锁骨下静脉置管误入同侧颈内静脉的相关因素及早期判断指标

Risk factors and early indicators for misplacement of subclavian vein catheter into ipsilateral internal jugular vein

目的探讨锁骨下静脉置管误入同侧颈内静脉的相关因素及早期判断指标。方法2008年8月至2009年7月间首都医科大学宣武医院普外科行锁骨下静脉置管成功的患者167例，均采取Seldinger技术进行置管。记录穿刺部位、穿刺位点、进针方向、穿刺过程中患者的主观感觉和操作者的感觉，分析上述各种因素及患者年龄、性别与锁骨下静脉置管进入颈内静脉的关系。结果共16例（9．58％）患者锁骨下静脉置管进人同侧颈内静脉。锁骨下静脉置管是否进入颈内静脉与患者的年龄（P=0．375）、性别（P=0．259）、穿刺部位（P=0．175）及穿刺位点（P=0．061）无关。进针方向为胸骨上窝与喉结连线的中点时较胸锁关节更易进入颈内静脉（P=0．002），而锁骨中内1／3交点下1cm位点的进针方向更倾向于朝向胸骨上窝与喉结连线的中点（P=0．010）。穿刺过程中患者有耳痛及耳周不适（P=0．000）、导丝放置过程中有阻力感（P=0．000）时更易进入颈内静脉。结论锁骨下静脉置管进针方向为胸骨上窝与喉结连线的中点时导管易进入同侧颈内静脉。穿刺过程中患者有耳痛及耳周不适、导丝放置过程中有阻力感可作为判断导丝进入同侧颈内静脉的早期指标。

Objective To identify the risk factors and early indicators for misplacement of subclavian vein catheter into ipsilateral internal jugular vein. Methods From August 2008 to July 2009, subclavian vein catheterization was successfully performed with Seldinger method in 167 patients in Department of General Surgery, Xuanwu Hospital of Capital Medical University. The paracentesis side, paracentesis site, direction of puncture needle, and the perceptions of both patients and operators during catheter placement were recorded. The correlation of these factors, age, and gender with the misplacement of subclavian vein catheter into internal jugular vein was analyzed. Results Sixteen patients （9.58 % ） experienced misplacement of subclavian vein catheter into ipsilateral internal jugular vein, which was not significantly correlated with age （P = 0. 375 ）, gender （P = 0. 259 ）, paracentesis side （P = O. 175 ）, or paracentesis site （ P = 0. 061 ）. Misplacement of subclavian vein catheter into internal jugular vein was significantly more frequent when the direction of puncture needle was toward the midpoint of suprasternal fossa and laryngeal prominence （ P = 0. 002）. When the paracentesis site was located at a point at the junction of medial one-third and lateral two-thirds of the clavicle, it was more frequent that the puncture needle was toward the midpoint of suprasternal fossa and laryngeal prominence （P =0. 010）. There were more misplacement events when the patients feel ears pain （ P = 0. 000 ） and when the operator felt resistance when inserting guidewire during cath- eter placement （ P = 0. 000）. Conclusions Misplacement of subclavian vein catheter into ipsilateral internal jugular vein occurs more frequently when the direction of puncture needle is towards the midpoint between suprasternal fossa and laryngeal prominence. Patients feel ears pain and operators feel resistance when inserting guidewire during catheter placement are early indicators of misplacement.