超声用于先天性心脏病患儿大隐静脉穿刺的学习曲线

目的本研究旨在使用累计和分析方法(CUSUM)探讨超声用于传统穿刺经验丰富的麻醉科医师在外周静脉穿刺中学习曲线的变化。方法选择先天性心脏病(CHD)患儿60例,男36例,女24例,年龄1~3岁,根据CHD类型分为两组:紫绀组和非紫绀组,每组30例。由一位穿刺经验丰富的麻醉科医师通过超声引导行大隐静脉穿刺。主要指标为大隐静脉首次穿刺成功率。CUSUM设定接受及无法接受的失败率分别为20%及40%。次要指标为首次穿刺时间及首次穿刺调整方向次数。记录大隐静脉直径、大隐静脉深度以及首次穿刺成功患儿累计比例。采用Kaplan-Meier检验比较两组首次穿刺成功率及穿刺时间。结果紫绀组与非紫绀组大隐静脉首次穿刺成功率分别为19例(63%)及24例(80%),两组差异无统计学意义。紫绀组在30次穿刺后CUSUM值在决定线之间,无法判断操作者穿刺技术掌握。非紫绀组在28次穿刺后CUSUM值穿过可接受的失败率边界,提示操作者能掌握穿刺技术。紫绀组及非紫绀组首次穿刺时间分别为(61.2±24.8)s和(65.6±26.5)s,首次穿刺调整方向次数分别为3(2~6)次和3(2~6)次,两组差异均无统计学意义。紫绀组大隐静脉直径明显短于非紫绀组(P<0.05),大隐静脉深度明显深于非紫绀组(P<0.05)。两组首次穿刺成功患儿累计比例差异无统计学意义。结论CUSUM法对于评估超声辅助技术外周静脉穿刺能力的掌握是一种非常有效的手段。超声辅助技术对于非紫绀型心脏病患儿的外周穿刺具有学习曲线周期较短,较易掌握的特点,而紫绀型心脏病患儿的穿刺则需要更长的学习周期。

Learning curve of ultrasound-assisted technique for the peripheral saphenous venous cannulation in children with congenital heart disease

Objective To evaluate the learning curve of an anesthesiologist with extensive experience of blind peripheral venipuncture in performing the procedures under ultrasound guidance using cumulative sum analysis.
Methods Sixty children with congenital heart disease were selected and enrolled into the cyanotic group and acyonotic group, 30 children in each group. An anesthesiologist with extensive experience of venipuncture performed the peripheral venous cannulation under ultrasound guidance. The primary outcome aimed at the first attempt success rate of the saphenous venous cannulation. Cumulative sum analysis was performed with acceptable and unacceptable failure rates set as 20% and 40%, respectively. The secondary outcomes were the first attempt time and the redirection number at the first attempt. The median time to cannulation at the first attempt and the cumulative proportion of children with successful cannulation between the two groups was estimated using the Kaplan-Meier method. The diameter of the great saphenous vein, the depth of the great saphenous vein, and the cumulative proportion of children with successful first puncture were recorded.
Results The success rates of saphenous vein puncture in the cyanotic group and non-cyanotic group were 19 (63%) and 24 (80%), respectively, and there was no significant difference between the two groups. The CUSUM score was still between the decisions lines after 30 attempts in the cyanotic group showing an indeterminate result, whereas the CUSUM score in the acyanotic group was able to pass lower decision boundary with 28 attempts, suggesting that the operator was competent in the method. The first puncture time of the cyanotic group and the non-cyanotic group were (61.2 ± 24.8) seconds and (65.6 ± 26.5) seconds, respectively. And the first puncture adjustment direction was 3 (2-6) times and 3 (2-6) times, respectively. No significant differences were seen in all these variables. The diameter of the saphenous vein in the cyanotic group was smaller than that in the non-cyanotic group (P < 0.05), and the depth of the saphenous vein was deeper than that in the non-cyanotic group (P < 0.05). There was no statistically significant difference in the cumulative proportion of children with successful first puncture between the two groups.
Conclusion CUSUM analysis is an effective method to evaluate the competency in peripheral venous cannulation using the ultrasound-assisted technique. The ultrasound-assisted technique has the characteristics of a shorter period of a learning curve and being easier to grasp for the peripheral venous cannulation in children with acyanotic heart disease. However, it seems that more practice is needed for children with cyanotic heart disease.