双侧锁骨下静脉交替置管与单纯右侧锁骨下静脉置管血培养对比研究

目的探讨双侧锁骨下静脉交替置管与单纯右侧锁骨下静脉置管在ICU患者中的应用效果。方法将我科收治的50例患者随机分为实验组和对照组各25例,两组患者均行锁骨下静脉置管,实验组采用双侧锁骨下静脉交替置管,对照组采用传统的单纯右侧锁骨下静脉置管,观察两组患者的一次置管成功率、置管时间和术后血肿发生情况,并于置管后1、2、3、5天于穿刺口取样及拔管前取导管血、拔管后导管头端行细菌培养,比较两组细菌培养的情况。结果两组患者的一次置管成功率、置管操作时间和术后血肿发生率比较,差异有统计学意义(均P0.05);术后导管相关感染发生率比较,差异无统计学意义(P0.05)。结论双侧锁骨下静脉交替置管术的应用效果优于单纯右侧锁骨下静脉置管术。     

彩色超声与盲探穿刺右颈内静脉并发症比较

目的比较彩色超声引导与盲探穿刺右侧颈内静脉置管术的并发症情况。方法将我院拟择期(在腹腔镜下)行结直肠肿瘤切除术的患者100例,ASA分级Ⅰ~Ⅲ级,年龄23~81岁,体重32~81kg。采用抛硬币法将患者随机分为彩色超声组(C)和盲探穿刺组(M)各50例。记录两组病人黑色细针试穿中静脉时次数、薄壁蓝空针穿刺中静脉时次数、穿刺点的数目、导管置入失败的次数,并记录病人由于穿刺引起的机械并发症及术后留置导管并发症情况。结果两组患者均未见明显机械并发症,且两组比较无统计学意义;两组无误穿动脉、血气胸及心律失常或心脏损伤的情况。结论彩色超声引导下行右颈内静脉穿刺成功率较盲探穿刺高,盲探穿刺刺破颈内静脉后壁概率较彩色多普勒超声引导下穿刺组高,其余机械并发症及留置中心静脉导管并发症比较无统计学意义。     

PICC置管在妇科恶性肿瘤化疗中的应用观察及护理

目的探讨经外周插管的中心静脉导管技术(PICC)在妇科恶性肿瘤化疗中的应用及护理效果。方法回顾分析2012年2～8月在我科治疗的84例妇科恶性肿瘤化疗患者留置PICC的临床资料,观察PICC置管期间相关并发症发生的原因及相应的护理措施。结果 84例PICC置管均成功,置管时间38～128天,置管长度38～50cm;出现机械性静脉炎10例,导管破损、漏液6例,穿刺侧肢体肿胀4例,导管脱出3例,导管堵塞3例,皮肤过敏2例,感染1例。结论 PICC具有操作简单、留置时间长、并发症相对少、感染率低等特点,尤其适用于多疗程化疗的妇科恶性肿瘤病人。     

腋静脉留置针在肥胖危重婴幼儿救治中的应用

目的 探讨腋静脉留置针在肥胖危重儿救治中的应用.方法 将2009年1月~2012年12月我科收治的98例肥胖危重儿随机分为腋静脉留置针组(42例)与外周静脉留置针组(56例),观察两组患儿的首针穿刺成功、留置时间及并发症.结果 腋静脉组留置针留置时间较长,患儿首针穿刺成功率较高,脱管、堵管、静脉炎、渗血和外渗发生率均较外周静脉留置针组低.结论 在肥胖危重婴幼儿救治中,选择腋静脉留置针穿刺置管优于外周静脉留置针置管.     

超声多普勒技术在323例危重症患者颈内静脉穿刺置管术中的应用

目的:探讨超声多普勒技术在危重症惠者颈内静脉穿刺置管中的临床应用价值.方珐:选取323例预计颈内静脉穿刺困难的危重症患者,在超声引导下行右颈内静脉穿刺置管,记录穿刺时间、一次穿刺置管成功率、二次以上穿刺置管成功率及并发症发生例数.结果:323例患者均在超声引导下行右颈内静脉穿刺置管成功.无一例因穿刺失败改行其他部位中心静脉穿刺.超声多普勒引导穿刺置管操作时间184.6±20.5s.超声多普勒引导一次穿刺置管成功率93%.超声多普勒引导二次以上穿刺置管成功率100%.并发症发生率4.64%.结论:应用超声多普勒技术引导危重症怠者颈内静脉穿刺置管.缩短了置管时间,减少了穿刺次数,提高了一次穿刺成功率.     

