经右侧颈内静脉放置中心静脉导管置入深度的简易计算公式

目的 探求经右侧颈内静脉放置中心静脉导管时导管置入深度的简易计算公式.方法 选择需要放置中心静脉导管的成年患者600例.采用右侧中路法颈内静脉穿刺进针,穿刺成功后,放入J形导丝,引导放入中心静脉导管.用两种方法确定导管头端的位置:(1)当导管刻度与导丝刻度重合时,观察心电图P波的变化.导管头端进入右心房时P波增高;导管头端从右心房退出到上腔静脉后,P波恢复正常.当P波恢复正常后,再将导管后撤2 cm至最终位置.(2)用C臂透视定位,带导丝的导管尖端在靠近右心耳水平,即相当于胸骨右缘第2肋间.根据所得导管深度数据与患者身高的相关性推算简易计算公式.结果 600例患者平均身高为165.0 cm,平均置入深度为14.0 cm;其中男性410例,平均身高为169.1 cm,平均置入深度为14.2 cm;女性190例,平均身高为156.5 cm,平均置入深度为13.1 cm.置入深度的简易计算公式:深度(cm)＝身高(cm)× 0.06+4.结论 成年患者经右侧颈内静脉放置中心静脉导管时导管置入深度的简易计算公式为:深度(cm)＝身高(cm)×0.06+4.     

小儿颈内静脉置管深度研究进展

颈内静脉(internal jugular vein,IJV)穿刺置管是临床常用技术,用于液体或药物管理,以及CVP测定等。随着小儿身高、体重的变化,IJV导管置入的合适深度也会随之发生变化。文章描述了IJV导管尖端理想位置,介绍了通过经食管超声心动图(transesophageal echocardiography,TEE)、经胸超声心动图(transthoracic echocardiography,TTE)、胸部X线检查(chest radiograph,CXR)和腔内心电图等方法确定导管尖端位置。此外,还对右侧IJV置管深度、特殊人群的IJV置管深度、左侧IJV解剖特点及置管深度进行了综述。目前已有不少计算IJV置管深度的公式,由于儿童在发育阶段存在一定的发育差异,它对于个体的适用性仍有待临床进一步考证。     

超声引导经锁骨下静脉置入植入式输液港的效果

目的 探讨应用超声引导定位在经锁骨下静脉人路置入植入式输液港的效果.方法 选择乳腺癌患者60例,年龄28～63岁,体重41～70 kg,身高150～168 cm,ASA Ⅰ或Ⅱ级,拟经锁骨下静脉穿刺置入植入式输液港行长期输液及化疗,输液港导管尖端位置应在上腔静脉和右心房交界处.随机分为2组(n=30):对照组(C组)经锁骨下静脉穿刺,采用脉冲注射冰盐水实验的方法引导定位植入式输液港导管尖端位置.超声组(U组)经锁骨下静脉穿刺,采用超声引导定位植入式输液港导管尖端位置.所有患者术后均经过X线摄片进行导管定位.计算两组患者首次置入成功率.结果 U组患者术后X线摄片显示输液港导管尖端均在上腔静脉和右心房交界处,未发生导管偏离进入颈内静脉的现象,首次置入成功率100%.C组术后X线摄片显示有6例患者的输液港导管发生了偏离,进入颈内静脉,需回手术室在超声引导定位下重新穿刺置管,首次置入成功率80%.U组首次置入成功率高于C组(P<0.05).结论 超声引导定位是经锁骨下静脉正确放置植入式输液港的有效手段.     

超声引导经锁骨下静脉置入植入式输液港的效果

目的 探讨应用超声引导定位在经锁骨下静脉人路置入植入式输液港的效果.方法 选择乳腺癌患者60例,年龄28～63岁,体重41～70 kg,身高150～168 cm,ASA Ⅰ或Ⅱ级,拟经锁骨下静脉穿刺置入植入式输液港行长期输液及化疗,输液港导管尖端位置应在上腔静脉和右心房交界处.随机分为2组(n=30):对照组(C组)经锁骨下静脉穿刺,采用脉冲注射冰盐水实验的方法引导定位植入式输液港导管尖端位置.超声组(U组)经锁骨下静脉穿刺,采用超声引导定位植入式输液港导管尖端位置.所有患者术后均经过X线摄片进行导管定位.计算两组患者首次置入成功率.结果 U组患者术后X线摄片显示输液港导管尖端均在上腔静脉和右心房交界处,未发生导管偏离进入颈内静脉的现象,首次置入成功率100%.C组术后X线摄片显示有6例患者的输液港导管发生了偏离,进入颈内静脉,需回手术室在超声引导定位下重新穿刺置管,首次置入成功率80%.U组首次置入成功率高于C组(P<0.05).结论 超声引导定位是经锁骨下静脉正确放置植入式输液港的有效手段.     

