体表标志定位法在颈内静脉入路完全置入式静脉输液港置入中的应用

Application of body surface markers localization in totally implantable venous access port implantation via internal jugular vein approach

目的探讨经颈内静脉入路完全置入式静脉输液港(TIVAP)置入手术中,应用体表标志定位法确定导管尖端正确位置(上腔静脉下1/3或上腔静脉和右心房交界)的可行性。方法回顾性分析2019年6月—2021年6月首都医科大学附属北京同仁医院收治的220例TIVAP置入手术患者的临床资料,其中168例采用经颈内静脉入路,根据术中确定中心静脉导管(CVC)长度的方法分为两组:采用体表标志定位法的136例为研究组;采用术中X线定位法的32例为对照组。比较两组置入后即刻的CVC尖端定位优良率以及置入手术时间的差异等,并对右侧与左侧颈内静脉置管患者的身高、年龄、导管尖端距气管隆突距离因素与CVC留置长度的相关性进行分析。计量资料的统计分布采用Kolmogorov-Smirnov检验,呈正态分布的计量资料以均数±标准差(χ±s)表示,组间比较采用独立样本t检验;计数资料组间比较采用χ^(2)检验;以TIVAP导管留置长度为因变量,身高为自变量,进行Pearson相关性分析,并通过一元线性回归分析得出理想导管留置长度与患者身高的关系方程。结果CVC尖端位于第2肋间、第3胸肋关节、第3肋间时,分别有34.8%、83.3%、95.0%的机率位于正确位置。CVC尖端在第3胸肋关节或第3肋间的正确定位机率高于第2肋间,差异均具有统计学意义(P<0.001);CVC尖端位于第3胸肋关节与位于第3肋间时的正确定位机率差异无统计学意义(P=0.149)。研究组较对照组(未调整导管位置前)可明显提高导管位置优良率(94.1%比46.9%),差异具有统计学意义(χ^(2)=41.99,P<0.001);显著缩短手术时间[(33.04±6.69)min比(42.50±5.54)min],差异具有统计学意义(P<0.05)。CVC留置长度与身高呈线性相关,右侧颈内静脉入路导管留置长度(cm)=0.159×身高(cm)-1.284(r=0.597,r^(2)=0.356,P<0.001);左侧入路导管留置长度(cm)=0.097×身高(cm)+12.139(r=0.322,r^(2)=0.104,P=0.020)。结论经颈内静脉TIVAP置入手术中,采用体表标志定位法,导管尖端对应的体表标志为第3胸肋关节或第3肋间。体表标志定位法较术中X线定位法可明显缩短手术时间,且操作简便易于掌握,在确定导管长度、导管尖端位置方面具有较高的可靠性。

Objective To investigate the feasibility of using body surface marker localization method to determine the correct position of catheter tip(lower 1/3 of the superior vena cava or the junction of superior vena cava and right atrium)in totally implantable venous access port(TIVAP)implantation via internal jugular vein approach.Methods The clinical data of 220 patients who underwent TIVAP implantation in Beijing Tongren Hospital,Capital Medical University from June 2019 to June 2021 were retrospectively analyzed.Among them,168 patients used the internal jugular vein approach.According to the method implemented for determining the length of central venous catheter(CVC)during the operation,the patients were divided into two groups:136 patients using the body surface marker localization method were defined as the study group;and the remaining 32 cases treated by the intraoperative X-ray fluoroscopic localization method were defined as the control group.The difference in the excellent or good rate of CVC tip position immediately after implantation and the time of implantation was compared between the two groups.In addition,the correlation between the length of CVC indwelling,height,age,and the distance between the catheter tip and tracheal carina was analyzed for the patients with right and left internal jugular vein catheterization.Kolmogorov-Smirnov test was used for statistical distribution of measurement data.Normal distribution of measurement data was expressed as mean±standard deviation(χ±s),independent sample t-test was used for comparison between groups.Chi-square test was used for comparison between counting data.With TIVAP catheter indenture length as dependent variable and height as independent variable,Pearson correlation analysis was performed,the relationship equation between ideal catheter indenture length and patient height was analyzed by unitary linear regression.Results When the CVC tip was located at the second intercostal space,the third sternocostal joint and the third intercostal space,the corresponding probability of being in the correct position was 34.8%,83.3%and 95.0%respectively.The third sternocostal joint or the third intercostal space had a higher probability of correct CVC tip location than the second intercostal space,and the difference were statistically significant(P<0.001).Furthermore,there was no significant difference in the possibility of the CVC tip located in the correct position between the third sternocostal joint and the third intercostal space(P=0.149).Compared with the control group(before adjusting catheter position),the proportion of excellent or good CVC position in the study group was significantly improved(94.1%vs 46.9%),and the difference was statistically significant(χ^(2)=41.99,P<0.001);while the total operation time was significantly shortened[(33.04±6.69)min vs(42.50±5.54)min],and the difference was statistically significant(P<0.05).There was a linear correlation between the length of CVC insertion and height.Indwelling catheter length via right internal jugular vein approach(cm)=0.159×height(cm)-1.284(r=0.597,r^(2)=0.356,P<0.001);length of catheter indwelling through the left approach(cm)=0.097×height(cm)+12.139(r=0.322,r^(2)=0.104,P=0.020).Conclusions The third sternocostal joint or the third intercostal space would be the corresponding correct surface landmark of the CVC tip when the body surface marker localization method was adopted during the TIVAP implantation via the internal jugular vein approach.Compared with the intraoperative X-ray fluoroscopy localization,the operation time is significantly shortened with the application of the body surface marker localization method.This technique is simple and easy to master and has high reliability in determining the length of catheter and the position of CVC tip.