Prediction of Hypotension During Neuraxial Anesthesia in Patients with Pregnancy-Induced Hypertension Through Subclavian Vein Collapsibility Index

Objective:To explore and evaluate the predictive value of subclavian vein collapsibility index(SCV-CI)on hypotension during neuraxial anesthesia in patients with pregnancy-induced hypertension(PIH).Methods:Pregnant women with PIH who underwent elective cesarean section in our hospital from January to July 2021 were selected as the research subjects.Patients who experienced hypotension during anesthesia were included into the hypotension group,whereas patients who had a normal blood pressure during anesthesia were included in the normotensive group.The SCV-CI was then calculated for three respiratory cycles,the average value was taken as the base value,and the patient was monitored for another 20 minutes.The blood pressure,heart rate,blood oxygen saturation,and SCV-CI of the patients were measured,and the incidence of maternal nausea and vomiting and cord blood gas were recorded.Then,a correlation analysis was conducted on the relationship between subclavian vein collapsibility index and hypotension.A receiver operating characteristic curve was drawn to seek the threshold value of subclavian vein collapsibility index for post-anesthesia hypotension.Results:There was no significant difference in systolic blood pressure(SBP),diastolic blood pressure(DBP),and heart rate(HR)between the two groups before anesthesia(P>0.05).After anesthesia,the above indexes(SBP,103.25±12.48 mmHg;DBP,58.94±7.46 mmHg;and HR,52.96±6.48 beats/min)were significantly lower than those of the normal blood pressure group,and the difference was statistically significant(P<0.05).In comparison,the SCV-CI in the hypotension group was 35.82±4.93%greater than that in the normal blood pressure group(23.85±5.27%),and the incidence of nausea and vomiting in the hypotension group(40.0%)was significantly higher than that in the normotensive group(10.53%),and the difference was statistically significant(P<0.05).The area under the curve of SCV-CI prediction against hypotension in patients with PIH under neuraxial anesthesia was 0.825(95%CI:0.762-0.893,P<0.001),the cut-off value was 25.68%,the predictive sensitivity was 92.68%,and the specificity was 81.24%.Conclusion:SCV-CI has a good predictive value for the occurrence of hypotension in patients with PIH during neuraxial anesthesia.

Successful upgrade to cardiac resynchronization therapy for cardiac implantation-associated left subclavian vein occlusion:A case report

BACKGROUND Subclavian vein stenosis or occlusion may be caused by a transvenous pacemaker,which makes the reimplantation of a new pacemaker lead difficult.Transvenous pacemaker lead implantation-related subclavian vein occlusion may present difficulty with regard to cardiac resynchronization therapy(CRT)upgrade.CASE SUMMARY We report the case of a 46-year-old man who was admitted with total subclavian vein occlusion caused by a permanent pacemaker that had been implanted 2 years previously.We successfully treated this patient with an upgrade to a CRT pacemaker by utilizing transferable interventional coronary and radiological techniques.The patient recovered uneventfully during the follow-up period.CONCLUSION CRT upgrade is still a viable technique for the treatment of subclavian vein obstruction caused by previous pacemaker implantation.

Implantable Venous Access Ports for Chemotherapy in Lung Cancer Patients: Comparison of the Femoral and Subclavian Vein Approaches without Guidance

Background: The goal of this study was to retrospectively compare the initial success rate and rate of intraoperative and late complications between the femoral and subclavian vein approaches used to implant venous access ports without guidance in lung cancer patients. Methods: We conducted a retrospective review of total 163 lung cancer patients who underwent implantations of a central venous access port for chemotherapy. 95 patients received the ports by the femoral vein blind-puncture technique and 68patients had the port implanted via the subclavian vein blind-puncture technique. The initial success rate of port implantation and the frequency of occurrence of complications were calculated. Results: The primary success rate of venous port implantation was 93.7% for femoral approach and 88.2% for the subclavian approach respectively (p < 0.05). Intraoperative complications developed in two patients (2.1%) in the femoral approach group and in five patients (7.4%) in the subclavian approach group. Although a higher intraoperative complication ratio for the subclavian approach was encountered compared to that for the femoral vein approach, there was no statistically significant difference (p = 0.103). Nor was there any statistically significant difference in terms of the occurrence of late complications. Conclusions: Venous access port implantation via the femoral vein approach is safe, and its success rate is very high, with the equal complication rates comparable to the subclavian approach. This approach avoids many of the intraoperative complications. Thus, the femoral vein approach for implanting a venous access port in lung cancer patients should be considered a valid, and safe technique.