超声引导经锁骨下静脉置入植入式输液港的效果

目的 探讨应用超声引导定位在经锁骨下静脉人路置入植入式输液港的效果.方法 选择乳腺癌患者60例,年龄28～63岁,体重41～70 kg,身高150～168 cm,ASA Ⅰ或Ⅱ级,拟经锁骨下静脉穿刺置入植入式输液港行长期输液及化疗,输液港导管尖端位置应在上腔静脉和右心房交界处.随机分为2组(n=30):对照组(C组)经锁骨下静脉穿刺,采用脉冲注射冰盐水实验的方法引导定位植入式输液港导管尖端位置.超声组(U组)经锁骨下静脉穿刺,采用超声引导定位植入式输液港导管尖端位置.所有患者术后均经过X线摄片进行导管定位.计算两组患者首次置入成功率.结果 U组患者术后X线摄片显示输液港导管尖端均在上腔静脉和右心房交界处,未发生导管偏离进入颈内静脉的现象,首次置入成功率100%.C组术后X线摄片显示有6例患者的输液港导管发生了偏离,进入颈内静脉,需回手术室在超声引导定位下重新穿刺置管,首次置入成功率80%.U组首次置入成功率高于C组(P<0.05).结论 超声引导定位是经锁骨下静脉正确放置植入式输液港的有效手段.     

利用导丝经临时静脉导管置入涤纶环导管的临床评价

目的评价利用导丝经右颈内静脉临时导管置入涤纶环导管在维持性血液透析中的应用价值。方法观察22例次利用导丝经右颈内静脉临时导管置入涤纶环导管（A组）和24例次新穿刺右颈内静脉留置涤纶环导管（B组）的临床应用情况。结果A组和B组导管中位使用寿命分别为19、21个月,导管使用寿命生存曲线差异无统计学意义（χ^2=0．05,P=0．82）。A组和B组插管处皮肤感染的发生率分别为（O．13±0．01）、（0．15±0．02）次／100导管日,导管引起的全身感染发生率分别为（O．31±0．03）、（0．32±0．02）次／100导管日,组间比较差异无统计学意义;A组和B组插管时局部出血或血肿发生率[40．91％（9／22）比45．83％（11／24）]、使用导管透析时血流量[（230．53±28．27）ml／min比（238．71±25．94）ml／min]和导管血栓形成率[31．82％（7／22）比33．33％（8／24）]比较,差异无统计学意义（P〉0．05）;两组均无纤维鞘形成和颈内静脉狭窄发生。结论利用导丝经右颈内静脉临时导管置入涤纶环导管可避免再次穿刺颈内静脉,同时不增加导管相关并发症,可作为留置涤纶环导管的一种方法。     

血液透析患者颈内静脉导管意外3例经验总结

<正>自体动静脉内瘘为血液透析最佳通路,对于无法行内瘘手术以及内瘘未成熟者,深静脉置管仍是建立血透通路的常用办法。导管穿破血管误入胸腔及纵膈为少见并发症,一旦发生可危及生命,此并发症处理的经验总结鲜有报道。近5年来,我院共3例尿毒症患者发生经颈内静脉置入透析导管意外,现报道如下。临床资料病例1:男,56岁,尿毒症患者。右颈内静脉已闭塞,采用seldinger方法行左颈内静脉长期导管(带涤纶套的双腔导管)置入术,放入导丝遇阻力,用力后导丝可进入,扩皮后将导丝退     

