斜轴法与短轴法超声引导颈内静脉穿刺的对比临床研究

Clinical study of oblique-axis view ultrasound-guided internal jugular vein puncture compared with short-axis view

目的比较斜轴法和短轴法引导颈内静脉穿刺的效果,包括一次穿刺成功率、总成功率、穿刺置管完成时间和并发症。方法 2014年1月至2015年1月本院60例拟实施右颈内静脉穿刺置管的患者随机分为超声短轴组（n=30）和超声斜轴组（n=30）。患者常规心电图、血氧饱和度、有创动脉血压监测,全麻诱导采用静脉注射咪达唑仑0.05mg/kg,丙泊酚1mg/kg,芬太尼2~3μg/kg,罗库溴铵0.1mg/kg,行气管内插管,机械通气,潮气量8~10ml/kg,频率12次/分。患者去枕平卧,头低15°,略转向左侧,常规消毒铺巾。超声探头频率为5~10MHz。短轴组超声探头放置使超声波可以横向（短轴视野）观看颈内静脉的粗细、走向、血管壁弹性、血流充盈情况以及与颈动脉和周围组织的关系。超声斜轴组先用短轴法定位血管后旋转探头45°,使探头内侧指向患者对侧乳头或肩膀。超声定位后超声引导下行右颈内静脉穿刺置管。记录颈内静脉试穿成功次数、穿刺置管完成时间、有无并发症发生。结果斜轴组30例患者中一次穿刺成功21例（70%）,成功率为100%;短轴组中一次穿刺成功10例（33%）,成功率为80%。两组一次穿刺成功率、穿刺成功率差异均有显著性（P〈0.05）。斜轴组平均穿刺次数和穿刺置管时间明显短于短轴组,差异均有显著性（P〈0.05）。斜轴组无血肿病例,短轴组为1例,差异无显著性。结论与短轴法比较斜轴法超声引导颈内静脉穿刺可大大提高颈内静脉穿刺置管成功率及缩短穿刺置管时间,同时减少了并发症发生及邻近组织的损伤,具有临床推广价值。

Objective The study is designed to compare the guiding puncture effects for oblique-axis and short axis views,including the first puncture success rate, the procedural success rate, the need for multiple needle advances, the time of internal jugular vein catheterization and complications. Method Sixty patients requiring internal jugular vein catheterization were randomly divided into ultrasound shortaxis group（n=30） and ultrasound oblique-axis group（n=30）. The patients are monitored ECG, SPO2, ABP. Anesthesia was induced with midazolam 0.05mg/kg, propofol 1mg/kg, fentanyl 2~3μg/kg, vecuronium 0.1mg/kg, then endotracheal intubation and mechanical ventilation were facilitated, Vt 8~10ml/kg, f 10/min. First step was to remove pillow and let patients lie supine with his head slightly 15°down and towards left. Second step was to disinfect and put sterile drapes. Ultrasonic probe frequency was between 5~10MHz.Short-axis group with ultrasound probe could be placed transversely（short-axis view） to view the internal jugular vein thickness,the vessel wall elasticity and visualize all relevant anatomically significant structures. Oblique-axis group with ultrasound probe could be placed transversely（short-axis view） to view the internal jugular vein first, then the probe was rotated approximately 45°so that the medial end of the ultrasound probe aligned with the patient,s contralateral nipple or shoulder. The next step was to puncture internal jugular vein with ultrasound guided, and catheterize the central line.The last step was to record the first puncture success rate,the procedural success rate,the need for multiple needle advances, the time of central venous catheterization and complication. Result Cannulation of the right internal jugular vein was successful in all 30 patients in the O group and in 24 of 30 patients（80%） in the S group（P〈0.05）. 21 of 30（70%） patients in the O group were cannulated with one attempt as compared with 10 of 30（33%） in the S group（P〈0.05）. Times of the attempting puncture and the time of cannulation were compared between the two groups, for O group,the attempting puncture times are less than S group（P〈0.05）, the time of cannulation was also shorter than S group（P〈0.05）. There was one carotid puncture in S group（3%）. Conclusion The oblique-axis view is a potentially superior technique than short-axis view because it optimizes the capabilities of dynamic ultrasound-guided vascular access. As a result,central venous cannulation success rates may be improved while complications and damage to adjacent structures decrease. The oblique-axis view for internal jugular vein puncture and cannulation has its value for clinical application and promotion.