Real-time ultrasound-guided versus landmark-guided subclavian vein catheterization in the intensive care unit: a prospective randomized study

Background:The subclavian vein(SCV)is an alternative to the internal jugular vein when it is difficult to locate,such as in patients with hypovolemia or obesity.Ultrasonography(USG)guidance for SVC cannulation has evolved,resulting in fewer complications and higher first-pass success rates.This study aimed to compare the effectiveness and safety of SCV cannulation with USG-and landmark-guided techniques.Methods:In this prospective randomized interventional controlled study,80 patients admitted to the intensive care unit between July 2022 and October 2022 were randomly assigned to the landmark method group(LM group)and USG group.In the LM group,SCV cannulation was performed using the traditional landmark technique,whereas in the USG group,it was performed using USG guidance.The primary objective of this study was to evaluate the ease of subclavian central venous cannulation in critically ill patients using the 2 techniques.The secondary objectives were to compare the success rate of cannulation between these 2 techniques,evaluate the number of attempts,assess cannulation failure,and assess mechanical complications.Results:The first-pass success rates were 70%and 92.5%in the LM and USG groups,respectively(P<0.001).The average numbers of attempts in the LM and USG groups were 1.275(±0.520)and 1.075(±0.266),respectively(P=0.034).The average procedure durations were 7.45(±1.10)and 8(±0.933)minutes in the LM and USG groups(P=0.018),respectively.The rates of complications in both groups were not statistically significant.Conclusion:The USG guidance for SCV cannulation has an advantage over landmark-guided methods in a critical care setting.The SCV is a good alternative to internal jugular vein cannulation.The average time to cannulation was longer in the USG group than in the LM group,which can decrease with the frequent use of USG and increasing operator experience.Clinical trials:This study was registered in the Clinical Trials Registry-India(CTRI Trial No.CTRI/2022/07/043694,dated May 7,2022).

Subclavian vessels injury:An underestimated complication of clavicular fractures

Clavicle fractures are frequent orthopedic injuries,often resulting from direct trauma or a fall.Most clavicle fractures are treated conservatively without any complications or adverse effects.Concomitant injuries of the subclavian vein or artery are rarely encountered and most commonly associated with high-energy trauma or comminuted clavicle fractures.They are potentially life-threatening conditions leading to hemorrhage,hematoma,pseudoaneurysm or upper limb ischemia.However,the clinical presentation might be obscure and easily missed,particularly in closed and minimally displaced clavicular fractures,and timely diagnosis relies on early clinical suspicion.Currently,computed tomography angiography has largely replaced conventional angiography for the assessment of subclavian vessel patency,as it demonstrates high accuracy and temporal resolution,acute turnaround time,and capability of multiplanar reconstruction.Depending on the hemodynamic stability of the patient and the severity of the injury,subclavian vessel lesions can be treated conservatively with observation and serial evaluation or operatively.Interventional vascular techniques should be considered in patients with serious hemorrhage and limb ischemia,followed by stabilization of the displaced clavicle fracture.This review aims to provide a comprehensive overview of the incidence,clinical presentation,diagnostic approaches,and current management strategies of clavicle fractures associated with subclavian vessel injuries.

Optimized Axillary Vein Technique versus Subclavian Vein Technique in Cardiovascular Implantable Electronic Device Implantation： A Randomized Controlled Study

Background：The conventional venous access for cardiovascular implantable electronic device （CIED） is the subclavian vein,which is often accompanied by high complication rate.The aim of this study was to assess the efficacy and safety of optimized axillary vein technique.Methods：A total of 247 patients undergoing CIED implantation were included and assigned to the axillary vein group or the subclavian vein group randomly.Success rate of puncture and complications in the perioperative period and follow-ups were recorded.Results：The overall success rate （95.7% vs.96.0%） and one-time success rate （68.4% vs.66.1%） of punctures were similar between the two groups.In the subclavian vein group,pneumothorax occurred in three patients.The subclavian gaps of three patients were too tight to allow operation of the electrode lead.In contrast,there were no puncture-associated complications in the axillary vein group.In the patient follow-ups,two patients in the subclavian vein group had subclavian crush syndrome and both of them received lead replacement.The incidence of complications during the perioperative period and follow-ups of the axillary vein group and the subclavian vein group was 1.6% （2/125） and 8.2% （10/122）,respectively （χ^2=5.813,P =0.016）.Conclusion：Optimized axillary vein technique may be superior to the conventional subclavian vein technique for CIED lead placement.