锁骨下径路行锁骨下静脉置管导管误入颈内静脉二例

例1女，75岁，因呼吸困难、意识不清于2003年12月18日入院。诊断：（1）急性左心衰、肺水肿；（2）肺部感染、呼吸衰竭。在局麻下经右锁骨下径路行锁骨下静脉穿刺置管（舒贝康中心静脉导管，佛山特种医用导管有限公司生产）。穿刺成功后用Selldinger法置入导管，当J型导丝进入约15cm时感阻力稍大，置人中心静脉导管15cm，回血良好，测CVP为25cmH2O。术毕摄床边胸部x线平片显示中心静脉导管位于右颈内静脉内，即再行左锁骨下静脉穿刺置管，置管成功后摄胸部x线片证实左侧导管位于上腔静脉内。然后以第4肋间腋中线为“O”点，同步测量两侧静脉压，右管静脉压为23．5cmH2O，左管CVP为16cmH2O，即拔除右侧导管。     

中心静脉导管位置与新型静脉内心电图

目的观察不同中心静脉导管尖端位置下新型静脉内心电图(NVECG)的波形变化。方法6头猪颈外静脉入路中心静脉置管(CVC)并开胸,记录4个标志点的NVECG和导管尖端深度,并与置管前常规体表心电图(O点)作对照(A点,导管尖端位于胸廓入口水平,代表外周深静脉;B点,位于心包反折水平,代表中心静脉1;C点,位于右心房入口水平,代表中心静脉2;D点,到达右心房入口再深入4cm,代表右心房内)。比较这5个标志点的P波主波方向、振幅、波形特点及A、B、C、D四点导管置入的深度。结果O、D点P波主波方向全为正向,A、B、C三点P波主波方向全为负向。A点与O、B、C、D点P波振幅比较差异有统计学意义(P<0.05),B、C、D点P波振幅之间差异亦有统计学意义(P<0.05)。当CVC导管尖端分别位于A、B、C、D点时导管平均深度为8、12.8、15.2、19.2cm。结论NVECG法引导CVC时出现的特征性宽大负向P波反映导管尖端到达上腔静脉,而细小振幅的负向P波标志导管尖端位于外周深静脉。     

经颈外静脉径路置入Swan-Ganz导管的经验

本文介绍在患病条件下经颈外静脉径路置入Wwan-Ganz导管的体会,经右或左侧颈外静脉置入Swan-Ganz导管,90％病人是可行的。该径路比经颈内静脉径路并发症少。我们在167例置管中无一例并发症发生。因之颈外静脉径路的穿刺方法是值得推荐的。特别在经颈内静脉径路十分困难或有增加并发症危险的情况下,该径路是值得采用的。     

Optimal insertion depth of central venous catheters—Is a formula required? A prospective cohort study

IntroductionTo determine the optimal length for initial insertion of central venous catheters (CVCs) and to evaluate whether a recommended depth predicted optimal positioning of CVCs.Materials and methodsAll patients who were CVC-cannulated and who underwent chest computed tomography (CT) during a 10-month period were included. We measured the distance from catheter insertion to the superior vena cava/right atrium (SVC/RA) junction and calculated a recommended insertion depth. We compared the accuracy of the recommended depth with that suggested by the formula of Peres for predicting optimal positioning of a CVC.ResultsOf the 1238 patients who were CVC-cannulated over 10 months, 106 underwent chest CT. Based on the mean distance from the CVC insertion point to the distal SVC, we determined that the recommended depth of insertion should be 14 cm for the right subclavian vein, 15 cm for the right internal jugular vein, 17 cm for the left subclavian vein and 18 cm for left internal jugular vein. Using these guidelines, initial placement of a CVC in the distal SVC was more accurate than when the Peres formula was used (91.5% vs. 77.4%, p < 0.05).ConclusionsFor Asian populations, we found that these guidelines are more accurate than those derived from the Peres formulae and more simple to use, thus increasing the likelihood of optimal tip location within the SVC on the first attempt and eliminating the need for later repositioning.     

