经左、右侧上肢外周静脉置入中心静脉导管对置管结局的影响:458例前瞻性随机对照研究

目的比较经左、右侧上肢床旁行经外周静脉置入中心静脉导管（PICC）对置管结局的影响。方法2007年5月至2008年5月在武汉大学中南医院行PICC的患者458例，按随机表分为经左侧置入组（n=230）和右侧置入组（n=228）两组，于置管后即刻行胸部X线检查确认导管头端位置，并随访至导管停止使用时为止。结果右侧置入组出现送管困难的比率明显低于左侧置入组（14．9％比24．8％，P=0．003），导管头端大于40°成角的比率也明显低于左侧置入组（2．2％比23．4％，P=0．000）。两组患者导管头端位于中心静脉部位的到位率差异尤统计学意义（54．4％比53．0％，P=0．538），右侧置入组头端位于上腔静脉近心段的比率明显高于左侧置入组（21．0％比6．6％，P=0．001）；右侧置入组导管头端异位于头臂静脉的比牢明显低于左侧置入组（48．1％比66．7％，P=0．008），异伉于颈内静脉（P=0．859）和锁骨下静脉（P=0．696）的比率与左侧置入组差异无统计学意义。两组患者在导管留置时间（P=0．617）、穿刺血管局部静脉炎发生率（P=0．561）、导管堵塞率（P=0．774）及导管相关感染率（P=0．854）方面差异尤统计学意义，右侧置入组的上肢肿胀发生率明显低于左侧置入组（4．4％比8．3％，P=0．043）。结论经右侧上肢置入PICC的效果优于经左侧上肢，建议临床中置入PICC时优先选择经右侧上肢置管。

Comparison of the outcomes of central venous catheters inserted from the left side and right side: a prospective randomized controlled study

Objective To compare the effectiveness and safety of central venous catheters inserted from the left side and right side during peripheral inserted central catheterizations (PICC). Methods Totally 458 adult patients undergoing PICC between May 2007 and May 2008 were enrolled in this study and divided randomly into right-sided group (n = 228)and left-slded group (n = 230). Chest X-ray was performed immediately after catheterization to identify the initial tip locations. Other parameters were evaluated during follow-up. Results The rate of difficult insertion was significantly lower in right-sided group than in left-sided group (14.9% vs 24. 8% , P =0.003). The rate of tip projection angle ＞40°was also significantly lower in right-sided group (2.2% vs 23.4% ,P = 0. 000). The rate of tips reaching the central veins was not significantly different between two groups (54.4%vs 53.0% , P = 0. 538). Compared with right-sided catheters, the tip positions in the left-sided group was significantly less frequently located in the inferior segment of superior vena cave in the central tip locations (6. 6% vs 21.0% , P =0. 001)and more commonly positioned in the nominate vein in non-central tip locations (66. 7% vs 48.1% , P = 0. 008). In addition, the catheter detaining time (P = 0. 617), incidence of local phlebitis after puncture (P = 0. 561), catheter obstruction rate (P = 0. 774), and catheter-related infection rate (P = 0. 854)showed no significant differences between two groups. The incidence of swollen limb was significantly lower inright-sided group than in left-sided group (4. 4% vs 8.3%, P = 0. 043). Conclusions Right-sided catheters provide better outcomes than left-sided catheters. PICC through the right elbow veins should be preferred in clinical practices.