Impact of misplaced subclavian vein catheter into jugular vein on transpulmonary thermodilution measurement variables

Objective： The subclavian vein （SCV） is usually used to inject the indicator of cold saline for a transpul- monary thermodilution （TPTD） measurement. The SCV catheter being misplaced into the internal jugular （IJV） vein is a common occurrence. The present study explores the influence of a misplaced SCV catheter on TPTD variables. Methods： Thirteen severe acute pancreatitis （SAP） patients with malposition of the SCV catheter were enrolled in this study. TPTD variables including cardiac index （CI）, global end-diastolic volume index （GEDVI）, intrathoracic blood volume index （ITBVI）, and extravascular lung water index （EVLWl） were obtained after injection of cold saline via the misplaced SCV catheter. Then, the misplaced SCV catheter was removed and IJV access was constructed for a further set of TPTD variables. Comparisons were made between the TPTD results measured through the IJV and mis- placed SCV accesses. Results： A total of 104 measurements were made from TPTD curves after injection of cold saline via the IJV and misplaced SCV accesses. Bland-Altman analysis demonstrated an overestimation of ＋111.40 ml/m2 （limits of agreement： 6.13 and 216.70 ml/m2） for GEDVI and ITBVI after a misplaced SCV injection. There were no significant influences on CI and EVLWI. The biases of ＋0.17 L/（min.m2） for CI and ＋0.17 ml/kg for EVLWI were re- vealed by Bland-Altman analysis. Conclusions： The malposition of an SCV catheter does influence the accuracy of TPTD variables, especially GEDVI and ITBVI. The position of the SCV catheter should be confirmed by chest X-ray in order to make good use of the TPTD measurements.

Modification of the right subclavian vein catheterization and its anatomic basis and techniques

Background Several million subclavian-vein catheters are placed in patients each year to enable caregivers to administer chemotherapy, total parenteral nutrition, or long-term antibiotics or to manage preoperative fluids. Subclavian venipuncture requires the position of a deep vein to be identified with only surface landmarks. But the traditional right subclavian vein (RSV) catheterization (primitive procedures) is not the answer for all patients. The precise location of the vein is not known, and it is important to select the most appropriate method to achieve central venous access safely in any given patient. To modify the primitive procedures of the RSV catheterization for greater success and reduce the complications, anatomic studies and ultrasonography were conducted and clinical applications were validated. Methods Anatomical observation and measurement of the RSV and its adjacent structures were performed on 20 adult cadavers according to modified procedures. The RSV catheterization of 2900 cases was carried out by the modified procedure, 500 of these cases were observed by ultrasonography after the operation. Results The anatomical studies and clinical application showed that the insertion point differs from the bodily form of fatness or leptosome. The clinical data revealed that in the 2900 cases which were performed with the modified approach, the success rate was 98.90% (2868 cases), the failure rate was 1.10% (32 cases), and the complication rate is 0.79% (23 cases), and the catheterization time is (31.2±10.5) minutes. Five hundred and sixty cases of the RSV catheterization were carried out by the recommended insertion procedure; the results were compared with the modified approach and the traditional approach. The successful rate of the traditional approach was 73.0%, of which the complication rate was 6.1%; the two approaches were significantly different (successful rate: χ 2=626.642, P <0.01; complication rate: χ 2=80.708, P <0.01). Conclusions The modified RSV catheterization is characterized with a higher success rate and less complications, and the insertion procedure differs from the bodily form of fatness or leptosome.

