高危患者颈内静脉穿刺术的经验与教训

目的：总结高危患者颈内颈脉穿刺术的经验。方法：回顾性分析4例慢性肾功能衰竭患者颈内静脉穿刺术的方法及出现渗血、血肿的原因。结果：穿刺过程中1例误入动脉,3例顺利穿刺入颈内静脉。分别于穿刺后4h内,不同时间穿刺侧颈部出现血肿,被迫施行气管插管和切开术。结论：肾功能衰竭患者出凝血机制异常,用肝素后更易发生出血。一旦发生出血,应积极采取有力措施。     

颈内静脉穿刺插管并发症防治体会

1995年1月至1996年10月,我们共行颈内静脉穿刺插管316例,其中男179例,女137例;年龄4个月至71岁。穿刺插管均取右侧颈内静脉中间径路。本组出现并发症38例,其中局部血肿31例,血胸3例,气胸及锁骨下动脉穿透损伤各2例,未发生气栓、感染或心包填塞。 体会:局部血肿多因误刺伤颈动脉所致,由于颈动、静脉紧邻,所以操作中极易误伤颈动脉造成血肿。为避免该并发症发生,我们采取了以下措施:①穿刺插管前先用细针试穿刺,以确定颈内静脉位置;②穿刺插管时在三角区触及颈动脉搏动,用两个手指将动脉拉向内侧,可避免误伤颈动脉;③优先选择右侧颈内静脉穿刺插管,因右侧颈动脉和颈内静脉重叠百分率低于左侧。④令患者头部处于<40°转动位置,尽可能减少颈动脉和颈内静脉重叠。当穿刺误伤颈动脉时应迅速局部加压5～10分钟,防止局部血肿形成,然后再行穿刺插管。一旦血肿形成,应改行锁骨下静脉或股静脉穿刺插管。 气胸、血胸也是颈内静脉穿刺插管常见的并发症。气胸多见于穿刺过程中穿刺方向偏向内侧或进针过深。若同时将颈动脉或颈内静脉穿透或外套管将动脉或静脉管壁撕裂,局部形成血肿,血肿经破口流入胸腔则为血胸。气胸、血胸的防治关健为施术者熟悉局部解剖,穿刺点定位准确,穿刺方向正确,进针勿深。 本组2例锁骨下     

颈内静脉穿刺并发锁骨下动脉出血4例报告

临床资料　经颈内静脉穿刺置中心静脉测压管在体外循环手术时常被采用 ,锁骨下动脉出血是较常见的严重并发症。 1994年 1月以来 ,我院共发生急性锁骨下动脉出血 4例 ,经及时诊治均康复 ,报告如下。4例患者年龄 3～ 2 4岁 ,皆为男性 ,均患先天性心脏畸形 ,拟行心内畸形矫治术。术前行右侧颈内静脉穿刺置管术时 ,4例均因穿刺困难而反复穿刺 ,其中 3例发现穿入动脉 ,经压迫止血后再行颈内静脉穿刺成功或改行大隐静脉切开置管术。 4例病人体外循环手术顺利。第 1例患者体外循环期间曾出现循环血量不足 ,需补充液体才能维持循环平衡 ,回ＩＣＵ病…     

肝衰竭患者深静脉置管的选择

目的:探讨肝衰竭患者理想的深静脉置管方式.方法:肝衰竭患者根据病情选择不同深静脉置管方式,观察患者发生血肿、穿刺点渗血、瘀斑、导管感染等并发症发生率.结果:股静脉穿刺瘀斑发生率明显高于颈内静脉(P＜0.01);颈内静脉穿刺点渗血明显高于股静脉(P＜0.01);动脉损伤发生率股静脉穿刺高于颈内静脉(P＜0.05).同一患者颈内静脉穿刺点发生渗血高于股静脉(P＜0.05),股静脉的瘀斑发生率高于颈内静脉(P＜0.001).结论:颈内静脉是肝衰竭患者最安全、最常用的深静脉置管位置,当进行血液净化、血浆置换等治疗时,股静脉可以作为置管首选方式.     