封管及穿刺部位使用抗生素预防锁骨下静脉导管相关感染

目的探讨预防锁骨下静脉导管相关感染的方法。方法将锁骨下静脉置管的51例患者随机分为对照组(25例)和实验组(26例)。对照组采用肝素封管;实验组采用肝素加头孢唑啉封管,穿刺点外涂莫匹罗星和氧氟沙星软膏。结果实验组无导管出口部位发生感染患者,对照组4例患者发生导管出口部位感染,两组比较差异有统计学意义(P0.05)。血行感染,实验组1例,对照组1例,差异无统计学意义。结论局部使用抗生素对锁骨下静脉导管出口部位有预防作用,对血行感染则可能无效。     

两种腹膜透析手术置管术的临床对比研究

目的:探讨腹腔镜下腹膜透析置管术与手术切开腹膜透析置管术的临床对比与应用价值.方法:选择2007年3月1日至2012年3月1日在新疆维吾尔自治区人民医院肾病科收治的慢性肾功能衰竭且自愿行腹膜透析的患者96例,其中45例在局麻下行常规手术切开置管术(A组),51例行腹腔镜置管术(B组),术后均使用百特双联系统装置进行腹膜透析.并对术后导管相关性并发症、住院天数、手术费用等方面进行回顾性分析和对比.结果:A组中:导管移位3例(6.7％),网膜包裹2例(4.4％),胸膜瘘1例(2.2％),腹膜炎1例(2.2％),短期透析引流时疼痛2例(4.4％),总体导管相关并发症发生率(19.9％),手术时间为25-40 min,人均手术费用1000元,住院时间7-15天.B组中:无一例发生漂管,阴囊水肿2例(3.9％％),透析管周围渗液2例(3.9％),胸膜瘘1例(2.0％),腹壁疝2例(3.9％),腹膜炎1例(2.0％),总体导管相关并发症发生率(15.7％),手术时间为15-25min,人均费用5500元,住院时间12-25天.结论:腹腔镜置管术与手术切开置管术各有利弊,选择哪种方法要根据患者经济、身体状况、患者意愿来选择.     

超声引导与传统PICC 置管术在老年患者中应用的对比性研究

目的:比较超声引导下PICC置管术与传统PICC置管术在老年患者中的应用情况,评价其效果。方法:回顾性分析2009年1月至2010年12月期间解放军总医院南楼老年患者PICC置管情况,记录超声引导及传统PICC置管两种方法的成功率与并发症情况。结果:超声引导组共512例次,传统PICC组共384例次,超声引导组均选择肘上静脉置管,传统PICC置管组均选择肘下静脉;超声引导组一次置管成功率及总成功率分别为96.7%,99.6%,传统PICC组分别为78.6%,86.2(P<0.01);超声引导组相关并发症发生率5.9%,对照组为12.0%(P<0.01)。结论:采用超声引导下PICC穿刺置管术显著提高了置管成功率,降低了PICC相关并发症发生率,与传统PICC组比较优势明显,值得临床推广。     

血管与导管选择对PICC置管引发并发症的影响

目的:通过比较PICC置管的血管与导管选择,探讨其对并发症发生率的影响。方法:2005年10月至2006年7月共336例恶性肿瘤病人应用B/BRAUN单腔导管,"可分裂"穿刺针355型173例,257型163例分别选择头静脉、贵要静脉、颈外静脉进行观察。结果:头静脉病人>50%出现并发症,其中30%出现中途拔管;贵要静脉<10%出现并发症,90%完成治疗计划;颈外静脉2例因固定不妥导致导管脱出。结论:在非高速度滴注的情况下,尽量选用小管径的导管;对血管的选择应当首选责要静脉,优选右侧,穿刺点最好过肘关节,其次选择颈外静脉优选右侧;选择PICC置管操作应慎重,操作之前做好详细的评估。     

超声引导改良外周静脉导入中心静脉置管术临床应用经验

目的:探讨超声引导下改良的外周静脉导入中心静脉置管术(Peripherally Inserted Central Catheter,PICC)的临床应用。方法:对42例有恶性肿瘤病史需行PICC置管、浅静脉直视下不明显或触摸不到、不适合盲穿患者42例进行超声引导下改良的PICC术。改良方法包括穿刺支架超声引导以及用一次性使用麻醉用针替代Seldinger包内的穿刺针进行,并与23例标准PICC法对比分析穿刺成功率及穿刺并发症发生率。结果:两种方法穿刺成功率均为100%,其中改良PICC患者41例穿刺一次成功,一次成功率为97.6%;标准PICC患者21例穿刺一次成功,一次成功率为91.3%。两种方法一次成功率差异无统计学意义(P0.05)。42例改良患者中发生2例并发症,包括局部水肿1例及导管异位1例;23例标准PICC患者中发生6例并发症,包括局部水肿2例,导管异位1例,静脉炎1例及局部感染2例。两种方法并发症发生率差异有统计学意义(P=0.019)。结论:超声引导下改良的PICC术一次成功率高,并发症少,值得临床推广。     

