改良经锁骨下静脉穿刺置管术的临床应用

目的：对经锁骨下行锁骨下静脉穿刺中心静脉置管术的方法进行改进。方法：穿刺点在锁骨中点下方１ｃｍ，再偏外侧１ｃｍ，方向指向锁乳突肌胸民锁骨的夹角平分线上１ｃｍ处，紧贴锁骨进针行针。置管深度为１２－１５ｃｍ，结果：经锁骨下行锁骨下静脉穿刺置管各类病人共２１５８例，穿刺成功２１３８例，占９９．０７％，穿刺失败２０例，占９．９３％，失败原因包括畸形、出血倾向、导管质量、操作技术等，导管放置时间最短３天，最     

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。     

PICC与锁骨下静脉置管在肿瘤患者化疗中的应用效果比较

目的 探讨PICC与锁骨下静脉置管在肿瘤化疗患者中的应用效果,为临床护理工作提供依据。方法 将80例肿瘤化疗患者根据所选择导管类型分成PICC组和锁骨下静脉置管组各40倒,比较两组置管成功率、导管留置时问、并发症发生率。结果 两组一次穿刺置管成功率、导管留置时间比较,PICC组显著优于锁骨下静脉置管组（均P〈0．01）;两组并发症发生率比较,差异无显著性意义（P〉0．05）,但锁骨下静脉置管组发生严重感染2例、血气胸1例、动脉损伤2例,PICC组无严重并发症发生。结论 PICC一次穿刺置管成功率高、留置时间长,无严重并发症发生,可作为肿瘤患者长期化疗的首选。     

体表定位经锁骨下静脉穿刺中心静脉置管的几个操作细节

依据体表定位经锁骨下静脉穿刺中心静脉置管由于局部解剖特殊和易出现严重的并发症而使其应用受到限制,本文根据作者多年的操作经验就穿刺置管过程中如何提高成功率和预防并发症的发生从操作细节给予介绍。     

锁骨下静脉置管导管误入颈内静脉的临床探讨

目的对锁骨下静脉穿刺置管导管误入颈内静脉的方法进行探讨。方法将600例锁骨下静脉穿刺置管术患者分为A、B两组,采用不同穿刺置管方法。结果经X线透视、X线摄片检查证实,锁骨下静脉导管误入颈内静脉者20例,其中A组18例,B组2例。结论采用阻断颈内静脉法,可降低导管误入颈内静脉的概率。     

小儿经皮锁骨上途径行锁骨下静脉穿刺置管的临床研究

中心静脉穿刺置管术在重大手术麻醉期间快速输血输液，监测中心静脉压及危重病人的抢救中有重要意义，并同样适用于小儿。上世纪90年代以来，该技术在小儿应用越来越受到重视，并在不断探索和改进。其中，经皮颈内静脉锁骨下途径行锁骨下静脉穿刺置管术在临床上已经得到较广泛应用。而锁骨上途径锁骨下静脉置管法自1965     

婴幼儿锁骨下静脉置管86例临床体会

1999年 6月～ 2 0 0 0年 11月 ,我们对 10ｋｇ以下婴幼儿进行锁骨下静脉穿刺置管 ,共 86例 ,现将临床体会报告如下。资料与方法本组男 4 6例 ,女 4 0例 ,年龄 3个月～ 3岁 ,体重 8 1～10ｋｇ 60例 ,6 1～ 8ｋｇ 17例 ,<6ｋｇ 9例 ,其中 2例 4ｋｇ ,均患先天性心脏病 ,拟在体外循环下行心内直视手术。所有病例肌注氯胺酮 4～ 8ｍｇ/ｋｇ ,入睡后监测血压、心电图和脉搏血氧饱和度。除 8例因无法建立外周静脉输液通路而未行气管内插管外 ,其余均静注维库溴铵 0 2ｍｇ/ｋｇ后气管内插管 ,在机械通气下施行穿刺。穿刺管为Ａｒｒｏｗ6Ｆｒ(ＲＥ…     

