不同穿刺体位和头偏左转各角度对患者右颈内静脉B超影像的影响

Effects of different puncture positons on the ultrasound images of the right internal jugular vein

目的研究不同穿刺体位和头偏左转各角度对患者右颈内静脉B超影像的影响。方法随机选择择期手术患者100例,ASAⅠ~Ⅲ级,男62例,女38例,年龄21~79岁。患者依次取去枕垫肩平卧位（肩下垫6cm薄枕）、平卧位、Trendelenburg体位（15°~30°头低足高位）,分别将患者头偏左转0°、30°、45°和60°。超声探头置于患者右侧胸锁乳突肌三角的顶点,通过二维B超测量上述不同穿刺体位和头偏左转各角度时患者右颈内静脉的横径和横截面积等指标。计算右颈内静脉和颈总动脉重叠率和安全穿刺范围。结果与Trendelenburg位比较,头偏左转不同角度去枕垫肩平卧位和平卧位患者右颈内静脉横截面积明显减小（P〈0.05）,且去枕垫肩平卧位明显小于平卧位（P〈0.05）。与头偏左转0°比较,头偏左转30°、45°和60°时三种体位右颈内静脉横截面积明显增加（P〈0.05）。与Trendelenburg位比较,头偏左转不同角度去枕垫肩平卧位和平卧位患者安全穿刺范围明显减小（P〈0.05）。头偏左转30°、45°和60°角度三种体位的安全穿刺范围依次减小（P〈0.05）。与Trendelenburg比较,头偏左转不同角度去枕垫肩平卧位和平卧位患者动-静脉重叠程度评分明显降低（P〈0.05）,且去枕垫肩平卧位明显小于平卧位（P〈0.05）。头偏左转30°、45°和60°时三种体位患者动-静脉重叠程度评分依次升高（P〈0.05）。结论患者取Trendelenburg位是经右侧胸锁乳突肌三角顶点颈内静脉穿刺置管时理想的穿刺体位。头偏左转有利于右颈内静脉的充盈,但为了减少误穿动脉的风险,头偏左转角度以不超过30°为宜。

[Abstract] Objective To evaluate the effects of different puncture positions on cross-sectional area of the right internal jugular vein （RIJV）, overlap of the R]JV and carotid artery （CA） and safe puncture range by ultrasound imaging assessment. The optimal positions of the RIJV catheterization were recommended. Methods One hundred elective surgical patients including male 62 and female 38 were enrolled, aged 21-79 years old, ASA I -Ⅲ. The patients were placed in the shoulder-padded po- sition with a pillow, the supine position or the 15-30° Trendelenburg position. An ultrasound probe was placed on the right neck at the apex of the triangle formed by the head of the sternocleidomastoid muscle and the clavicle. For each simulated puncture position, two-dimensional ultrasound images of the RIJV and CA were repeatly obtained and saved at four different degrees of head rotation to the left from midline： 0°, 30°, 45°, 60°. The cross-sectional area of the RIJV, the overlap degree of the RIJV and CA and the secure puncture range were measured. Results Compared with the 15°-30° Trendelen- burg position, the cross-sectional area of RIJV was significantly decreased in the supine position and the shoulder-padded position （P〈0.05）, and shoulder-padded position was more less than the supine position （P〈0. 05）. The cross-sectional area of the RIJV was largest in 15-30° Trendelenburg posi- tion （P〈0.05）. Compared with head rotation to the left 0°, the cross-sectional area of the RIJV in- creased significantly at head rotation to the left 30°, 45°, 60° （P〈0.05）. Compared with the 15-30° Trendelenburg position, the safe puncture range was decreased significantly in the shoulder-padded position or the supine position （P〈0. 05）. Compared with the 15-30° Trendelenburg position, the o- verlap score of the RIJV and CA decreased significantly in the supine position and the shoulder-padded position （P〈0. 05）. When the head was rotated to the left from 0° to 60°, the safe puncture range decreased significantly （P〈 0. 05） and the CA RIJV overlap degree increased significantly （P 〈 0.05）. Conclusion The 15- 30° Trendelenburg position may be the most ideal poslure for RIJV cathe tcrization. Head rotated to the left increased the RIJV distension. To decrease The risk of punture of the carolid artery, the head should be kept 〈30° rotation to the left during RIJV catheterization.