颈静脉、锁骨下静脉汇入无名静脉区的影像解剖分型研究及其在中心静脉置管中的应用

目的 研究双侧颈静脉、锁骨下静脉汇入无名静脉“三岔口”区的局部影像解剖并进行分型,初步探讨其在中心静脉置管中的应用。方法 河南科技大学第一附属医院2020年10月至2022年11月中心静脉置管病例389例,根据锁骨下静脉、颈静脉汇入无名静脉区局部影像解剖特点进行分型,右侧分为5型,左侧分为4型,结合置管后胸部X线片、CT检查、腔内心电及超声等资料明确中心静脉管位置,采用统计学方法分析“三岔口”区影像解剖分型与中心静脉导管异位的关系。结果 389例病例右侧“三岔口”区影像解剖分型中Ⅰ型占44.7%、Ⅱ型占24.7%、Ⅲ型占10.3%、Ⅳ型占17.2%、Ⅴ型占3.1%;左侧“三岔口”区影像解剖分型中Ⅰ型占29.3%、Ⅱ型占59.9%、Ⅲ型占9.8%、Ⅳ型占1.0%。经外周置入中心静脉导管(PICC)共271例,右侧入路180例中导管异位共24例,其中Ⅰ型3例、Ⅱ型5例、Ⅲ型4例、Ⅳ型7例、Ⅴ型5例,左侧入路91例中导管异位共3例,其中Ⅱ型2例、Ⅲ型1例;中心静脉导管异位发生率PICC右侧入路各型比较差异有统计学意义(χ^(2)=11.796,P=0.019),左侧入路各型比较差异无统计学意义(χ^(2)=2.073,P=0.557)。CVC置管118例,右侧入路104例中导管异位5例,其中Ⅱ型2例、Ⅲ型2例、Ⅳ型1例,左侧入路14例中导管异位3例,其中Ⅱ型2例、Ⅳ型1例,中心静脉导管异位发生率CVC右侧入路各型比较差异无统计学意义(χ^(2)=7.403,P=0.116),左侧入路各型比较差异无统计学意义(χ^(2)=4.497,P=0.213)。结论 颈静脉、锁骨下静脉汇入无名静脉区的影像解剖分型右侧Ⅰ型最多见,左侧Ⅱ型最多见,局部影像解剖分型与中心静脉导管异位存在一定关系。

不同路径植入中心静脉导管安全有效性的网状Meta分析

目的采用网状Meta分析比较经颈内静脉、锁骨下静脉和腋静脉植入中心静脉导管(central venous catheter,CVC)的安全性及有效性,以期为临床选择中心静脉导管最佳穿刺路径提供证据支持。方法系统检索中国知网、万方、维普中文科技期刊数据库、中国生物医学文献服务系统(CBM)、PubMed、Web of Science、Cochrane library、Embase数据库,检索建库至2022年7月有CVC不同植入路径的已发表文献,采用Review Manager 5.3软件进行传统Meta分析和Stata 14.0软件进行网状Meta分析。结果共纳入18篇随机对照试验,包含6746例研究对象。Meta分析显示,3种路径中经腋静脉植入CVC首次穿刺成功率优于颈锁骨下静脉[RR(95%CI):0.88(0.84~0.91)]、经腋静脉植入CVC总体并发症发生率低于经锁骨下静脉植入[RR(95%CI):1.90(1.23~2.92)],但高于经颈内静脉植入CVC[RR(95%CI):1.76(1.35~2.30)],差异具有统计学意义(P<0.05);锁骨下静脉组误穿动脉发生率高于腋静脉组[RR(95%CI):2.36(1.02~5.45)],气胸发生率高于腋静脉组[RR(95%CI):2.36(1.03~5.39)]和颈内静脉组[RR(95%CI):2.34(1.14~4.80)],导管相关感染发生率颈内静脉组高于锁骨下静脉组[RR(95%CI):0.34(0.16~0.69)],差异均具有统计学意义(P<0.05)。结论经腋静脉植入CVC在首次穿刺成功率和并发症发生率比较中有优势,推荐临床CVC植入首选腋静脉路径,但仍应充分考虑患者情况,个体化选择最优路径植入CVC。

