特殊体位患者颈内静脉置管策略

目的探讨特殊体位患者行颈内静脉置管的可行性和临床效果。方法对47例特殊体位(被动体位9例,强迫体位38例)下行颈内静脉置管的患者作好物品与患者准备,根据不同体位确定穿刺步骤和固定导管。结果 47例颈内静脉置管均成功,其中一次置管成功38例。中心静脉置管留置4~151d,中位数22d。留置过程中无与置管相关的不良反应或并发症发生。结论对特殊体位患者行颈内静脉置管需重视各操作环节,尤其是穿刺点定位、穿刺方向、穿刺深度及角度,以提高置管成功率,减少置管相关并发症的发生。     

两针法股静脉穿刺置管抢救小儿失血性休克

目的为失血性休克患儿快速建立有效补液途径,提高抢救成功率。方法将100例外伤致失血性休克患儿随机分为观察组和对照组各50例。对照组采用传统股静脉穿刺方法;观察组以股动脉搏动内侧0.3～0.5cm或脐部引一直线垂直于腹股沟的垂直交叉点内侧约0.5cm定位为第1针穿刺点,第1针穿刺点垂直下方3.0～4.0cm处为第2针穿刺点留置股静脉置管。结果观察组留置成功率显著高于对照组,操作时间显著短于对照组(均P<0.01)。结论两针法股静脉穿刺置管能保证失血性休克患儿静脉通道及时建立。     

Pulsed Doppler Ultrasonography Guidance for Catheterization of the Subclavian Vein: A Randomized Study

Background: Catheterization of the subclavian vein may lead to severe complications. The current randomized study compared a technique of pulsed Doppler ultrasonography guidance and the standard method for subclavian vein catheterization.

Methods: Standard and Doppler ultrasonography guidance methods were performed by the same physician in 286 patients, 143 in each group. Primary end points were immediate complications (arterial puncture, pneumothorax, wrong position of catheter tip), failures, the number of subclavian vein catheterizations with immediate complication or failure, the number of skin punctures per catheterization, and the time to placement of the guide wire. The secondary end points were the determination of predicting factors of successful cannulation in each group.

Results: Both groups were similar according to morphologic parameters of the patients. A greater number of subclavian vein catheterizations were performed on the right side using Doppler guidance (105 vs. 73, P < 0.01). Doppler guidance decreased complications (5.6% vs. 16.8%, P < 0.01), largely because of a smaller number of catheters for which the tip was defined to be in incorrect position (0.7% vs. 7.7%, P < 0.01). The time to catheterization was longer with Doppler guidance (300 vs. 27 s, P < 0.001). Failures, catheterizations of the subclavian vein with immediate complications or failure, and the total number of skin punctures per catheterization were similar in both groups. Using Doppler guidance, the presence of a good Doppler signal (124 of 143) was predictive of successful catheterization (123 successful cannulations, P < 0.001).     

低分子量肝素预防股静脉置管后血栓形成的临床疗效

目的：观察低分子量肝素预防股静脉置管术后深静脉血栓形成的效果。方法122例下肢深静脉置管患者随机分为治疗组（63例）和对照组（59例）。治疗组每日皮下注射低分子量肝素5000IU,对照组采取下肢主被动活动等常规预防方法。观察2组深静脉血栓的发生率及治疗组治疗前后凝血功能及血小板有无变化。结果治疗组有7例出现深静脉血栓,对照组有15例出现,2组间差异具有统计学意义（P〈0．05）。治疗组治疗前后APTT、PT、INR、PLT均无显著差异。结论股静脉置管术后使用低分子量肝素可以有效预防下肢深静脉血栓形成。     

Limiting Vein Puncture to Three Needle Passes in Subclavian Vein Catheterization by the Infraclavicular Approach