颈内静脉插管建立血管通路的护理

颈内静脉插管因操作方便、安全,并能克服锁骨下静脉插管和股静脉插管的某些缺点,已作为急症血液透析中首选血液通路。现将我院颈内静脉插管进行血透的护理体会报告如下:1　资料与方法1.1　临床资料我院1995年10月至1996年10月进行深静脉插管血透40例,其中颈内静脉插管者15例,男性10例,女性5例,年龄26～72岁,平均50.6岁。其中挤压综合症2例,药物中毒1例,慢性肾功能衰竭(CRF)8例,CRF并糖尿病4例。插管最短2周,最长3.5月。1.2　方法选右侧颈内静脉行导管置入,患者取仰卧位,将两肩胛骨间垫高,头后仰15～30°,并转向穿刺对侧,穿刺部位取胸锁乳…     

锁骨下穿刺静脉置管术在重型肝炎患者中的应用——附506例临床分析

目的总结重型肝炎患者行锁骨下静脉穿刺置管术期间的并发症,探讨其安全性和处理方法。方法对桂林市第三人民医院2001年10月-2012年12月期间506例重型肝炎患者做双重血浆置换联合胆红素吸附(DPMAS)等非生物型人工肝手术前进行锁骨下静脉穿刺置管,严密观察记录术中、术后各种不良反应。结果本组穿刺成功492例(97.2%),发生相关并发症38例(7.5%),其中穿刺点局部血肿/出血不止15例,导管感染13例,误入锁骨下动脉10例。结论锁骨下静脉穿刺术穿刺成功率高,可充分保障临床抢救与治疗需要,多数并发症经对症处理后不影响治疗。锁骨下静脉穿刺置管术可安全地应用于有凝血机制障碍的重型肝炎患者。     

经右颈内静脉紧急床边临时心脏起搏

目的 了解经右颈内静脉紧急床边临时心脏起搏的可行性和效果.方法17例缓慢心律失常的危重患者,穿刺右颈内静脉,送入起搏电极,根据体表心电图判断起搏电极是否在右心室内.结果16例起搏成功,1例因阈值过高而改在X光透视下安置成功.从穿刺至起搏成功约需时3～5min,手术时间10min左右,电极插入深度25～30cm,临时起搏保留时间3～11天.4例急性心肌梗塞患者在溶栓后,穿刺点有出血;2例出现间歇性起搏,调整后恢复正常起搏.无严重并发症.结论 经右颈内静脉紧急床边临时心脏起搏是治疗缓慢性心律失常的一种可靠有效方法.     

冠脉介入术后并发症发生原因及其处理

对664例冠心病患者行冠状动脉介入（冠脉介入）治疗，术后出现并发症46例，其中桡动脉前臂血肿15例，经股动脉穿刺部位血肿10例（并发假性动脉瘤2例），动-静脉瘘2例，血管迷走反射7例，肺栓塞、造影剂过敏各2例，硝酸甘油过敏1例，消化道出血5例，。肾功能损害2例。经及时处理，上述并发症均治愈。提示对冠脉介入治疗后出现并发症患者经严密观察和规范处理可控制其发展，减少和避免发生严重并发症。     

超声引导下右颈内静脉穿刺置管在血液透析中的应用

目的总结右颈内静脉穿刺置管的经验,探讨超声引导下右颈内静脉穿刺置管在血液透析中的应用价值。方法回顾性分析535例使用传统盲穿、超声定位及超声引导三种方法行右颈内静脉穿刺置管术成功率、穿刺时间、病人满意度和发生并发症的种类和例数。结果传统盲穿218例中,一次成功103例（47.25%）,穿刺时间（65±11）s,总成功率83.01%（181例）,发生局部气肿、血肿17例（7.80%）,误伤颈动脉9例（4.29%）,神经损伤3例（1.38%）,血气胸1例（0.46%）,病人满意度54.13%;超声定位210例中,一次成功121例（57.62%）,穿刺时间（45±8）s,总成功率91.43%（192例）,发生局部气肿、血肿12例（5.71%）,误伤颈动脉4例（1.90%）,神经损伤1例（0.48%）,无血胸、气胸病例,病人满意度77.62%;超声引导107例,一次成功92例（85.98%）,穿刺时间（30±7）s,总成功率100%,除1例发生局部皮下血肿外,未发生其他并发症,病人满意度达82.22%。与传统盲穿比较,超声定位,尤其超声引导穿刺有很大的优越性。结论血液透析患者行右颈内静脉穿刺置管,是一种风险较大的有创性操作,在超声引导下穿刺能缩短操作时间,提高成功率,减少并发症,提高病人满意度。     

经彩超引导颈内静脉穿刺置管术在AECOPD患者中的临床应用

目的探讨经彩超引导颈内静脉穿刺技术在慢性阻塞性肺疾病急性加重期(AECOPD)患者中的临床应用价值。方法通过彩色多普勒显像定位颈内静脉,然后在其引导下对23例AECOPD患者进行颈内静脉穿刺置管,同期另选23例AE-COPD患者进行常规盲穿作为对照组。结果实验组穿刺成功率为100%,其中20例1次穿刺成功,3例进针3次成功,且无1例误穿颈动脉和肺脏;而对照组穿刺成功率为87.0%,10例1次穿刺成功,10例进针3～5次成功,3例不成功而改为超声引导下才穿刺成功,误穿颈动脉4次,发生气胸1例。结论彩超引导下颈内静脉穿刺置管术对于AECOPD患者是安全有效的方法。     