骑跨锁骨技术超声引导下腋静脉与锁骨下静脉穿刺效果分析

目的:探讨骑跨锁骨技术超声引导下腋静脉与锁骨下静脉穿刺在临床中的应用效果。方法:选取2023年1月-2024年1月新疆维吾尔自治区塔城地区人民医院收治的200例需要中心静脉置管治疗的患者为研究对象,按照随机数字表法将患者分为对照组与研究组,每组100例。对照组采用骑跨锁骨技术超声引导下腋静脉穿刺,研究组采用锁骨下静脉穿刺。对比两组的穿刺情况、超声影像学情况、并发症发生情况及临床满意度。结果:研究组一次穿刺成功率为94.00%,高于对照组的77.00%,二次成功率为6.00%,低于对照组的23.00%,差异均有统计学意义(P<0.05)。研究组静脉深度、静脉最大内径均长于对照组,超声定位时间短于对照组,差异均有统计学意义(P<0.05)。研究组并发症发生率为5.00%,低于对照组的13.00%,差异有统计学意义(P<0.05)。研究组临床总满意度为94.00%,高于对照组的82.00%,差异有统计学意义(P<0.05)。结论:与骑跨锁骨技术超声引导下腋静脉穿刺相比,锁骨下静脉穿刺的一次穿刺成功率高,并发症发生率低,且临床满意度高,具有较高的临床应用价值。

手臂位置对超声引导锁骨下静脉穿刺置管的影响

目的探讨手臂位置对超声引导锁骨下静脉平面内穿刺置管的影响。方法选取2021年8—12月在复旦大学附属中山医院青浦分院需行中心静脉穿刺置管的90例全麻手术患者,随机分为外展组(n=45)和内收组(n=45),均在超声实时引导下行锁骨下静脉平面内穿刺置管,观察并记录两组一次穿刺成功率、穿刺总成功率和穿刺并发症情况。结果在超声实时引导锁骨下静脉平面内穿刺置管过程中,外展组一次穿刺成功率为88.9%(40/45),高于内收组的68.9%(31/45),差异有统计学意义(P=0.020);外展组和内收组的总穿刺成功率分别为95.6%(43/45)和82.2%(37/45),差异有统计学意义(P=0.044)。在穿刺并发症方面,内收组有8例穿刺失败,其中2例出现局部血肿,外展组有2例穿刺失败,未发生局部血肿情况,两组均未出现气胸并发症,所有穿刺失败的病例均改行同侧颈内静脉穿刺。结论全麻手术患者中手臂外展90°便于超声实时引导锁骨下静脉平面内穿刺置管,值得临床推广。

不同消毒方法对超声引导锁骨下静脉穿刺超声成像和敷贴牢固度的影响

目的探讨不同消毒方法对超声引导锁骨下静脉穿刺超声成像和敷贴牢固度的影响。方法选取超声引导锁骨下静脉穿刺138例患者为研究对象,随机分为氯己定醇组、碘伏组和氯己定醇+碘伏组3组,每组46例,分别使用氯己定醇、碘伏和氯己定醇+碘伏消毒。对3组患者的消毒效果、超声成像和敷贴粘贴情况进行比较。结果3组患者消毒前后穿刺点的菌群计数及消毒合格率比较,差异均无统计学意义(P>0.05);氯己定醇组患者穿刺时超声成像清晰率显著低于碘伏组和氯己定醇+碘伏组(P<0.05),碘伏组患者穿刺后24 h的敷贴起翘或脱落率显著高于氯己定醇组和氯己定醇+碘伏组(P<0.05)。结论先使用氯己定醇消毒穿刺区域2次,再使用碘伏对超声探查区域消毒1次,可以使超声引导锁骨下静脉穿刺患者获得满意的消毒效果,同时超声成像更清晰,敷贴粘贴更牢固。

