锁骨下静脉置管误入同侧颈内静脉的危险因素分析

The analysis on risk factors of misplacement of subclavian venous catheterization 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危险因素。方法收集2011年1月至2012年12月间上海交通大学医学院附属仁济医院外科监护室行锁骨下静脉置管成功的患者178例，均采用Seldinger技术进行置管。记录患者性别、年龄、穿刺部位、穿刺位点、进针方向、穿刺针针尖斜面方向、导引钢丝J型头方向、穿刺时头部位置，先以单因素分析筛选出有统计学意义的危险因素，再应用多因素非条件logistic回归分析患者在锁骨下静脉置管进入颈内同侧颈内静脉的独立危险因素。结果单因素分析表明：锁骨下静脉置管是否进入同侧颈内静脉与患者的性别（P=0．504）、年龄（P=0．200）、进针方向（P=0。370）、穿刺针针尖斜面方向（P=0．670）无关，与穿刺部位（P=0．012）、穿刺位点（P=0．012）、穿刺时导引钢丝J型头方向（P=0．000）、穿刺时患者头部位置（P=0．030）有关。多因素回归分析显示：锁骨下静脉置管时穿刺部位在右侧[危险度比值比（oddsratio，OR）=55．573，95％可信区间（confidenceinterval，CI）：5．145。595．845，X2=10．965，P=0．001]、导引钢丝J型头朝向颈内静脉（OR=24．116，95％CI：6．848～84．918，x^2=24．558，P=0．000）和穿刺时头部偏向穿刺对侧（OR=3．681，95％CI：1．210—11．199，x^2=5．268，P=0．022），为锁骨下静脉置管误人同侧颈内静脉的独立危险因素。共29例（16．29％）患者锁骨下静脉置管时进入同侧颈内静脉。结论锁骨下静脉置管误入同侧颈内静脉是其常见的并发症，影响锁骨下静脉置管误人同侧颈内静脉的主要因素有穿刺部位选择右侧、导引钢丝J型头朝向颈内静脉、穿刺时头部偏向穿刺对侧。

Objective To identify the risk factors of misplacement of subclavian venous catheterization into ipsilateral internal jugular vein. Methods From January 2011 to December 2012, subclavian venous catheterization was successfully performed with Seldinger method for 178 patients in department of surgical intensive care unit, Renji Hospital. The patients＇ sex, age, side and site of paracentesis, direction of puncture needle, direction of puncture needle bevel, direction of the J-Tip of the guidewire and position of the head during puncture were recorded. They were subjected to single factor analysis, and then independent risk factors for subclavian venous catheterization into ipsilateral internal jugular vein were determined with multivariate stepwise non-conditional logstic regression analysis. Results Single factor analysis showed that subclavian venous catheterization into ipsilateral internal jugular vein had no correlation with sex（P=0.504）, age （P=0.504）, direction of puncture needle （P=0.370）, direction of puncture needle bevel （P=0.670）, but had a correlation with paracentesis side （P=0.012）, paracentesis site （P=0.012）, direction of the J-Tip of the guidewire （P=0.000）,and position of the patient head （P=0.030）. Multivariate stepwise non-conditional logistic regression analysis showed that subclavian venous catheterization on the right side [odds ratio （0R）=55.373, 95% confidence interval （CI）：5.145-595.845,x^2=10.965, P=0.001], J-Tip of the guidewire directed toward internal jugular vein （0R=24.116, 95% CI：6.848-84.918, X2=24.558, P=0.000）, and the head to the contralateral side of puncture（OR=3.681, 95% CI：1.210-11.199,X2=5.268, P=0.022） were independent factors. A total of 29 cases （16.29%） of patients experienced invasion of ipsilateral internal jugular vein during subclavian venous catheterization. Conclusions Subclavian venous catheterization misplacement into ipsilateral internal jugular vein is common. The risk factor of the catheter misplacement into ipsilateral internal jugular vein are subclavian venous catheterization on the right side, J-Tip of the guidewire-directed toward internal jugular vein, and the head to the contralateral side of puncture.