下入路锁骨下静脉穿刺置管术的解剖学研究

Anatomical Study of Subclavian Vein Catheterization under the Inferior Approach

目的找到下入路锁骨下静脉穿刺置管术较好的体位、进针部位、穿刺方向及定位方法。方法对5具成人尸体颈根部及腋窝进行解剖,观测与下入路锁骨下静脉穿刺置管术有关结构、结构间位置关系及其随体位变化,比较不同部位进针穿刺锁骨下静脉。结果腋-锁骨下静脉上缘与锁骨下缘相交处(下称A点)在锁骨上缘对应的结构是前斜角肌外侧缘等。上肢贴躯干时、肩外展90°时,腋-锁骨下静脉上缘与锁骨下缘的夹角分别是41.3°±2.2°(45.2°~36.8°)、22.4°±1.8°(24.6°~19.8°)。肩前屈、外展时,锁骨与第一肋之间间隙变大;反之变小。在A点外下方1~1.5cm处(下称B点)进针,朝A点穿刺,针尖能顺利到达A点,再贴锁骨后面往胸锁关节穿刺,针尖能顺利到达胸锁关节;在锁骨外、中1/3交界处下1~1.5cm处进针,按相同方向穿刺,针尖在锁骨内、中1/3交界处被第一肋顶住。结论进行下入路锁骨下静脉穿刺置管术时,应采取肩前屈、外展体位;用前斜角肌外侧缘在体表定位A点、B点;应在B点处进针,朝A点穿刺。

Objective This study aimed to find a better posture,needle location,puncture direction and location method of subclavian vein catheterization under the inferior approach.Methods Five adult specimens of cervical and axillary root were dissected to investigate location related subclavian vein catheterization under inferior approach,and the change of adjacent relationship of anatomical structure with posture,the different points of the needle puncture were observed and compared.Results The intersection of the upper and lower margin of the axillary subclavian vein（hereinafter referred to as the A point）was corresponds to the lateral border of the anterior scalene muscle on the supraclavicular margin.When the upper limb was attached to the trunk and the shoulder abduction was 90°,the angle between the upper and lower margin of the axillary subclavian vein was 41.3°±2.2°（45.2°-36.8°）,22.4°±1.8°（24.6°±19.8°）,respectively.The space between the clavicle and the first rib became greater when the shoulder is bent or crossed,but vice versa.At the bottom of the A point 1-1.5 cm（hereinafter referred to as B point）into the needle,the needle toward the A point,the needle tip can reach the A point smoothly,then paste the clavicle to the sternoclavicular joint,the needle tip can reach the sternoclavicular joint smoothly.At the lower 1-1.5 cm part of the clavicle and the middle 1/3 junction,the tip of the needle in the same direction was withheld from the first rib at the junction of the clavicle and the middle 1/3.Conclusion The subclavian approach and abduction position should be adopted in subclavian vein catheterization under the inferior approach.The points A and B on the body surface were locate with the lateral border of the anterior scalene muscle.The needle should be inserted at the point B,and the point A be punctured.