Traumatic chyle leak: a rare complication of left internal jugular venous cannulation

A traditional method for internal jugular vein catheterization has been through the transjugular approach. These days, ultrasound-guided cannulation is the preferred mode because of the higher success and lower complication rates. Complications associated with the transjugular approach include neck hematoma caused by carotid artery puncture, pleural puncture leading to pneumothorax and air embolism. Thoracic duct injury is a rare complication of left internal jugular vein catheterization. This complication occurred in one of the patients in whom ultrasound-guided left internal jugular vein catheterization was used. The anatomical basis of this injury is discussed here.     

Traumatic internal jugular vein cannulation

A 63-year-old man with acute myocardial infarction complicated by atrioventricular block underwent an insertion of a temporary electrode for cardiac pacing. The posterior approach for right internal jugular vein cannulation was used. A 15-gauge needle was inserted under the sternocleidomastoid muscle aiming at the suprasternal notch with a 30-degree posterior angle of entry. An hour later the patient started to hiccup. The hiccups were resistant to drug therapy and to cessation of pacing. A chest radiograph revealed elevation of the right diaphragm and hematoma on the right side of the trachea, possibly compressing the right phrenic nerve on its route beneath the sternocleidomastoid muscle and the internal jugular vein. Within seven days the hiccups gradually ceased. Our case shows the advantages and complications of internal jugular vein cannulation.     

Safety of thrombolytic treatment in patients with central venous cannulation.

OBJECTIVES--To determine the safety of thrombolytic treatment in patients with central venous cannulation. BACKGROUND--Thrombolytic treatment significantly reduces mortality in patients with myocardial infarction. Because of the fibrinolytic state induced and the potential for haemorrhagic complications, thrombolysis is currently considered a strong relative contraindication in patients who have had central venous cannulation. There are few data available to support this practice. METHODS--Complications in 56 consecutive patients admitted between 1989 and 1992 with infarction and who had cannulation shortly before, or within 24 h of thrombolysis were studied. RESULTS--Central venous access was achieved via the subclavian route in 52 patients, the internal jugular in three, and the supraclavicular in one. The main indications were for inotropic drugs in 15 patients, pacing in 17, amiodarone infusion in 19, and pressure monitoring in five. Minor haemorrhagic complications occurred in five patients. Two of these patients required either blood or plasma transfusion. Possible major haemorrhagic complications occurred in one patient who became hypotensive shortly after cannulation. Two further patients with severe cardiac failure became hypotensive after cannulation but there was no radiological evidence of effusion and the hypotension was attributed to worsening cardiac failure. Importantly, none of the 19 patients who had cannulas for amiodarone infusion developed significant bleeding complications. CONCLUSION--Central cannulation in the fibrinolytic state is associated with a low incidence of important bleeding complications. Thrombolysis should not be withheld in these patients. Cannulation via the subclavian route, however, should be avoided in patients undergoing thrombolysis.     

老年患者床旁快速临时起搏器安置术路径的研究

目的探讨老年患者床旁快速临时起搏器安置术路径。方法回顾性分析2009年7月至2013年2月收治于本院ICU行床旁快速临时起搏器安置术的老年患者(≥70岁)128例,其中右颈内静脉组25例、左锁骨下静脉组37例、右锁骨下静脉组27例和股静脉组39例,比较各组间植入时间、起搏器电极脱落例数、并发症等情况。结果各组间穿刺失败和起搏器电极脱落例数比较均无统计学差异。左锁骨下静脉组成功植入时间明显短于其余3组,右颈内静脉组总并发症多于股静脉组。结论从穿刺的并发症方面、起搏失败和起搏器电极脱落来说更趋向于经股静脉植入起搏器,如果出现植入困难或失败后建议行左锁骨下静脉途径。     

