心电图辅助中心静脉导管定位技术在胸段脊柱侧后凸患者中的应用

Application of ECG-guided central venous catheter positioning in patients with thoracic segments idiopathic scoliosis

目的采用心电图辅助中心静脉导管定位技术,探讨胸段脊柱侧后凸患者与同龄无脊柱侧后凸的患者中心静脉导管置入深度是否存在差异,以确定其最佳置管深度。方法观察组为37例择期胸段脊柱侧后凸矫形手术患者,ASAⅠ～Ⅲ级,年龄16～40岁;对照组为40例无脊柱畸形的择期手术患者,ASAⅠ～Ⅱ级,年龄16～40岁。两组患者均于麻醉诱导后行右侧颈内静脉穿刺(中路),在心电图出现P波改变时停止送入导管,再后退1cm作为导管最终留置深度。记录心电图出现P波改变时的导管深度及导管最终留置深度;手术结束后24h内拍床旁胸片,确认导管位置。结果观察组实际完成33例,2例中心静脉导管未放置成功,2例未做术后床边胸片。观察组患者身高、体重显著低于对照组患者[(137.9±24.5)vs.(168.2±9.4)cm,(52.3±14.1)vs.(68.4±11.7)kg,P<0.01];观察组心电图出现P波改变时的导管深度和最终留置深度均小于对照组[(12.2±3.7)vs.(14.3±3.1)cm,(11.4±2.9)vs.(13.3±2.6)cm,P<0.05],两组患者平卧位时测得的中心静脉压(CVP)差异无统计学意义(P>0.05)。术后床边胸片显示,观察组患者中心静脉导管尖端与心影的相对位置较好者29例(87.9%),基本位于上腔静脉入口水平,另4例(12.1%)则略偏浅,导管尖端与胸椎的相对位置则变化较大;对照组患者中心静脉导管尖端与心影和胸椎的相对位置均较好,导管尖端基本位于上腔静脉入口水平及第4胸椎上下缘范围内。结论胸段脊柱侧后凸手术患者中心静脉置管深度明显短于同龄无脊柱侧后凸的手术患者。心电图辅助中心静脉导管定位技术,有助于精确定位导管尖端的位置。

Objective To investigate the differences in the length of central venous catheter （CVC） in patients with and without idiopathic thoracic segment scoliosis. The CVC was placed into the optimal position of internal jugular vein （IJV） guided by ECG. Methods Thirty-seven patients who were ASA Ⅰ-Ⅲ , aged 16-40 years old, and with selective thoracic segments idiopathic scoliosis operations were selected as the study group. Forty patients who were ASA Ⅰ-Ⅱ, aged 16-40 years old, and with other selective operations patients without spinal deformity were selected as the control group. After induction of anesthesia, all patients were placed CVC into the right IJV through the midway with ECG=guided central venous catheter positioning. CVC was put forward until the P wave of ECG changed. CVC was retreated 1 cm and fixed. The following data were recorded： the length of CVC when the P wave changed, the length of CVC after the catheter had been fixed. Bedside chest radiography were done in 24 h after operation to confirm the position of the tip of CVCI Re-suits The height and weight of patients of the study group were significantly lower than those of patients in the control group [（137.9±24.5） vs. （168.2±9.4）cm, （52.3±14.1） vs. （68.4±11.7）kg, P 〈 0.01]. The length of CVC of the study group was significantly shorter than that of the control group whether the P wave changed or the CVC was fixed [（12.2±3.7） vs. （14.3±3.1）cm, （11.4±2.9）vs. （13.3±2.6）cm, P 〈 0.05]. The data of CVP between both groups had no significant difference （measured in Supine position）. Bedside chest radiography showed 29 （87.9%） patients of the studyhad the tip of CVC posi-tioned exactly at the entrance of the Superior vena cava, while the other 4 cases （12.1%）, had the CVC tip a little far away from the entrance of the superior vena cava. X-ray image of the thoracic vertebra was not reliable to the judgement of the relative position between the CVC tip and the superior vena cava. For all patients of the control group, the CVC tips were positioned exactly at the entrance of the Superior vena cava, and with a good association with the X-ray image of the heart and the thoracic vertebra. Conclusion For patients with idiopathic thoracic scoliosis, the inserted length of CVC is signif- icantly shorter than that of the age-matched normal adults. The ECG-guided CVC positioning can help to put the CVC tip accurately at the entrance of the superior vena cava.