Gladwin M T, Slonim A, Landucci D L, Gutierrez D C, Cunnion R E
Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892, USA.
Crit Care Med. 1999 Sep;27(9):1819-23. doi: 10.1097/00003246-199909000-00019.
To determine whether clinical features can be used in a decision rule to prospectively identify a subgroup of internal jugular catheter placements that are correctly positioned and free from mechanical complications, thus obviating the need for routine postprocedural chest radiographs in selected patients.
Prospective cohort study.
Tertiary care teaching hospital.
A total of 107 consecutive patients who presented to our catheter service for internal jugular catheter insertion because of clinical indications between November 1995 and April 1996. Exclusion criteria were mechanical ventilation, an altered mental status, an age of <15 years, and a height of <152 cm.
Right or left internal jugular vein catheter placement followed by a postprocedural chest radiograph.
The operating physician completed a detailed questionnaire for each catheter insertion, designed to detect potential complications and to predict the necessity, or lack of necessity, for a postprocedural chest radiograph. The questionnaire documented patient characteristics, the number of needle passes, difficulty establishing access, operator experience, poor anatomical landmarks, number of previous catheter placements, resistance to wire or catheter advancement, resistance to aspiration of blood or flushing of the catheter ports, sensations in the ear, chest, or arm, and development of signs or symptoms suggestive of pneumothorax. After catheter insertion, chest radiographs were obtained to assess for mechanical complications and malpositioned catheters.
In 46 cases, the decision rule predicted either a complication or a malposition and, thus, the need for a chest radiograph. In 61 cases, neither was predicted (no chest radiograph was needed). Radiographs confirmed one complication (pneumothorax) and 15 catheter tip malpositions (nine in the right atrium and six in the right axillary vein). Among the 46 cases predicted to have a potential complication or malposition, there were one actual complication (pneumothorax) and six actual malpositions (three axillary vein malpositions and three right atrial malpositions). The positive predictive value of this decision rule is 15%. Among the 61 cases predicted to be free from complications or malpositions and not to require a postprocedural chest radiograph, there were nine unexpected malpositions (three axillary vein malpositions and six right atrial malpositions). The negative predictive value is 85%. The overall sensitivity of the decision rule for detecting complications and malpositions is 44%, and the specificity is 55%.
In experienced hands, internal jugular venous catheterization is a safe procedure. However, the incidence of axillary vein or right atrial catheter malposition is 14%, and clinical factors alone will not reliably identify malpositioned catheters. Chest radiographs are necessary to ensure correct internal jugular catheter position.
确定临床特征是否可用于决策规则，以前瞻性地识别一组颈内静脉导管置入位置正确且无机械并发症的患者，从而避免在部分患者中进行常规的术后胸部X线检查。
前瞻性队列研究。
三级护理教学医院。
1995年11月至1996年4月期间，因临床指征前来我们导管服务部门进行颈内静脉导管插入术的107例连续患者。排除标准为机械通气、精神状态改变、年龄小于15岁及身高小于152厘米。
进行右侧或左侧颈内静脉导管置入，随后进行术后胸部X线检查。
手术医生为每次导管插入完成一份详细问卷，旨在检测潜在并发症并预测术后胸部X线检查的必要性或不必要性。问卷记录了患者特征、穿刺次数、建立通路的难度、操作者经验、解剖标志不佳、既往导管置入次数、导线或导管推进阻力、回血抽吸或导管端口冲洗阻力、耳部、胸部或手臂的感觉以及提示气胸的体征或症状的出现情况。导管插入后，进行胸部X线检查以评估机械并发症和导管位置不当情况。
在46例病例中，决策规则预测有并发症或位置不当，因此需要进行胸部X线检查。在6例病例中，两者均未被预测到（无需进行胸部X线检查）。X线检查证实1例并发症（气胸）和15例导管尖端位置不当（9例位于右心房，6例位于右腋静脉）。在预测有潜在并发症或位置不当的46例病例中，有1例实际并发症（气胸）和6例实际位置不当（3例腋静脉位置不当和3例右心房位置不当）。该决策规则的阳性预测值为15%。在预测无并发症或位置不当且无需术后胸部X线检查的61例病例中，有9例意外位置不当（3例腋静脉位置不当和6例右心房位置不当）。阴性预测值为85%。检测并发症和位置不当的决策规则的总体敏感性为44%，特异性为55%。
在经验丰富的操作者手中，颈内静脉置管是一种安全的操作。然而，腋静脉或右心房导管位置不当的发生率为14%，仅靠临床因素无法可靠地识别位置不当的导管。胸部X线检查对于确保颈内静脉导管位置正确是必要的。