不同部位与静脉PICC置管障碍发生率比较

目的了解不同部位与静脉PICC置管障碍的发生情况,为扩大PICC应用范围、提高应用效果提供参考。方法观察146例（180例次）PICC置管术的患者不同置管部位（右上肢、左上肢）和置管静脉（责要静脉和头静脉）置管障碍发生率。结果不同部位置管障碍发生率差异不显著（P〉0．05）,但不同静脉有显著差异（P〈0．05）。发生较多的置管障碍为：送管困难、置入过深、置入颈静脉及返折入腋静脉。组间比较除不同静脉置管返折入腋静脉和不同部位置管送管困难发生率有显著差异（均P〈0．05）外,其余差异不显著（均P〉0．0,5）。结论不同部位置管障碍发生率差异不大,选取置管静脉和部位应结合患者的具体情况,建议首选贵要静脉;在置管过程中要重点防范送管困难和置入过深。     

颈内、锁骨下静脉穿刺置管术的比较

目的探讨颈内静脉、锁骨下静脉穿刺中心静脉置管术的临床应用效果.方法将89例行中心静脉置管术的患者随机分为锁穿组(41例)和颈穿组(48例),颈穿组行颈内静脉穿刺置管,锁穿组行锁骨下静脉穿刺置管.观察两组一次置管成功率及并发症的发生情况.结果两组一次置管成功率及并发症发生率比较,差异有显著性意义(P＜0.01,P＜0.05).结论颈内静脉穿刺应作为中心静脉置管的首选路径.     

不同部位与静脉PICC置管障碍发生率比较

目的 了解不同部位与静脉PICC置管障碍的发生情况,为扩大PICC应用范围、提高应用效果提供参考.方法 观察146例(180例次)PICC置管术的患者不同置管部位(右上肢、左上肢)和置管静脉(贵要静脉和头静脉)置管障碍发生率.结果 不同部位置管障碍发生率差异不显著(P>0.05),但不同静脉有显著差异(P<0.05).发生较多的置管障碍为:送管困难、置入过深、置入颈静脉及返折入腋静脉.组间比较除不同静脉置管返折入腋静脉和不同部位置管送管困难发生率有显著差异(均P<0.05)外,其余差异不显著(均P>0.05).结论 不同部位置管障碍发生率差异不大,选取置管静脉和部位应结合患者的具体情况,建议首选贵要静脉;在置管过程中要重点防范送管困难和置入过深.     

Subclavian Venous Catheterization in Children

During a 12-month period, infraclavicular subclavian catheterization, using a Seldinger technique, was attempted on 77 occasions in 54 children with a median age of 2 years (range newborn to 10 years). General anaesthesia was used in the majority of cases, and catheterization was successful in 74 cases (96%). The initial catheter tip position was satisfactory in 81% of the cases, and catheters remained in situ for a median period of 7 days (range 1-28 days). There were few complications. Providing extensive experience in subclavian venous cannulation is gained in the adult, there is in our experience no minimal age or size which should limit the use of a subclavian vein catheter.     

Complications of Central Venous Catheterization of the Subclavian Vein: The Influence of a Parenteral Nutrition Team

Early and late complications of central venous catheterization were investigated in 488 consecutive catheters, 389 introduced in the subclavian vein by a percutaneous puncture technique, 84 by a cut down technique of the cephalic vein, and 15 by a peel away technique. Care and introduction of the catheters was controlled by the parenteral nutrition team in 239 cases.
Immediate and late complications were found using both the puncture and venous cut down techniques, but immediate complications differed in the two groups due to the different methods of insertion.
The rate of catheter related sepsis (CRS) did not differ significantly when the group under control of the nutrition team was compared with the group without nutritional control (5.9 vs. 6%). The rate of CRS was 1 CRS/220.7 days of therapy in the puncture group and 1 CRS/342.2 days of therapy in the venous cut down group. Catheter tips and blood were cultured from both CRS and non-CRS patients, and the micro-organisms identified.
Catheters were withdrawn, under supervision of the nutrition team, for a number of reasons including death, thrombosis, and technical problems, but suspicion of CRS accounted for a high percentage of withdrawals (18% in the puncture group, 16.6% in the venous cut down group). It is suggested that, when CRS is suspected, removal of the catheter should be delayed until all other possibilities have been investigated.     