超声检测下腔静脉和锁骨下静脉内径变异在预测全身麻醉诱导后低血压中的价值

目的:分析超声检测下腔静脉(IVC)和锁骨下静脉(SCV)内径变异在预测全麻诱导后低血压(PIH)中的价值。方法:回顾性选取2021年5月—2023年5月在咸宁市第一人民医院行全麻手术的204例患者作为研究对象,根据是否发生PIH将其分为研究组(发生PIH,86例)和对照组(未发生PIH,118例)。对两组患者的基础资料、麻醉诱导前血压、麻醉诱导药物用量进行对比。比较IVC内径的最大值(IVCmax)和最小值(IVCmin)、SCV内径的最大值(SCVmax)和最小值(SCVmin),并计算IVC塌陷指数(IVCCI)和SCV塌陷指数(SCVCI)。采用受试者工作特征(ROC)曲线分析IVC、SCV内径及变异对全麻PIH的预测价值。结果:两组基础资料、麻醉诱导前血压指标和麻醉诱导药物用量比较,差异均无统计学意义(P>0.05)。研究组IVCmax、IVCmin、SCVmax、SCVmin水平均低于对照组,IVCCI、SCVCI水平均高于对照组,差异均有统计学意义(P<0.05)。受试者操作特征(ROC)曲线分析结果显示,麻醉诱导前IVCmax、IVCmin、SCVmax、SCVmin、IVCCI、SCVCI水平预测PIH的ROC曲线下面积(area under curve,AUC)分别为0.674、0.675、0.618、0.707、0.895、0.905,其中,SCVCI的AUC和cut-off值下的敏感度均为最高,分别为0.905、65.12%。结论:全麻PIH患者可表现为IVC和SCV内径缩小及IVCCI、SCVCI等内径变异指标的增高,采用血管超声技术检测上述变异指标可辅助预测PIH风险。

锁骨下静脉置管术在脑卒中患者治疗中的应用效果及对并发症的影响

目的:探讨锁骨下静脉置管术在脑卒中患者治疗中的应用效果及对并发症的影响。方法:选取该院2021年2月—2023年2月收治的60例脑卒中患者为该次研究对象,根据不同部位置管术分为观察组(n=30例)与对照组(n=30例),观察组患者实施锁骨下静脉置管术,对照组患者实施浅静脉留置针。比较两组患者应用效果(1次置管成功率、穿刺时间、置管后留置时间)、并发症情况(导管堵塞、导管脱出、导管感染、静脉炎)及满意度情况。结果:观察组患者1次置管成功率为96.67%(29/30),显著比对照组患者的80.00%(24/30)高,差异有统计学意义(P<0.05)。观察组患者穿刺时间比对照组短,置管后留置时间比对照组患者长,差异均有统计学意义(P<0.05)。观察组患者导管堵塞、导管脱出、感染、静脉炎总发生率为6.67%(2/30),明显比对照组患者的33.33%(10/30)低,差异有统计学意义(P<0.05)。观察组患者总满意度为96.67%,对照组的为70.00%,观察组满意度显著比对照组患者高,差异有统计学意义(P<0.05)。结论:锁骨下静脉置管术在脑卒中患者治疗中的应用效果明显,能有效提升1次置管成功率,缩短穿刺时间,延长导管留置时间,降低并发症发生率,更易被患者认可,具有较好的临床推广价值。

DSA引导下颈内、锁骨下及腋静脉入路输液港的临床应用

目的探讨DSA引导下颈内、锁骨下及腋静脉入路输液港的临床应用及安全性。方法 选取2016年3月28日至2018年6月28日在江阴市人民医院行DSA引导下静脉输液港植入术的肿瘤患者827例。根据患者输液港不同入路途径分为3组:经颈内静脉组(A组)125例,经锁骨下静脉组(B组)87例,经腋静脉组(C组)615例,比较3组患者的穿刺成功率及并发症发生情况。结果 DSA引导下A组首次穿刺成功率98.40%(123/125), B组穿刺成功率94.25%(82/87),C组穿刺成功率97.89%(602/615),差异有统计学意义(P<0.05);其中B组穿刺成功率低于C组,其余各组间差异无统计学意义(P>0.05)。对所有患者随访(15.56±2.91)个月(3~26个月),术后早期并发症总发生率为3.75%,A组为4.00%(5/125),B组为9.20%(8/87),C组为2.93%(18/615),其中B组发生率高于C组(P<0.016 7),各类并发症组间比较差异无统计学意义(P>0.05);术后远期并发症总发生率为4.72%(39/827), A组发生率为4.80%,B组发生率为14.95%,C组发生率为3.25%,B组并发症发生率高于A组及C组,差异有统计学意义(P<0.05)。各类并发症组间比较,B组导管断裂发生率高于C组,夹闭综合征仅发生于B组,差异有统计学意义(P<0.016 7),其余各类并发症组间差异无统计学意义(P>0.05)。非正常取港率为1.45%,A组3例,B组7例,C组2例,B组患者术后非正常取港率最高(8.05%),与C组比较差异有统计学意义(P<0.016 7)。结论 经腋静脉入路是一种安全、舒适、微创、高效的输液港植入方式,较经颈内静脉、经锁骨下静脉入路更能有效降低并发症发生率、术后非正常取港率,可作为临床应用的首选。