Venous valves in the large branches of superior vena cava

In 97 human cadavers the valves of the following blood vessels were investigated with regard to their cusps and their sizes and positions: the internal jugular veins, the subclavian veins, the brachiocephalic veins, and the superior vena cava. The cusps of each of the valves, which consist of two or three parts, are neither always of equal size nor obligatorily sufficient. Unipartite valves may be sufficient as well as insufficient. Internal jugular veins: The inferior bulb of the internal jugular vein is provided with valves which in 6% of the cases consist of three parts, in 66% of two parts, and in 15% of only one cusp. The concave margins of most of them go down as far as the venous angle. The convex edges attached to the wall of the vein extend to a higher level on the right side than on the left. In 13% there do not exist any valves. Varieties are described separately in this paper. Subclavian veins: Valves are found along the length of the vessel. Only few of them reach the venous angle. In rare cases there exist two valves: one at the beginning, the other at the end of the subclavian vein. In 4% of the cases the valves consist of three, in 75% of two cusps. In 12% they are unipartite. In 9% there are no valves to be found. The right side is more often without valves than the left. Brachiocephalic veins: Only a minority of these vessels is provided with valves. Most of these consist of one cusp, are insufficient, and are situated in the left innominate vein.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ultrasonic locating devices for central venous cannulation: meta-analysis

Objectives To assess the evidence for the clinical effectiveness of ultrasound guided central venous cannulation.Data sources 15 electronic bibliographic databases, covering biomedical, science, social science, health economics, and grey literature.Design Systematic review and meta-analysis of randomised controlled trials.Populations Patients scheduled for central venous access.Intervention reviewed Guidance using real time two dimensional ultrasonography or Doppler needles and probes compared with the anatomical landmark method of cannulation.Data extraction Risk of failed catheter placement (primary outcome), risk of complications from placement, risk of failure on first attempt at placement, number of attempts to successful catheterisation, and time (seconds) to successful catheterisation.Data synthesis 18 trials (1646 participants) were identified. Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Three studies in infants confirmed a higher success rate with two dimensional ultrasonography for internal jugular procedures (0.15, 0.03 to 0.64). Doppler guided cannulation of the internal jugular vein in adults was more successful than the landmark method (0.39, 0.17 to 0.92), but the landmark method was more successful for subclavian vein procedures (1.48, 1.03 to 2.14). No significant difference was found between these techniques for cannulation of the internal jugular vein in infants. An indirect comparison of relative risks suggested that two dimensional ultrasonography would be more successful than Doppler guidance for subclavian vein procedures in adults (0.09, 0.02 to 0.38).Conclusions Evidence supports the use of two dimensional ultrasonography for central venous cannulation.     

Complications of central venous catheterization from an anatomical point of view

For access to the central venous system numerous percutaneous methods and approaches exist. Questions are often raised concerning which approach is the safest. In 18 human cadavers, we punctured the internal jugular vein via an anterior and posterior approach and the subclavian vein via an infraclavicular route to determine which of these approaches is better with respect to success rate and frequency of puncture complications. The position of the needles was assessed by dissection. Successful venipunctures were achieved in 81% by the posterior approach, as opposed to 58% by the anterior approach and the infraclavicular route. The lowest frequency of complications was attained by the posterior approach (17%) too, whereas the anterior approach (33%) and the subclavian route (25%) had higher complication rates. The main complication of posterior and anterior approaches was inadvertent arterial puncture (9 vs. 19%). At the subclavian approach puncture of a 'wrong' vein was frequent (14%), and the complications included a case of pleura lesion. In conclusion the posterior approach to the internal jugular vein is superior to the other investigated approaches, and therefore, it can reasonably be proposed as a usual route for the insertion of a central venous catheter.     

