儿童腰椎穿刺操作临床教学的难点与应对

Difficulty in the clinical teaching of lumbar puncture for children patients and its countermeasures

儿童腰椎穿刺(腰穿)难度大,技巧性高,是神经儿科住院医生及实习生临床培训及教学的重要内容。该文总结了多年的儿童腰穿教学经验与穿刺技巧,提出了儿童腰穿操作难点、技巧差异性及应对补救方法。儿童抗拒不合作及腰椎间隙狭小是儿童腰穿困难的主要原因。在儿童腰穿教学中,导致学员穿刺失败的主要原因有:1采用不同穿刺针有不同次数的突破层次感;2腰椎间隙选择不当;3进针角度太垂直;4偏离身体纵轴中线;5麻醉不当;6患儿极度不合作等。因此,让学员了解儿童腰穿的差异性及技巧要点,同时培训出操作熟练的二线及三线补救替补人员,加强术后护理,是学员穿刺失败后的补救应对方法。希望能为广大儿科医生及儿童腰穿教学提供借鉴经验。

Lumbar puncture for children is a difficult technique and is an important aspect of clinical teaching for residents and interns in the neurological department of pediatrics.In this article,we summarized techniques and experiences of clinical teaching in pediatric lumbar puncture,and discussed difficulty,variability and remedial strategy for lumbar puncture in children.Narrow intervertebral space,poor compliance and resistance of children are the main difficulty for pediatric lumbar puncture.The causes of failure for medical students include different sensations of breakthrough when using different needles,choice of un-preferable intervertebral space,excessive vertical angle for needling performance,deviation from the longitudinal midline of the body,incorrect anesthesia,and exceeding resistance of children patients.Corresponding remedial strategy for failure of puncture includes informing students of the technique and variability of puncture,training experienced staff for second-and third-line substitutes,and reinforcing nursing after surgery.This summary of techniques for pediatric lumbar puncture and experiences of clinical teaching will benefit pediatricians and their clinical training.