks and chemotherapy.

Indication For PICC

Duration Annals of Internal Medicine Vol.163, September 2015

Why Choose PICC ? Infiltration Infusional phlebitis Dopamine Amiodarone

Why Choose PICC ?

PICC In Our Hospital Member (Total 3 doctors, one assistant) Indication Our checklist Ultrasound-guided insertion Chest x-ray for tip position follow-up?

PICC In Our Hospital Visit patient: > Medical record including port-a, A-V shunt, pacemaker, and past surgical history (MRM), Lab data: platelet, PT, APTT > Patient’s condition: Fever?, forearm condition. Indication and explanation of the procedure.

Medication 7.4 5.3—6.3 Drug pH (N=7.32-7.45) mOsmol/L (N ~ 300) Discipline Acyclovir 10.5-11.6 316 Infectious disease Amiodarone 4.1   Cardiac/ CCU/ ICU Ampicillin 9 400 Azithromycin 6.4-6.8 280 Bactrium 10 541 Caspofungin 6.6 Ciprofloxacin 3.3-4.6 285 Dobutamine HCL 3.5 Dopamine HCL 3.3 277 Erythromycin 6.5-7.7 291 Foscarnet 7.4 271 Ganciclovir 11 320 Imipenenem 6.6-7.5 310 Iron Infusion/ dextran 5.2-6.5 2000 Anaemia/ CKD Meropenem 7.3-8.3 300 Morphine sulphate 4 295 Pain management Parenteral Nutrition 5.3—6.3 >600 >800 Intestinal failure Phenytoin 12 312 Neuro Potassium HCL 5 200-800 (0.1-0.4 mEq/ml) General Vancomycin 2.5-4.5

Duration Annals of Internal Medicine Vol.163, September 2015

PICC In Our Hospital Preparation CVC bundle Hat and mask. Hands washed. Alcoholic 2% chlorhexidine . Sterile gloves, gown and full draping. Right insertion side.

PICC In Our Hospital Ultrasound machine for insertion guide Ultrasound machine check IJV after insertion

PICC In Our Hospital Final tip position All confirmed by chest X –ray

X-RAY

Checklist

Follow-up 1. Infection rate total PICC (1.43 / 1000 catheter day), CVP (4.04 / 1000 catheter day), Port-a (2.81 / 1000 catheter day )

Collection Data

Collection Data

Limitation Of The Collection Infection rate collection (tip culture or clinical sign). Patient’s follow-up. Other complication collection including venous thromboembolism.

Future When and why removal of PICC. Outpatient department for follow-up feedback May add criteria for PICC insertion

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