Purpose With central venous catheterization, each additional vein puncture raises the risk of complications. We assessed the rate of failure and complications using a limiting rule whereby the number of needle passes for subclavian vein catheterization was restricted to three. Methods A prospective clinical trial was conducted between September 2001 and December 2003 in a university hospital surgical department. Two hundred and thirty-two adult patients were enrolled to undergo subclavian vein catheterization under non-emergency conditions. The patients were subjected to right subclavian vein catheterization by the infraclavicular approach. Vein puncture failure was defined as such if venipuncture was not accomplished after three attempts. Any arterial puncture was judged to be a failure immediately. Results Vein puncture failure occurred in nine patients (3.9%), and included two arterial punctures (0.9%). No other complications, such as pneumothorax, hemothorax, plexus lesion, mediastinal hematoma or bleeding, or air embolism, were observed. In multivariate analyses, a close to average body mass index (weight in kilograms divided by the square of the height in meters, odds ratio 0.74; 95% confidence interval 0.56–0.97; P = 0.028) was associated with a low risk of failure. Conclusion Limiting the number of needle passes to three may therefore prevent mechanical complications. A low body mass index was predictive of vein puncture failure.     

Catheter-related infections following axillary vein catheterization

Background : The aim of this study was to determine the rate of infectious complications following axillary vein cannulation and a compare to that observed after internal jugular vein cathterization.
Methods : A prospective comparative open study was carried out to determine the rate of infectious complications related to the use of catheters inserted via the axillary vein or the internal jugular vein. During the study period all patients submitted to central venous catheterization were evaluated. A total of 141 patients entered and completed the study. Catheter insertion sites were either the axillary vein punctured in the axilla, or the internal jugular vein punctured using an anterior approach. Catheter tips were cultured using a quantitative technique. Clinical information pertaining to the analysis was prospectively collected.
Results : A total of 141 catheters from 141 patients entered was studied. Clinical characteristics and risk factors for catheter infection were similar in both groups. The incidence of catheter-related infection (including catheter-related sepsis, and bacteremia) was not different between the two groups (axillary vein: 8.1%; internal jugular vein: 7.6%). Catheter-related bacteremia were seen at a rate of 3.7% in the internal jugular vein group and a rate of 1.6% in the axillary vein group (NS). The incidence of catheter colonization was similar in both groups (axillary vein: 14.5%; internal jugular vein: 11.4%).
Conclusion : Catheter-related infection after axillary vein catheterization was similar to that observed after internal jugular vein catheterization. The chance of developing catheter-related sepsis was less than 10% with either route when catheters were used for the treatment of severely ill patients.     

Use of the subclavian vein in angiographic studies on children]

The experience with catheterization of the subclavian vein in angiography in children aged from several months to 15 years is presented. 835 angiographies via the subclavian vein were carried out. The puncture of the subclavian vein is a convenient procedure in angiography, particularly in younger children. A relative safety and technical simplicity of catheterization of the subclavian vein allow to recommend it for a broader use in angiography.     

经皮门静脉入路在门静脉病变介入治疗中的意义

目的探讨经皮门静脉入路在门静脉病变介入治疗中的意义。方法回顾性分析87例因门静脉病变接受介入治疗的门静脉插管患者的资料,入路方法包括经门静脉右支属支(48例)、左支属支(26例)和脾内静脉属支(13例)入路,比较不同入路门静脉插管的技术成功率和并发症。结果经门静脉右支、左支和脾静脉入路的插管技术成功率分别为95.83%、96.15%和92.31%,差异无统计学意义(P均0.05)。门静脉插管操作的并发症包括腹腔出血、气胸及血气胸、胆道系统损伤、假性动脉瘤形成和死亡。经脾静脉入路的并发症发生率显著高于其他两种入路(P均0.05)。结论门静脉左支、右支及脾静脉入路是可供选择的经皮门静脉插管入路方式。病情允许时,应尽可能采用门静脉左支入路,而避免经脾静脉入路。     

Short-term femoral vein catheterization: A safe alternative venous access?