Severe Vascular Complications of Central Venous Line Placement

Objective: To determine the outcome and management of iatrogenic neck-vessel complications after central venous line placement (CVLP). Design: Retrospective study. Setting: Department of Cardiovascular Surgery and the Intensive Care Unit of a 1000-bed university hospital. Patients: Eleven patients with acute central venous line placement complications were identified between 1998 and 2002. Of them, eight were inadvertent arterial punctures (one cannulation of the vertebral artery, one resulting in late pseudoaneurysm formation). There were eight lacerations of carotid, subclavian, or vertebral arteries, two perforations of the superior vena cava, and one uncontrollable jugular venous bleeding. Intervention: Eight arterial cannulations were treated operatively: suture of the artery was performed in five; litigation in one; one pseudoaneurysm was reconstructed; one pleural empyema was evacuated after initial conservative management. One uncontrollable jugular vein bleeding was treated operatively, one perforation of the superior vena cava conservatively, one surgically. Results: Two patients died: one intraoperatively due to uncontrollable bleeding after inadvertent cannulation of the subclavian artery; one arterial laceration resulted in a large subpleural hematoma, which led to an empyema. The patient died from sepsis two weeks after the initial complication. Both high-risk patients suffered from pulmonary hypertension. The other surgically treated patients made an uneventful recovery. Conclusion: Arterial complications of CVLP are very rare, but may be life-threatening. Venous perforations may seal spontaneously, but bleeding can be uncontrollable. In highly selected cases, vascular surgical consultation may be advantageous, when 24-hour service is available. Open exploration or radiological intervention may be considered.     

Cardiac catheterization through the internal jugular vein in pediatric patients. An alternative to the usual femoral vein access.

The percutaneous femoral vein approach is used routinely for cardiac catheterization in the pediatric age but in some children, it may be impossible as in the case of iliac vein or inferior vena cava thrombosis due to previous cardiac catheterization, or inconvenient as for right ventricular endomyocardial biopsies. In the period between 1982 and 1990, 160 cardiac catheterizations or right ventricular endomyocardial biopsies were performed in 102 children. Patients ranged in age between 2 months and 17 years (mean, 3.8 years) and in weight from 3.2 to 57.3 kg (mean, 14.4 kg). Indications for the internal jugular vein approach were as follows: (1) thrombosis of the inferior vena cava due to previous cardiac catheterization in 42 patients (41 percent); (2) right ventricular endomyocardial biopsy after cardiac transplant in 19 patients (19 percent); (3) control catheterization of the pulmonary arteries following classic or bidirectional cavopulmonary anastomosis in 16 patients (16 percent); (4) superior vena cava obstruction following Mustard's procedure in 14 patients (14 percent); (5) failed percutaneous femoral venous approach in six patients (6 percent); and (6) absence of the hepatic segment of the inferior vena cava in four patients (4 percent). The right or left internal jugular vein could be entered in all but three procedures (98 percent). Seventeen patients had more than one procedure through the same internal jugular vein and the vein was found patent in all. A complete right heart cardiac catheterization was performed using this route. Right ventricular endomyocardial biopsy and interventional procedure were performed through this route. Two major complications occurred. A patient developed a central transient ischemic attack and another patient developed a persistent Horner syndrome. Accidental carotid puncture occurred in five patients without consequences. Our data indicate that cardiac catheterization in infants and children can be performed safely through the internal jugular vein, with a high success rate and a low incidence of major complications.     

Venovenous extracorporeal life support via percutaneous cannulation in 94 patients

STUDY OBJECTIVE: The objective of this study was to demonstrate the safety and utility of a method of percutaneous access for cannulation of adult patients for venovenous extracorporeal life support (ECLS). DESIGN: A retrospective review of a patient series. SETTING: A surgical ICU at a university teaching hospital. PATIENTS: The study group consisted of 94 adults > 17 years old with respiratory failure who were placed on venovenous ECLS by means of percutaneous cannulation. INTERVENTIONS: The cannulation of the internal jugular and femoral veins (FVs) using the Seldinger technique for venovenous ECLS. MEASUREMENTS AND RESULTS: Between May 1992 and November 1997, we performed percutaneous cannulation for venovenous ECLS in 94 adult patients with respiratory failure. The mean (+/- SD) age was 36.1+/-12.7 years old (range, 17 to 65 years). The mean (+/-SD) weight was 80.7+/-22.3 kg (range, 36 to 156 kg). The right internal jugular vein (RIJV) was used for venous drainage access in all but four cases. The right FV (n = 86), the left FV (n = 3), or the RIJV (n = 4) was utilized for venous reinfusion. The maximum blood flow (+/-SD) during ECLS was 57.6+/-17.5 mL/kg/min (range, 22.4 to 127.8 mL/kg/min), with a postmembrane outlet pressure (+/-SD) of 146+/-43 mm Hg (range, 56 to 258 mm Hg) at the maximum flow rate. There were 11 unsuccessful percutaneous cannulation attempts. In three patients (3%), the complications consisted of arterial injury requiring operative cutdown and repair. In six patients (6%), cannula-site bleeding required pursestring suture reinforcement of the cannula site. One patient died from the perforation of the superior vena cava during cannulation. CONCLUSIONS: Based on these data, we conclude that percutaneous cannulation may be utilized to provide venovenous ECLS in adults.