Hemidiaphragmatic paralysis following subclavian vein catheterization

The right subclavian artery was inadvertently punctured during attempted preoperative insertion of a right subclavian venous catheter in a 59-yr-old woman undergoing radical hysterectomy. Large supraclavicular swelling became apparent soon after the arterial puncture. The postoperative chest X-ray obtained approximately 24 h after the catheterization revealed significant elevation of the right hemidiaphragm, which was further augmented on the 2nd to 4th postoperative days; oxygenation was concurrently impaired during these days. It was clinically judged that the hemidiaphragmatic paralysis was responsible for the elevated diaphragm. Both chest roentogenogram and arterial blood gas analyses started to improve on the 5th day, finally returning to normal on the 6th day. It is unlikely that the surgical procedure caused the paralysis, because it dealt only with the lower abdomen. Rather, the attempts at the subclavian venous catheterization probably caused the phrenic nerve paralysis, because the phrenic nerve travels very close to the subclavian vessels. Both the large haematoma formation following the arterial puncture and the time course of the paralysis suggest that compression of the right phrenic nerve by the haematoma, rather than needle trauma, was responsible for the paralysis.     

Deep Venous Thrombosis with Clinical Signs after Catheterization of the Superior Vena Cava System

This clinical investigation examined deep venous thrombosis with clinical signs indicating superior vena caval involvement, secondary to installation of central venous catheters. Thrombophlebitis was rare, but very dangerous if of septic origin.     

Central Venous and Pulmonary Artery Catheterizations via the Axillary Vein

We report the results of over 300 central venous and pulmonary artery catheterizations via the axillary vein. We found that the success rate with this method compares well with those of other catheterization routes, whilst the risk of mechanical injury, even for artificially ventilated patients, was virtually eliminated.     

Primary Subclavian Venous Thrombosis Which Developed After Sleeping with the Arm in an Outstretched Position: Report of a Case

Primary subclavian venous thrombosis is more rare than secondary thrombosis. This type of thrombosis is called "effort thrombosis" or Paget-Schroetter syndrome, and develops after a strenuous effort of the superior limb. A day after a 55-year-old man got drunk and slept in the left lateral position in combination with an abducted and elevated position of the left superior limb, he became aware of swelling and an oppressive feeling in his left superior limb and was admitted 9 days later. Thrombus of the left axillary-subclavian vein was confirmed by venography, and thrombolytic therapy with urokinase was performed immediately. The left arm symptoms improved for the most part. Venography after the therapy revealed thrombolysis at the site of the axillary vein, while the subclavian vein enhanced the collateral vessel pathway. The patient was discharged on the seventh hospital day, and anticoagulant therapy with oral warfarin sodium has since been continued. This is considered to be a rare case of subclavian venous thrombosis caused by sleeping in an abnormal position with the arm outstretched. Received: February 9, 2000 / Accepted: September 26, 2000     

Right Internal Jugular Vein Is Recommended for Central Venous Catheterization

ABSTRACT

Background: The internal jugular vein (IJV) is one of the recommended sites for safe insertion of a central venous catheter (CVC). Although CVC insertion via the IJV has a lower risk of severe complications such as pneumothorax and arterial bleeding than insertion via the subclavian vein, few reports have provided concrete evidence for the safety of a right-sided approach. Purpose: To examine whether a right-sided approach, rather than a left-sided one is superior for CVC insertion via the IJV. Methods: A retrospective study was performed to compare the right IJV with the left in terms of characteristics such as vertical and horizontal diameters, depth from the skin, and the relationship between the IJV and the common carotid artery (CCA) using the same computed tomography axial slice. Results: From April 2006 to September 2008, 100 patients (50 male and 50 female) who underwent CVC insertion via the IJV before surgery for colorectal cancer were enrolled. Vertical and horizontal diameters of the right IJV were significantly larger than those of the left IJV [right: left (cm), 1.51 ± 0.41 vs 1.13 ± 0.34, p <.0001, 1.54 ± 0.36 vs 1.08 ± 0.33, p <.0001], respectively. The right IJV runs more superficially than the left IJV [right: left (cm), 1.74 ± 0.60 vs 1.87 ± 0.56, p <.0001]. Conclusions: Because the right IJV has a much wider diameter and runs more superficially than the left IJV, a right-sided approach is more acceptable than a left-sided one for CVC insertion via the IJV.