乳胶管穿刺实验对锁骨下静脉置管的指导意义

Guiding significance of latex - tube puncture experiment on subclavian vein catheterization

目的探讨以下五个因素对锁骨下静脉（subclavianvein，SCV）置管的影响：①穿刺针与SCV之间的夹角；②穿刺针刺入SCV的不同部位：包括靠近血管前壁、接近中央及靠近后壁；③穿刺针刺入SCV的不同深度；④穿刺部位指向SCV水平支及指向SCV与头臂静脉的相交拐角处；scv与头臂静脉之间的弯度变化。方法以6mE、8mE、10mm及12／fiE四种内径规格乳胶管注水后两端结扎，借助线的牵引和凳子脚的固定，使之形成类似人体上SCV与头臂静脉之间所成的角度和形状，根据上述五个因素的不同水平进行穿刺和放置导丝。结果①穿刺针与乳胶管之间的夹角（锐角）超过一定角度，即使穿刺成功，导丝也不能置入；该夹角越小，导丝放置阻力越小（P〈0．001）；②当穿刺针接近乳胶管下壁比接近上壁更容易置入导丝（P〈0．001）；③当穿刺方向指向乳胶管内侧拐角处时，容易造成导丝放置失败；④当穿刺方向指向乳胶管水平支时，乳胶管水平支与内侧降支之间的弯度大小对导丝能否成功置入无影响。结论临床上，在能穿刺到SCV的前提下，应采用穿刺针与SCV尽量小的夹角进行穿刺。逆向定位穿刺点法和间歇进针法都具有一定优势。

Objective To explore the influence of the following 5 factors on subclavian vein （SCV） catheterization, including angle between needle and SCV, different position of puncture needle into SCV （near the anterior wall, the central or the posterior wall of vessel）, depth of needle into SCV, puncture direction （pointed to the horizontal branch or to the corner of SCV and brachiocephalic vein） , as well as the curvature between SCV and brachiocephalic veins. Methods Foursizes of latex - tube with a internal diameter of 6 ram, 8 mm, 10 mm and 12 mm were filled with water, followed by ligation at both ends. Under the traction of threads and the fixation of thestools, an angle and shape similar with SCV and brachiocephalic vein were formed. Subsequently, the puncture and placement of guide wire was performed according to different levels of the 5 factors. Results Guide wire placement was failed when the acute angle between puncture needle and latex tube exceeded a certain angle although puncture was successfully performed. The angle was positively correlated with the resistance of wire placement （ P 〈 0. 001 ）. Wire placement was more easily performed when puncture needle was near the inferior wall of latex tube than near the superior wall （P 〈 0. 001 ）. Guide wire placement was easy to fail when puncture direction pointed to the comer of latex tube. When puncture direction was pointed to the horizontal branch of latex tube, camber size between the horizontal branch and descending branch of latex tube hadno effect on wire placement. Conclusion In clinical practice, under the premise that SCV can be reached, the angle between puncture needle and SCV should be as small as possible. The method of positioning puncture site in the opposite directionand the method ofintermittent needle entry have some advantages.