Results of femoral vein catheterization were compared with those of subclavian and antecubital vein catheterization in 2,345 combat casualties during treatment of hypovolemic shock. Femoral vein catheterization was successful in 95.5 per cent of cases. Accidental arterial puncture occurred in 6.3 per cent, hematomas in 1.3 per cent, and infection in 1.4 per cent. Subclavian vein catheterization was successful in 92.4 per cent. Arterial puncture occurred in 0.4 per cent, hematomas in 0.3 per cent, infection in 1.1 per cent, pneumothorax in 1.4 per cent, and hydrothorax in 0.4 per cent. Antecubital vein catheterization was successful in 77.6 per cent, infection developed in 3.3 per cent, and phlebitis occurred in 5.6 per cent. No clinically detectable phlebitis occurred after either femoral or subclavian vein catheterization. The low morbidity of femoral vein catheterization in this series suggests that this approach be considered when short-term massive intravenous fluid administration is indicated in the treatment of circulatory collapse or cardiac arrest.     

无血液透析插管史的中心静脉狭窄五例临床分析

目的 探讨无血液透析（血透）插管史的中心静脉狭窄患者的造影表现及诊治经验。 方法 回顾性分析上海交通大学医学院附属仁济医院2006年7月至2008年7月收治的5例无血透插管史的中心静脉狭窄的病例临床资料。 结果 女3例,男2例,年龄43~65岁,平均（53±8）岁;5例均表现为上肢肿胀;5例均为左腕部自体动静脉通路,平均建立时间（33.6±35.4）个月。静脉造影显示闭塞性病变2例,狭窄3例,其中头臂静脉狭窄1例,头臂静脉、锁骨下静脉各一处狭窄1例,锁骨下静脉双处狭窄1例。头臂静脉狭窄部位较恒定,均位于气管前方部位,CT显示局部受主动脉压迫。采用经皮血管腔内血管成形术（PTA）、锁骨下静脉-对侧锁骨下静脉旁路术、血透通路关闭术治疗后,症状缓解。 结论 高流量的动脉血流加剧了中心静脉潜在受压部位或瓣膜部位的内膜增殖,可能是导致无插管史的中心静脉狭窄的病因。静脉造影是首选诊断方法。治疗的远期疗效尚待进一步探讨。     

超声介导下门静脉穿刺置管在肝癌术后化疗中的应用

目的探讨超声引导门静脉置管在肝癌术后化疗中的安全性。方法68例原发性肝癌在手术切除后第3周接受门静脉置管化疗。采用超声引导下经皮经肝脏穿刺肝内门静脉分支,将导管插入到门静脉主干以建立化疗的给药途径。结果门静脉穿刺置管371次,成功356次,成功率为95.96%。主要的并发症有:腹腔内出血1例,气胸1例,剧烈腹痛12例,穿刺点血肿形成2例,导管堵塞3例。结论超声引导门静脉置管化疗是一种简便、安全的方法。     

Analysis of 13800 Subclavian Vein Catheterizations

During the period 1974-1983, 13 857 subclavian or internal jugular vein catheterizations were analysed in the same hospital. The data on the catheterizations have been collected prospectively in the hospital computer. In 93% of the cases, catheterization was subclavian vein cannulation performed through the infraclavicular route. In 15% of the cases the catheter position was not ideal, verified with x-ray; e.g. the catheter tip was turned into the internal jugular vein. Of the catheters 70% were kept in place for less than 7 days, and only 6% for over 2 weeks. More than one catheterization was required in 26% of the cases during the same hospitalization. Recatheterization is an important prophylactic measure for preventing septic complications, if suspicion of infection arises. In 5% of the cases, some complications occurred, but they were mostly minor, such as haematoma at the puncture site. More serious complications were 19 pneumothoraces (0.1%). The results suggest that subclavian vein catheterization is a fairly safe method for large-scale use in a hospital, if only a limited group of physicians perform it. Certain precautions should, however, be taken.     