改良颈静脉置管术在自身给药成瘾模型优化中的作用研究

目的:探讨技术和方法的改进,提高动物颈静脉置管以及药物成瘾自身给药模型构建的成功率,为成瘾研究提供更稳定和高效的建模方法。方法:对建立自身给药模型的传统颈静脉置管术进行改良,选取成年雄性SD大鼠60只,按照随机数字表法分为传统手术组(n=30)和改良手术组(n=30),分别完成颈静脉置管术后,按照随机数字表法,再将每组分为对照训练组(n=15)和成瘾训练组(n=15),构建大鼠自身给药模型,观察两组大鼠自身给药模型成功率。结果:大鼠的颈静脉置管手术可能出现的手术并发症主要包括堵管、漏管、感染甚至死亡等,最主要的并发症是漏管,占比最大。颈静脉置管传统手术组手术成功率为43.33%±3.333,颈静脉置管改良手术组手术成功率为90.00%±3.333,显著高于颈静脉置管传统手术组(P0.05)。两组成瘾训练组有效鼻触次数均分别明显高于其对照训练组(P0.05)。结论:大鼠改良后的颈静脉置管手术效果明显优于传统手术,颈静脉置管手术成功率明显提高。     

小鼠经颈外静脉右心导管法测定心室压力的实验方法研究

目的：研究可行性高的测定小鼠右心室压力的实验方法。方法：通过自制PE导管,连接powerlab多通道生物信号记录系统,经颈外静脉插管,右心导管法测定小鼠右心室压力,并借以研究肺动脉压力变化。结果：用此方法对51只小鼠进行插管,46例成功进入心室并测压,成功率90．2％。其中33只正常小鼠中,成功30例,测得压力值：收缩压（23．4±5．7）mmHg,舒张压（3．7±2．6）mmHg,平均压（12．0±3．7）mmHg;18只肺动脉高压模型小鼠中,成功16例,测得压力值：收缩压：（32．2±2．8）mmng,舒张压（3．8±2．0）mmng,平均压（14．94±2．3）mmHg。共失败5例,经解剖发现2例进入下腔静脉,2例穿破心耳,1例穿破腋静脉进入胸壁。结论：使用自制的PE导管经颈外静脉插管,右心导管法测定右心室压具有成功率高、数据更准确、操作省时、方法易普及的优点。是一种较好的对小鼠进行右心室压力测定的方法。     

Randomized Clinical Trial Comparing Ultrasound-Guided Procedure with the Seldinger’s Technique for Placement of Implantable Venous Ports

The aim of this randomized controlled study was to compare ultrasound-guided procedure with the Seldinger’s technique for placement of implantable venous ports. A total of 214 patients were randomized to receive TIAP placement by either ultrasound-guided procedure or the Seldinger’s technique. Complications and pain perception were compared between these two groups. No severe perioperative or periinterventional complication occurred. Significantly (P < 0.05) lower pain perception was observed in the ultrasound-guided group. Seldinger’s technique group showed higher rate in incidence of early and late complications including catheter dislocation, catheter occlusion, venous thrombosis, fever of unknown origin, skin necrosis, and sepsis. In conclusion, both techniques, the TIAP implantation via ultrasound-guided jugular vein puncture and via Seldinger’s technique subclavian vein puncture, are feasible and safe. Regarding intrainterventional pain perception and implantation-related complications, the jugular vein puncture under ultrasound guidance seems to be advantageous.     

Radiofrequency Ablation Of Typical Atrial Flutter Via Right Subclavian/jugular Vein Access In A Patient With Implanted Filter In The Inferior Vena Cava

Radiofrequency ablation of Cavotricuspid Isthmus-dependent Atrial Flutter (CTI AFL), a usual and safe therapeutic procedure in interventional electrophysiology with a high success rate, aiming to induce permanent block of conduction over CTI, is normally performed via the femoral access, which allows practical access to the CTI through the inferior vena cava (IVC). In rare cases of obstruction of IVC, ablation of CTI can be performed only through the superior vena cava (SVC) access. We present a case of typical atrial flutter that was ablated through the right subclavian/jugular veins because of iatrogenic obstruction of the IVC due to a previously implanted thrombus filter. Furthermore we discuss about how we resolved access-related problems of instability during catheter ablation on CTI.     

Percutaneous transvenous retrieval of intracardiac port-a-cath catheter fragment: a case report

A female patient, 36 years of age, with a metastasised left breast cancer received several courses of chemotherapy for aggressive local tumour growth and multiple metastatic activity. In the current patient, surgical ablation of the left breast was carried out. Also loco-regional radio-therapy was conducted. To facilitate the administration of chemotherapy courses and prevent thrombophlebitis a vascular access port (port-a-cath) was surgically inserted via the right subclavian vein. After a few successful administrations of chemotherapeutic drugs the vascular port stopped functioning. It was demonstrated that a detached catheter fragment had dislodged into the right ventricle. Successful percutaneous, transvenous removal of the entrapped catheter fragment by the Gooseneck retrieval loop snare from the right ventricle was performed via the right femoral vein access. The procedure was uncomplicated and the patient tolerated the procedure well.