Depth of a central venous catheter tip: length of insertion guideline for pediatric patients

BACKGROUND: In pediatric patients, several studies have been undertaken to establish central venous catheter (CVC) tip optimal depth. Assessments of catheter tip position using chest radiographs may be misleading, whereas transesophageal echocardiography (TEE) has been shown to accurately monitor catheter tip placement at the superior vena cava-right atrial (SVC-RA) junction. The aim of this study was to issue a guideline for ideal catheter insertion depth, from the right internal jugular vein (IJV) using TEE to confirm the position of the catheter tip at the SVC-RA junction. METHODS: Over a 6-month period, we studied 60 right internal jugular vein catheterizations in infants and children undergoing surgery for congenital heart disease. Positions of CVC tips were confirmed to be at the SVC-RA junction by TEE. Distance from the skin puncture site to the SVC-RA junction, height, weight, and age were recorded. RESULTS: Distances measured were found to be highly correlated with patient height. The following guideline allows the CVC tip to be positioned above the RA in 97.5% of patients with an accuracy of 95%: optimal depth of insertion (cm) = 1.7 + (0.07 x height) in patients whose height is between 40 and 140 cm. CONCLUSION: The model proposed for the insertion of the CVC tip in pediatric patients could be used to prevent inadvertent catheter tip placement into the atrium.     

Predicting the optimal depth of left‐sided central venous catheters in children

The aim of this study was to predict the optimal depth for insertion of a left‐sided central venous catheter in children. Using 3D chest computed tomography angiography, we measured the distance from a point where the internal jugular vein is at the superior border of the clavicle, and from a point where the subclavian vein is inferior to the anterior border of the clavicle, to the junction of the superior vena cava and the right atrium in 257 children. Linear regression analysis revealed that the distances correlated with age, weight and height. Simple formulae for the depth of a central venous catheter via the left internal jugular vein (0.07 × height (cm)) and the left subclavian vein (0.08 × height (cm)) were developed to predict placement of the central venous catheter tip at the junction of the superior vena cava with the right atrium. Using these fomulae, the proportion of catheter tips predicted to be correctly located was 98.5% (95% CI 96.8–100%) and 94.0% (95% CI 90.8–97.3%), respectively.     

Accurate placement of central venous catheter--ECG-guided method vs patient height method

Correct positioning of central venous catheters (CVC) is important. We compared the positioning of CVCs by ECG-monitoring via the guidewire and that by method using patient height. "Certofix" triple-lumen CVCs were inserted in 60 cardiac surgical patients via right internal jugular puncture. Of these, 30 were placed with ECG guidance via the guidewire (Group ECG), and 30 with reference to patient height (modified Pere's method) (Group H). The distance from CVC tip to the superior vena cava/right atrial junction (C-J distance) was measured by postoperative chest X-ray. There was no difference in height between the two groups. The depth of insertion of CVC and C-J distance (cm) were 15.1 +/- 0.3 and 3.6 +/- 2.0 in group H and 14.3 +/- 1.5 and 4.9 +/- 1.2 in group ECG, respectively, with no statistically significant differences between the two groups. In one case of group H, the catheter tip was placed in the right atrium. In group ECG, there was a significant correlation between height and the depth of insertion of CVC. In conclusion, ECG guidance via the guidewire is useful for avoiding CVC displacement.     

Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n=147) or cephalad in Group 2 (n=148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P <0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = <0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.     

Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications

Aims

Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery.

Methods

Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery. Primary endpoint: Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used.

Results

Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively.

Conclusions

Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.     

Correct depth of insertion of right internal jugular central venous catheters based on external landmarks: avoiding the right atrium

OBJECTIVE: Radiographically, a central venous catheter (CVC) tip should lie at the level of the right tracheobronchial angle. Precalculation of length of CVC insertion may avoid unnecessary catheter malposition. The purpose of this study was to assess the accuracy of a method of CVC positioning, based on external topographic landmarks. DESIGN: A prospective, randomized study. SETTING: University-affiliated hospital, single institution. PARTICIPANTS: Patients scheduled for surgery. INTERVENTIONS: Patients were allocated for insertion of the catheter through the right internal jugular vein to either a fixed, predetermined, 15-cm length (n = 50) or to a depth calculated topographically (n = 50) by drawing a line from the level of the thyroid notch to the sternal manubrium. The catheter was repositioned if its tip was situated >5 cm above the carina or >1 cm below it. The distance from the catheter tip to the carina was measured. The main study endpoint was the need for catheter repositioning. MEASUREMENTS AND MAIN RESULTS: Two percent of patients required repositioning in the topographic group compared with 78% in the 15-cm length group (p < 0.001). No patient in the topographic group and 10 patients (20%) in the 15-cm group had the catheter placed in the right atrium (p < 0.05). The mean distance from the CVC tip to the carina was 2.9 +/- 1.4 cm above the carina in the topographic group and 1.9 +/- 1.1 cm below the carina in the 15-cm length group (p < 0.001). No patient had a too proximally placed catheter. Insertion lengths in the topographic group ranged between 9 and 12.5 cm. CONCLUSIONS: It is recommended to use the topographic approach in deciding CVC depth with right internal jugular CVC placement.     