PI、IVC和SCV对预测全身麻醉诱导期低血压的研究

目的探讨脉搏灌注指数(PI)、下腔静脉(IVC)和锁骨下静脉(SCV)对预测全身麻醉诱导期低血压的研究。方法回顾性选择2018年1月至2021年12月来新疆医科大学第一附属医院行全身麻醉手术的患者110例,根据全身麻醉诱导期是否出现低血压将110例患者分为2组,其中正常血压组60例,低血压组50例。所有患者在麻醉诱导前均用超声诊断仪检测最小横截面积(SIVCmin)、最大横截面积(SIVCmax)、最小直径(DIVCmin)、最大直径(DIVCmax)、最小横截面积(SSCVmin)、最大横截面积(SSCVmax)、最小直径(DSCVmin)、最大直径(DSCVmax)、下腔静脉的横截面积的塌陷指数(CIsivc)、下腔静脉直径塌陷指数(CIdivc)、锁骨下静脉横截面积塌陷指数(CIssvc)、锁骨下静脉直径塌陷指数(CIdsvc),麻醉诱导至手术开始前的每分钟,记录一次平均动脉压、收缩压、舒张压、心率,取最小值,记录两组诱导前后血流动力学指标、PI及PI增加率。比较两组患者麻醉诱导前后的血流动力学参数水平,比较两组患者麻醉诱导前后的PI、PI增加率、SIVCmax、DIVCmax、SSCVmax、DSCVmax、CIdivc、CIsivc、CIssvc、CIdsvc,以及低血压组麻醉诱导前后以上指标与血流动力学参数的相关性、对全身麻醉诱导期低血压预测价值的ROC曲线及诊断价值。结果麻醉诱导前,两组的舒张压、收缩压、平均动脉压、心率比较,差异均无统计学意义(P>0.05);诱导后,两组的舒张压、收缩压、平均动脉压、心率均明显较基础值降低,而低血压组明显较正常血压组低,差异均有统计学意义(P<0.05)。正常血压组麻醉诱导前后PI、PI增加率、SIVCmax、DIVCmax较低血压组高,CIsivc、CIdivc、CIssvc、CIdsvc明显较低血压组低,差异均有统计学意义(P<0.05);两组的SSCVmax、DSCVmax比较,差异无统计学意义(P>0.05)。低血压组的舒张压降低率、收缩压降低率、平均动脉压降低率与基础PI、诱导后PI、PI增加率、SIVCmax、DIVCmax呈正相关,舒张压降低率、收缩压降低率、平均动脉压降低率与CIsivc、CIdivc、CIssvc、CIdsvc呈负相关(P<0.05)。基础PI≥3.58%,诱导后PI≥4.71%,PI增加率≥46.32%,SIVCmax=2.180 cm^(2),DIVCmax为1.847 cm,CIsivc为40.50%,CIdivc为33.50%%,ROC曲线下面积均超过0.8(P<0.05)。结论SIVCmax、DIVCmax、CIsivc、CIdivc、PI可用于预测全身麻醉诱导期低血压,SCV的预测价值无临床意义。

