主页 > 医药生命 >
【NEJM】超声用于引导颈内静脉穿刺置管术
Ultrasound-Guided Internal Jugular Vein Cannulation
OVERVIEW
Traditionally, internal jugular vein cannulation has been performed with the use of external anatomical landmarks and palpation to guide insertion of the needle into the vessel. However, depending on the operator's experience and the patient's anatomy, this procedure may be difficult or unsuccessful. Over the past decade, the increased use of ultrasonography to guide internal jugular vein cannulation has improved success rates, reduced the time required to perform the procedure, and reduced complications.
INDICATIONS
Ultrasound-guided internal jugular vein cannulation is performed when direct ac¬cess to the central circulation is needed. Access may be required for a variety of purposes, including monitoring central venous pressure, inserting pulmonary- artery catheters, administering intravenous therapeutic agents and nutrition, performing hemodialysis, and placing cardiac pacemakers.
CONTRAINDICATIONS
General contraindications to internal jugular vein cannulation include infection of the placement site and suspected pathologic conditions affecting the internal jugular vein or the superior vena cava (such as occlusion caused by coagulopa- thy). Caution should be used when the landmarks have been distorted by trauma or when other anatomical anomalies are present. Be careful when using this pro¬cedure in patients who have prior injury to the internal jugular vein, have very small internal jugular veins, or are morbidly obese. In these circumstances, alterna¬tive sites should be considered; however, use of the femoral vein is associated with a higher incidence of infection and therefore should be avoided.
Ultrasonography is a noninvasive, nonionizing form of imaging that is safe for use in patients of all ages and in women who are pregnant. There are no contrain¬dications specific to the use of ultrasound guidance during internal jugular vein cannulation.
EQUIPMENT
Central venous catheters vary in size, length, and number of infusion ports. The choice of catheter depends on the clinical circumstance. Packaged central venous catheterization kits are commercially available. Kits may include drapes, disin¬fectant sponges, gauze pads, sutures with needles, a guidewire, a scalpel, a vein dilator, a penetration syringe, a guide syringe, an anesthetic syringe, and 1% or 2% lidocaine anesthetic solution. Sterile gloves, eye protection, a gown, a surgical cap, a mask, and a full-size sterile drape are also required.
Ultrasound machines with linear-array, high-resolution vascular transducers are preferred for this procedure (Fig. 1). You will also need sterile transduction gel, an acoustically transparent sterile transducer sheath, and sterile rubber bands or clips to secure the sheath around the transducer.
PREPARATION
When possible, explain the procedure to the patient and obtain written informed consent. Potential complications such as infection and bleeding should be discussed. Conduct a procedural time-out and review a checklist before performing the procedure. Maintain continuous electrocardiographic and pulse-oximetry moni¬toring throughout the procedure.
POSITIONING
Place the patient in the supine position. If the central venous pressure is not elevated, place the patient in the Trendelenburg position to increase jugular fill¬ing and to reduce the possibility of air embolism. Caution is advised when plac¬ing patients with high intracranial pressure or congestive heart failure into this position, since it may exacerbate these conditions. Rotate the patient's head slightly to the contralateral side of the chosen site. Minimizing head rotation makes it less likely that this positioning will cause the common carotid artery to lie posterior to the internal jugular vein.4 Cannulation of the right internal jugular vein is generally preferred to cannulation of the left vein, because it provides more direct access to the right atrium, avoids the thoracic duct, re¬duces procedure time, and is associated with fewer complications.
ANATOMICAL LANDMARKS
The two heads of the sternocleidomastoid muscle and the clavicle form a triangle at the anterior neck. The internal jugular vein may be accessed within this trian¬gle, approximately 2 to 3 cm above the clavicle (Fig. 2).
ULTRASOUND SURVEY
Variations in external landmarks and internal anatomy can make landmark-guid¬ed cannulation challenging. Ultrasound guidance minimizes the incidence of pos¬sible complications arising from these difficulties and permits visualization of the anatomy of the internal jugular vein and neighboring structures, particu¬larly the carotid artery. The use of ultrasonography also contributes to shorter procedure times and permits confirmation of the patency of the internal jugular vein before cannulation is attempted. These benefits allow for a decreased num¬ber of needlesticks and reduce the propensity for infection.5
阅读本文的人还阅读：
作者:admin@医学,生命科学 2011-01-09 00:02
医学,生命科学网