中心静脉导管内形成血栓，肿么办？
以前的办法：撸串！直接拔出导管。
现在的人聪明了，担心血栓会脱落，形成肺栓塞，不敢随便拔。
这个问题，没有人准确的知道肿么办。
但是，有个《中国血液透析用血管通路专家共识(第2版)》，里面讲了粗大的血液透析导管内长了血栓肿么办。
血液透析导管很粗大，形成的血栓也大，它的血栓处理办法，足够细小的中心静脉导管臭屁。
预防
导管回血后采用生理盐水“弹丸式注射”快速冲洗，对减少导管内血栓形成十分重要。
处理
导管周围的附壁血栓，一般不需全身抗凝治疗，但是，拔除导管时应警惕血栓脱落造成肺栓塞（拔管时，有学者建议，千万不能按压，因为按压皮肤，血栓不能随着导管一起拔出，会造成血栓留在体内）。
导管功能不良时（主要是因为血栓的形成），可以采用尿激酶或组织纤溶酶原激活物(t—PA)溶栓治疗。
1.尿激酶浓度：5千~1万IU/ml。
2.尿激酶用法：
A.在导管内保持约30分钟。
B.或者保留10分钟，每隔5分钟推注0.3ml。
C.25万～50万IU，导管内持续缓慢滴注6～10小时。
参考文献：
1.中国医院协会血液净化中心分会血管通路工作组.中国血液透析用血管通路专家共识(第2版)[J].中国血液净化,2019,18(6):365-381.
2.中国医院协会血液净化中心管理分会血液净化通路学组.中国血液透析用血管通路专家共识(第1版)[J].中国血液净化,2014,13(8):549-558.
文献1
Morazin F , Kriegel I , Asselain B , et al. [Symptomatic thrombosis in central venous catheter in oncology: a predictive score?].[J]. Revue De Medecine Interne, 2005, 26(4):273-279.
Abstract
BACKGROUND:
Central venous catheters are essential to management of cancer patients. Thrombotic complications are potentially severe, but it is difficult to prescribe systematically a prophylactic treatment. So it is necessary to identify the higher risk patients who need a prophylaxis.
AIM:
To identify factors associated with the development of clinically significant venous thrombosis in cancer patients with long-term catheters.
METHODS:
Monocentric prospective study about 5447 long-term central venous catheters inserted into patients receiving treatment for solid tumours (50% of breast cancers). Clinically significant catheter-related thromboses are confirmed by ultrasonography, phlebography or scanner.
RESULTS:
The median duration of catheter use is 147 days. There are 135 clinically significant catheter-related thromboses. The risk for thrombosis is 0.1149 events per 1000 device days. The incidence of symptomatic thrombosis is 0.9% at 30 days, 1.36% at 60 days, 1.83% at 90 days and 2.25% at 120 days. The multivariate analysis shows that female sex, duration of insertion procedure (more than 25 minutes) and place of insertion (femoral place) are factors associated with clinically significant venous thrombosis. The right subclavian insertion causes less risk. The catheters with their tip too "high" in the superior vena cava are systematically changed, so that the position of the catheter tip does not appear as a risk factor in our study. The disease stage and the type of treatments are not well examined.
CONCLUSIONS:
A predictive score can be made with the three risk factors that have been identified. Thanks to this score it is possible to determine the patients with higher risk for clinically significant catheter-related venous thrombosis. These patients must be more frequently watched over and must receive a prophylactic treatment. The best prophylaxis has to be determined.
摘要
背景：
中心静脉导管对癌症患者的治疗至关重要。血栓性并发症可能很严重，但很难系统地进行预防性治疗。因此，有必要对需要预防的高危患者进行识别。
目标：
探讨癌症患者长期使用导管时发生临床意义的静脉血栓形成的相关因素。
方法：
单中心前瞻性研究5447个长期中心静脉导管插入接受实体瘤治疗的患者（50%的乳腺癌）。有临床意义的导管相关血栓可通过超声、静脉造影或扫描仪确诊。
结果：
导管使用的平均时间为147天。有135例临床意义的导管相关血栓。血栓形成的风险是每1000设备天发生0.1149次事件。症状性血栓形成发生率30天为0.9%，60天为1.36%，90天为1.83%，120天为2.25%。多因素分析显示，女性、插入过程持续时间（超过25分钟）和插入部位（股骨部位）与临床上显著的静脉血栓形成有关。正确的锁骨下入路可降低风险。在我们的研究中，导管尖端在上腔静脉“高”的情况会被系统地改变，因此导管尖端的位置不会成为一个危险因素。疾病的阶段和治疗的类型没有得到很好的检查。
结论：
可以用已确定的三个风险因素进行预测评分。由于这一评分，有可能确定有较高风险的患者发生临床意义的导管相关静脉血栓形成。这些病人必须更经常地接受监护，并且必须接受预防性治疗。必须确定最好的预防措施。
文献2
Rawson K M , Newburn-Cook C V . The Use of Low-Dose Warfarin as Prophylaxis for Central Venous Catheter Thrombosis in Patients With Cancer: A Meta-Analysis[J]. Oncology Nursing Forum, 2007, 34(5):1037-1043.
PURPOSE/OBJECTIVES:
To determine whether the use of low-dose warfarin could reduce the incidence of thrombosis in patients with cancer who have a central venous catheter (CVC).
DATA SOURCES:
MEDLINE, CINAHL, CANCERLIT, EMBASE, and the Cochrane Library.
DATA SYNTHESIS:
Meta-analysis of four studies (N = 1,236 patients) revealed that 6.4% of warfarin-treated patients experienced a thrombotic event compared with 7.5% in the control (no treatment) group. The risk difference for thrombus formation was not significant (2.0%, confidence interval = -9.0% to 5.0%).
CONCLUSIONS:
The administration of warfarin did not reduce the incidence of symptomatic or asymptomatic CVC-associated thrombosis in patients with cancer.
IMPLICATIONS FOR NURSING:
Using research findings to inform clinical nursing practice is important in caring for patients and providing optimal and improved patient outcomes. Prophylactic use of low-dose warfarin may not prevent thrombus formation and is associated with potentially adverse patient outcomes.
目的/目标：
目的探讨小剂量华法林能否降低中心静脉导管（CVC）癌患者血栓形成的发生率。
数据源：
MEDLINE、CINAHL、CANCERLIT、EMBASE和Cochrane图书馆。
数据合成：
四项研究的荟萃分析（N=1236名患者）显示，华法林治疗的患者中有6.4%出现血栓事件，而对照组（未治疗）为7.5%。血栓形成的风险差异不显著（2.0%，置信区间为-9.0%-5.0%）。
结论：
华法林并没有降低癌症患者有症状或无症状的心血管相关血栓形成的发生率。
护理含义：
利用研究结果为临床护理实践提供信息，对护理患者和提供最佳和改善患者结局具有重要意义。预防性使用低剂量华法林可能不会阻止血栓形成，并与潜在的不良患者结局相关。
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