Stuck guidewire in the right atrium: an emergent situation in central vein catheter placement

Objective To investigate the emergency treatment and clinical effect when the guidewire stuck in the right atrium during central vein catheter placement for hemodialysis. Methods Five cases with guidewire stuck in the right atrium during central vein catheter placement for hemodialysis from January 2011 to July 2018 admitted into the First Affiliated Hospital of Zhejiang University were retrospectively analyzed. In two cases, the guidewires were found completely stuck when the insert depth was about 20 cm. The guidewires were not able to move forward nor backward. In the other three cases, the guidewires could be moved forward but not backward with the insert depth at about 18 cm. All patients received emergent computed tomography angiography (CTA) or digital subtraction angiography (DSA) imaging. Images showed that the guidewires were stuck in the right atrium near the ventricular valve. The guidewire core drawing method, the multipurpose angiography (MPA) catheter capturing method and the manual guidewire adjusting method were used for emergent treatment. Results One patient with completely stuck guidewire was successfully treated with guidewire core drawing method and the temporary central vein catheter catheterization through the internal jugular vein was performed under DSA. In a completely stuck case and a retrogradely stuck case, the J-shaped ends of the warped guidewires were captured into the MPA catheter, and the guidewires were then withdrawn from right atriums along with the contrast catheter. In the other 2 retrogradely stuck cases, under DSA, the guidewires were repeatedly pushed, the direction of J-shaped ends was manually adjusted, and then the guidewires were repeatedly pushed and pulled until catheters can be pulled out of the right atriums. The later 4 cases had permanent central vein catheter placement with the same guidewire after the stuck guidewires were withdrawn from the right atrium and readjusted. Conclusions All three methods can successfully solve the emergent situation of the stuck guidewire in the right atrium. For patients with completely stuck guidewires, the MPA catheter capturing method can be simpler, safer, and more effective.     

A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients.

Transesophageal echocardiography (TEE) and central venous catheter (CVC) placement are often used during congenital cardiac surgery. Complications of CVC placement include cardiac perforation, inadvertent arterial placement, and erroneous hemodynamic data from unrecognized malposition. In this study, we used a prospective, randomized, controlled design to evaluate the use of TEE to guide depth of insertion and confirm superior vena cava cannulation, and to improve the percentage of correctly placed CVCs and reduce complications of CVC placement. One hundred forty-five patients were studied. Eighty patients were randomized to have subclavian vein insertion, 64 to have internal jugular insertion, and 1 to have external jugular insertion of CVC. TEE-guided CVC placement resulted in 100% correct placement when assessed by preoperative TEE, versus 86% in the control group (72 of 72 vs. 63 of 73; P = 0.01). There was no difference in correct placement between the two groups when assessed by postoperative chest radiograph (81.9% TEE versus 75.3% control; P = not significant). One significant complication, a superior vena cava perforation, occurred in the control group. Time to placement was 9.6 min in the TEE group versus 8.0 min in the control group (P = 0.015). IMPLICATIONS: Transesophageal echocardiography can be used to guide central venous catheter placement in congenital heart surgery. Central venous catheters that seem to be located high in the right atrium by chest radiograph in these patients are often actually in the superior vena cava and pose little risk of cardiac perforation.     

Life-threatening hemothorax resulting from right brachiocephalic vein perforation during right internal jugular vein catheterization

We present a life-threatening case of hemothorax resulting from right brachiocephalic vein perforation during right internal jugular vein catheterization. We considered that the guidewire had punctured the right brachiocephalic vein extraluminally and the catheter inserted over the guidewire had enlarged the size of the perforation. Despite the use of proper technique, an angle-tip guidewire may perforate the venous wall. Therefore, when there is negative aspiration after central venous catheterization, it is important to perform an emergency chest radiograph before proceeding with surgery; it is also important not to use an angle-tip guidewire.