DiCarlo Joseph V, Auerbach Scott R, Alexander Steven R
Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Welch Road, Palo Alto, California 94304, USA.
Crit Care. 2006;10(5):230. doi: 10.1186/cc5035.
Obtaining or maintaining vascular access for continuous hemofiltration can sometimes be problematic, especially in the child or adult in multiple organ failure with edema and/or coagulopathy. Problems commonly encountered include obstruction of the femoral vein by the catheter, insertion difficulties, safety concerns when cannulating the subclavian vein in coagulopathy, and catheter and circuit occlusion due to disseminated intravascular coagulation. For access in infants we describe a technique utilizing two single-lumen thin-walled vascular sheaths. For infants and small children initial access to the vein may be difficult due to edema or poor perfusion. For this situation we describe the 'mini-introducer' technique of securing the vein and facilitating subsequent insertion of a relatively large guide wire. At any age an alternative route to the subclavian vein, from above the clavicle, is potentially 'compressible' in the event of hemorrhage during the procedure. We remind the reader of the utility of ultrasound guidance for cannulation of the internal jugular and subclavian veins. And lastly we review the options for venous return via the umbilical vein in infants, and via the antecubital vein in larger children and adults.
对于持续血液滤过而言，建立或维持血管通路有时会出现问题，尤其是对于患有水肿和/或凝血病的多器官功能衰竭的儿童或成人。常见问题包括导管阻塞股静脉、插入困难、凝血病患者锁骨下静脉插管时的安全问题以及弥散性血管内凝血导致的导管和管路阻塞。对于婴儿的血管通路，我们描述了一种使用两个单腔薄壁血管鞘的技术。对于婴儿和幼儿，由于水肿或灌注不良，最初进入静脉可能会很困难。针对这种情况，我们描述了一种“微型导引器”技术，用于固定静脉并便于随后插入相对较粗的导丝。在任何年龄，锁骨上进入锁骨下静脉的替代途径在手术过程中发生出血时可能是“可压迫的”。我们提醒读者超声引导用于颈内静脉和锁骨下静脉插管的作用。最后，我们回顾了婴儿通过脐静脉以及较大儿童和成人通过肘前静脉进行静脉回血的选择。