Impact of central venous port implantation method and access choice on outcomes

BACKGROUND Although the number of patients who need central venous ports for permanent vascular access is increasing,there is still no“gold standard”for the implantation technique.AIM To identify the implantation technique that should be favored.METHODS Two hundred central venous port-implanted patients in a tertiary hospital were retrospectively evaluated.Patients were assigned into two groups according to the access method.The first group comprised patients whose jugular veins were used,and the second group comprised patients whose subclavian veins were used.Groups were evaluated regarding age,sex,application side,primary diagnosis,active follow-up period in the hospital,chemotherapy agents administered,number of complications,and the Clavien-Dindo severity score.The distribution of the variables was tested with the Kolmogorov-Smirnov test and the Mann-Whitney U test.Theχ^(2) test was used to analyze the variables.RESULTS There was no statistically significant difference between the groups regarding age,sex,side,number of chemotherapy drugs,and duration of port usage(P>0.05).Only 2 patients in group 1 had complications,whereas in group 2 we observed 19 patients with complications(P<0.05).No port occlusion was found in group 1,but the catheters of 4 patients were occluded in group 2.One port was infected in group 1 compared to three infected ports in group 2.Two port ruptures,two pneumothorax,one revision due to a mechanical problem,one tachyarrhythmia during implantation,and four suture line problems were also recorded in group 2 patients.We also showed that it would be sufficient to evaluate and wash ports once every 2 mo.CONCLUSION Our results robustly confirm that the jugular vein route is safer than the subclavian vein approach for central venous port implantation.

锁骨下静脉置管内血栓形成危险因素分析及探讨

目的分析深静脉置管发生血栓的临床特征,探讨锁骨下深静脉置管内血栓形成的危险因素,为制定输液导管相关性血栓预防方案提供依据。方法回顾性纳入2021年2月至2022年10月在首都医科大学附属北京友谊医院消化科住院并接受超声引导下锁骨下静脉穿刺,置入Arrow抗感染中心静脉导管的138例患者为研究对象。入组患者按照导管内是否有血栓分为血栓组(n=98)和无血栓组(n=40)。收集患者基本信息、既往史、置管和血栓情况、置管前后血常规、血生化、凝血功能信息,以及患者日常生活活动能力Barthel指数量表、Branden压力伤风险评估量表和Padua静脉血栓风险评估模型评分,采用多因素Logistic回归分析影响导管内血栓形成的危险因素。结果血栓组和无血栓组患者的基本信息与既往史比较,差异均无统计学意义(P>0.05)。血栓组的深静脉置管中位留置时间为12(8~16)d,无血栓组的中位留置时间为10(6.5~13.0)d,血栓组留置时间长于无血栓组,差异有统计学意义(P<0.05)。血栓组静脉滴注高凝药品率为23.5%,高于无血栓组(5.0%),差异有统计学意义(P<0.05)。多因素Logistic回归结果提示,深静脉置管留置时间越长(OR=1.143,95%CI:1.047~1.249,P=0.003)、置管后白细胞数越高(OR=1.206,95%CI:1.021~1.423,P=0.027),血栓发生可能性越大。结论深静脉置管留置时间长和置管后白细胞数升高是血栓发生的独立危险因素。深静脉置管后,应关注留置时间较长、置管后白细胞数较高的患者发生血栓的危险性。

经胸超声引导结合极少X线透视指导双腔起搏器植入术的研究

目的探讨经胸超声引导下锁骨下静脉穿刺及结合极少X射线透视指导下完成双腔起搏器植入术的安全性和有效性。方法回顾性连续入选2019年1月至2020年1月住院拟行双腔起搏器植入的87例患者。按照是否应用超声引导下起搏器植入分为研究组(45例)和对照组(42例)。研究组在经胸超声引导下完成锁骨下静脉穿刺并经超声证实导丝进入下腔静脉,并在超声结合极少X线透视下完成起搏器电极植入。对照组在解剖定位下穿刺锁骨下静脉,X线确认导丝进入下腔静脉,并在X线指导下完成起搏器电极植入。比较两组间血管穿刺时间、手术时间、术中透视时间以及并发症发生情况。结果研究组的年龄明显高于对照组,体质指数明显低于对照组,差异均有统计学意义(均为P<0.05)。两组均完成起搏器植入术。与对照组相比,研究组完成两次锁骨下静脉穿刺的时间更短[(1.1±0.6)min比(3.2±1.7)min,t=7.786,P<0.001],放射剂量更少[(104.6±76.8)Gray比(617.3±347.2)Gray,t=9.660,P<0.001],术中透视时间更短[(43.8±14.6)s比(184.5±53.4)s,t=17.013,P<0.001]。对照组2例发生并发症,包括1例皮下血肿和1例少量气胸;而研究组未发生血肿及气胸等并发症,但两组间差异无统计学意义(χ^(2)=2.193,P=0.139)。结论超声引导下起搏器植入能够提高锁骨下静脉穿刺成功率,缩短穿刺时间,显著减少术中X线透视时间。