Left renal vein entrapment syndrome in two girls with orthostatic proteinuria

Left renal vein entrapment was documented by bilateral ureteral catheterization and imaging studies as a cause of orthostatic proteinuria in two girls. Renal ultrasonography showed compression of the left renal vein between the aorta and the superior mesenteric artery (Nutcracker phenomenon). Abnormal collateral veins and high pressure gradients between the left renal vein and the inferior vena cava were found on left renal venography and pressure tracing, respectively. The left kidney was documented as the source of postural proteinuria by bilateral ureteral catheterization. Our observations suggest renal congestion due to left renal vein entrapment was the cause of orthostatic proteinuria. Received October 5, 1995; received in revised form June 27, 1996; accepted July 22, 1996     

Skin-traction method prevents the collapse of the internal jugular vein caused by an ultrasound probe in real-time ultrasound-assisted guidance

Purpose  Real-time ultrasound-assisted guidance for catheterization of the internal jugular vein (IJV) is known to be useful, especially for a small-sized vein, which is difficult to catheterize. However, one of the problems with real-time ultrasound-assisted guidance is that the ultrasound probe itself can collapse the vein. We have developed a novel “skintraction method (STM)”, in which the puncture point of the skin over the IJV is stretched upwards with several pieces of surgical tape in the cephalad and caudal directions with the aim being to facilitate catheterization of the IJV. We examined whether this method increased the compressive force required to collapse the IJV. Methods  In ten volunteers, the compressive force required to collapse the right IJV, and the cross-sectional area and anteroposterior and transverse diameters of the IJV were measured with ultrasound imaging in the supine position (SP) with or without the STM or in the Trendelenburg position of 10° head-down (TP) without the STM. Results  The compressive force to required to collapse the vein was increased significantly with the STM, while the crosssectional area and anteroposterior diameter of the vein in the SP with STM were similar to those in the TP without the STM. Conclusion  With the STM, not only the cross-sectional area but also the compressive force required to collapse the IJV increased. Thus, the STM may facilitate real-time ultrasoundassisted guidance for catheterization of the IJV by maintaining the cross-sectional area of the vein during the guidance.     

Tolerance of femoral vein catheterization

The femoral vein is a convenient venous access site which has remained relatively neglected since earlier reports of major complications. However, over the last 10 years, its beneficial use for various purposes (mainly haemodialysis) justifies a reexamination of the value of femoral venous catheterization. The ease of femoral catheterization and its complications were prospectively studied in 92 intensive care patients. Of the 113 attempts made by physicians, 75% of whom were inexperienced, 103 (91.2%) were successful. Insertion resulted in 17 (15%) arterial punctures and 5 local hematomas. Seventy catheters were left in place for an average of 8.8 days. No clinical manifestations of thrombosis were observed. Bilateral phlebography was carried out before removal of the catheter in 70 cases; 45 (64%) of these controls were normal. Of the remaining 25 pathological phlebograms, there were 11 (15.7%) fibrin sleeves, 2 (2.8%) partial thromboses of the common femoral vein which could be directly linked to the venous cannulation, and various abnormalities not directly due to the catheterization (superficial femoral vein thrombosis (4), thrombosis of calf or popliteal veins (18]. One case of catheter septicaemia occurred. Microorganisms were present in 15 (18.3%) of 82 catheter cultured tips. Percutaneous catheterization of the femoral vein might therefore be considered as a good venous access route. It can be successfully used by inexperienced physicians. There is no serious risk of injury to surrounding structures and the risks of thrombosis and infection are acceptable in comparison with other routes.     

Transverse cervical artery pseudoaneurysm: a rare complication of internal jugular vein cannulation

Internal jugular vein cannulation has become the preferred approach for temporary hemodialysis catheter placement following reports of an increased incidence of subclavian vein stenosis due to subclavian vein catheterization. Internal jugular vein catheterization is associated with a high rate of successful catheter placement. However, significant complications such as internal carotid artery (ICA) puncture, pneumothorax, vessel erosion, thrombosis, airway obstruction and infection can occur. The most common complication is ICA puncture. More recently a few cases of thyrocervical trunk pseudoaneurysm and fistula following internal jugular vein and subclavian vein catheterization attempts have been reported. Patients with renal failure who are on hemodialysis may have to undergo multiple catheter placements and vascular access interventions. This, along with their comorbid conditions, increases the risk of such complications. Here we report a patient on hemodialysis who developed transverse cervical artery pseudoaneurysm following an attempted right internal jugular vein catheterization. We report this case because of its rarity, to raise awareness of such a complication and to discuss different treatment options, in particular endovascular coil occlusion. A review of relevant literature is also presented.     

