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【全文发布】《新英格兰杂志》最新综述(中文版
中心静脉穿刺
Alan S. Graham, M.D., Caroline Ozment, M.D., Ken Tegtmeyer, M.D.,Susanna Lai, M.P.H., and Dana A.V. Braner, M.D.
第一部分
Indications
Central venous catheterization provides a route for delivery of caustic or critical medications and allows measurement of central venous pressure.
介绍：
中心静脉穿刺为苛性药物和急性给药提供了一条通路，并可测定患者的中心静脉压。
Contraindications
General contraindications for the placement of a central venous catheter include infection of the area overlying the target vein and thrombosis of the target vein;site-specific and relative contraindications include coagulopathy, although this is not an absolute contraindication. Extreme care must be exercised in patients with coagulopathy and in other patients for whom complications would be life-threatening.
禁忌症：
埋置中心静脉导管的一般禁忌症包括覆盖欲穿刺静脉区域的感染和欲穿刺静脉血栓；特殊部位的和相对的禁忌症为凝血功能紊乱，但并不是绝对的。对于有凝血功能紊乱的患者和有危及生命的综合症的患者必须进行末端护理。
Equipment
Many institutions stock prepackaged catheter-insertion kits containing the necessary equipment. The catheter should have the appropriate lumen size to deliver the required medications, and its length should be appropriate to reach the junction of the vena cava and the right atrium. Approximate length can be measured against the patient’s external anatomical landmarks. Seven-French 20-cm catheters are the most commonly used. Dialysis or rapid fluid resuscitation requires larger-bore catheters. Each additional lumen decreases the size of the individual lumens, which will decrease the maximal rate at which fluids can be administered. The catheter should be flushed, and compatibility between the guide wire and the needle should be confirmed.
设备：
许多机构都存有备好的、含必须设备的导管穿刺包。导管必须有给药所需的适当内径，必须有能到达腔静脉和右心房结合的适当长度。近似的导管长度可以通过测量患者体外解剖学标志来决定。7.0周径（Fr）、20厘米（cm）长的导管是最常用的。透析或者快速液体复苏需要使用较大内径的导管。每增加一种输注成分将会减少所有输注成分各自的流量，使每一流体成分的最大流速下降。导管必须是充盈的，而且导线（丝）和针头必须是配套的。
Preparation
Explain the procedure to the patient, and obtain written informed consent. Select the insertion site on the basis of the comparisons noted in Table 1. Subclavian and internal jugular sites are generally preferred because they present a lower risk of infection and fewer mechanical complications.1 If the patient has challenging anatomy,a scar at the insertion site, or any other indication that could result in a difficult insertion, an expert operator should be in attendance.
Anatomical landmarks for the central approach to internal jugular venous catheterization begin at the apex of the triangle formed by the heads of the sternocleidomastoid muscle and the clavicle. A confluence between the internal jugular vein and the brachiocephalic vein facilitates cannulation at this location. After identifying the landmarks, sterilize the area with chlorhexidine, using a circular motion from the center outward, and then apply a sterile drape.
Administer local anesthesia, using 1 to 2 ml of 1% lidocaine or equivalent, with a 25-gauge needle at the cannulation site. To avoid air embolis , place the patient with head down, in the Trendelenburg position. The head should be rotated 45 degrees away from the site of cannulation; avoid excessive rotation of the head, which can cause collapse of the vein. During the procedure, place the index finger of your nondominant hand on the patient’s carotid artery to diminish the risk of inadvertent puncture of the artery.
准备：
（医生）穿刺前向患者解释整个过程，并获得（患者）书面同意书。对照表1来决定穿刺位点。由于锁骨下和颈内静脉穿刺感染率低、机械性综合症少，使得这两个穿刺位点成为首选位点。在患者的解剖结构异于常人、穿刺位点有疤痕、或者其他指征时，必须有一位穿刺专家在场。
颈内静脉穿刺的起始步骤是决定解剖学标志：由胸锁乳突肌的头端和锁骨所形成的三角的顶点。在这里，颈内静脉和无名静脉的汇合使套管插入更容易。在选定了解剖学标志后，用洗必泰（chlorhexidine）由中间向外周进行环状消毒，并覆以无菌铺单。
在将要插入套管的部位用25号针头、1到2毫升1%利多卡因(或相当的其他药物)局部麻醉。为避免空气栓塞，将患者头部放低，使其处于头低脚高位。患者头部必须偏离插套管部位，以旋转45度为最佳；但要避免过渡旋转，以免使静脉塌陷。在整个穿刺过程中，穿刺者将非惯用手的食指置于患者的颈动脉上，以避免不慎刺伤此动脉。
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作者:admin@医学,生命科学 2011-04-15 17:11
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