超声辅助血液透析临时血管通路建立的临床应用

Ultrasound-assisted establishment of temporary vascular access in hemodialysis patients

目的探讨超声辅助下血液透析用中心静脉置管术的安全性和有效性,以及减少置管近期并发症的措施。方法回顾性分析成都军区总医院肾内科近9年的中心静脉置管术,统计使用盲穿、B超定位、B超引导三种方法穿刺颈内静脉、股静脉和颈外静脉的例数、一次成功率和发生并发症的种类及例数;人为从时间上划分为二个阶段,分别观察二阶段颈内静脉和股静脉穿刺的一次成功率和误穿动脉发生率,数据进行统计学分析。结果 866例中颈内静脉置管术617例,股静脉置管术245例,颈外静脉置管术4例;常规盲穿512例,其中一次成功421例(82.2%),发生局部血肿10例(1.9%),误穿动脉33例(6.4%),伤及神经4例(0.8%),皮下气肿1例(0.2%);B超定位257例,其中一次成功238(92.6%),发生血肿1例(0.4%),误穿动脉2例(0.8%),未发生其他并发症;B超引导97例,一次成功92例(94.8%),未发生并发症;与常规盲穿比较,超声定位和引导穿刺的一次成功率明显提高(P<0.01),近期并发症的发生率明显降低;对比二阶段结果,第二阶段穿刺的一次成功率明显高于第一阶段(P<0.01),误穿动脉发生率明显低于第一阶段(P<0.05)。结论血液透析用中心静脉置管术是一种风险较大的有创性操作,掌握正确的操作方法和采用超声辅助穿刺能有效降低风险,减少并发症,提高成功率。

Objective To explore the efficacy and safety of ultrasound-assisted central venous catheterization for hemodialysis,and to discuss measures to reduce its early complications.Methods Clinical data of 866 hemodialysis patients in our department receiving central venous catheterization in last nine years were retrospectively analyzed.Cases punctured via internal jugular vein,femoral vein and external jugular vein using three methods including blind catheterization,B ultrasound localization and B ultrasound guidance were respectively counted.One-time success rate and the types and case numbers of complications were counted as well.Moreover,these patients were divided into two groups according to the observation period（the first period： from March 2000 to June 2008;the second period： from January 2008 to August 2009）.One-time success rate and the incidence of arterial mis-placement were recorded during the two periods,respectively.Results Internal jugular vein catheterization was conducted in 617 cases,femoral vein catheterization in 245 cases,and external jugular vein catheterization in 4 cases.There were 512 cases of routine blind catheterization.Among them,421 cases were one-time success（82.2%）,local haematoma occurred in 10 cases（1.9%）,arterial mis-placement in 33 cases（6.4%）,nerve injury in 4 cases（0.8%）,and subcutaneous emphysema in 1 case（0.2%）.Ultrasound-localized catheterization was conducted in 257 cases including 238 cases（92.6%）of one-time success.There were only 1 case（0.4%）of haematoma and 2 cases（0.8%）of arterial mis-placement.Ultrasound-guided catheterization was conducted in 97 cases with 92 cases（94.8%）of one-time success,and no complications occurred.Compared with routine blind catheterization,ultrasound-localized and ultrasound-guided catheterization were of high one-time success rate（P0.01）and low incidence of early complications.In addition,one-time success rate was significantly higher and the incidence of arterial mis-placement was significantly lower during the second period than those during the first period（P0.05 or P0.01）.Conclusion Central venous catheterization is a high-risk traumatic procedure.Correct methods and ultrasound assistance can effectively lower the risk,reduce complications and improve success rate.