Arteriovenous fistulas after cardiac catheterization

In a review of five Dayton, Ohio, area hospitals during a six-year period, seven patients who were treated for an acquired arteriovenous (A-V) fistula after cardiac catheterization were identified. Four patients had undergone cardiac studies in area hospitals, while three were studied elsewhere. The four A-V fistulas after 23,291 cardiac catheterization procedures in Dayton hospitals represented an incidence of 0.017% for this complication. Congestive heart failure and limb ischemia were the most frequent presenting symptoms that developed from two to ten months after catheterization. Intentional puncture of both the artery and vein of the ipsilateral groin for right- and left-sided heart studies was the probable cause of fistula formation in two cases. Five patients sustained inadvertent injury to both an artery and adjacent vein during percutaneous vascular access. Six A-V fistulas that involved femoral vessels were managed by division of the fistula with lateral repair of the artery and vein. An unusual communication between the right thyrocervical trunk and the internal jugular vein was handled by ligation of the affected vessels. Prompt surgical correction of this unusual complication of percutaneous vascular access is recommended as spontaneous closure is unlikely.     

Cannulation of the Internal Jugular Vein - 500 Cases

Five hundred consecutive cases of internal jugular vein catheterization are presented. The success rate varied from 88% in infants under 1 year of age to 99% in adults. There were 16 arterial punctures (3.2%). In one patient surgical removal of a haematoma was necessary. No pneumothorax occurred. Compared to other techniques for central venous catheterization, the internal jugular vein approach gives a high incidence of correct catheter positions and few complications, and is thus recommended.     

Ultrasound-guided infraclavicular axillary vein cannulation for central venous access

Background. Infraclavicular axillary vein cannulation is notcommonly used for central venous access because identifyingthe surface landmarks is difficult. Ultrasound guided axillaryvein puncture has not been well described. We assessed ultrasoundimaging to guide catheterization of the infraclavicular axillaryvein. Methods. In 200 consecutive patients we attempted to catheterizethe axillary vein using ultrasound imaging. After successfulvenepuncture, a tunnelled Hickman line was inserted for long-termcentral venous access. Surface landmarks of the skin puncturesite were measured below the clavicle. We measured the depthof the vein from the skin, the length of the guidewire fromskin to carina and the final length of catheter that was inserted. Results. The axillary vein was successfully punctured with thehelp of ultrasound imaging with first needle pass in 76% ofpatients. The axillary vein was catheterized successfully in96% of the cases. Guidewire malposition was detected and correctedby fluoroscopy in 15% of cases. Complications included axillaryartery puncture in three (1.5%) and transient neuralgia in two(1%) cases. Conclusion. Ultrasound-guided catheterization of the infraclavicularaxillary vein is a useful alternative technique for centralvenous cannulation with few complications.      

血液透析患者三种深静脉置管临床效果比较及护理体会

目的比较颈内静脉、股静脉、锁骨下静脉置管在血液透析患者临时置管中的疗效。方法 90例慢性肾功能衰竭行血液透析患者,随机分为三组,每组30例,分别行颈内静脉、股静脉、锁骨下静脉置管。结果颈内静脉、股静脉、锁骨下静脉一针穿刺成功率分别为90.0%(27/30),96.7%(29/30)及86.7%(26/30),组间比较无显著差异(P0.05)。三组置管使用天数分别为(35.5±16.5)d,(38.6±20.3)d,(58.9±22.5)d,使用次数分别为(12.3±5.0)次,(15.6±6.3)次,(23.7±8.7)次,静脉回流不畅发生率为26.7%,33.3%和6.7%,锁骨下静脉组优于其他两组(P0.05)。结论锁骨下静脉置管更适于作为慢性肾功能不全患者血液透析的临时通道。