Department of Surgery, Lucile Packard Children's Hospital - Stanford University Medical Center, Palo Alto, CA 94305, USA.
J Am Coll Surg. 2013 May;216(5):939-43. doi: 10.1016/j.jamcollsurg.2013.01.054. Epub 2013 Mar 7.
The purpose of this prospective randomized study was to compare landmark- to ultrasound-guided central venous access when performed by pediatric surgeons. The American College of Surgeons advocates for use of ultrasound in central venous catheter placement; however, this is not universally embraced by pediatric surgeons. Complication risk correlates positively with number of venous cannulation attempts.
With IRB approval, a randomized prospective study of children under 18 years of age undergoing tunneled central venous catheter placement was performed. Patient accrual was based on power analysis. Exclusion criteria included known nonpatency of a central vein or coagulopathy. After randomization, the patients were assigned to either ultrasound-guided internal jugular vein access or landmark-guided subclavian/internal jugular vein access. The primary outcomes measure was number of attempts at venous cannulation. Secondary outcomes measures included: access times, number of arterial punctures, and other complications. Continuous variables were compared using 2-tailed Student's t-test. Discrete variables were analyzed with chi-square. Significance was defined as p < 0.05.
There were 150 patients enrolled between April 2008 and September 2011. There was no difference when comparing demographic data. Success at first attempt was achieved in 65% of patients in the ultrasound group vs 45% in the landmark group (p = 0.021). Success within 3 attempts was achieved in 95% of ultrasound group vs 74% of landmark group (p = 0.0001).
Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.
本前瞻性随机研究的目的是比较小儿外科医生进行的基于体表标志和超声引导的中心静脉置管。美国外科医师学会提倡在中心静脉置管中使用超声，但并非所有小儿外科医生都接受这一做法。并发症风险与静脉穿刺尝试次数呈正相关。
在获得机构审查委员会批准后，对 18 岁以下接受隧道式中心静脉导管置入术的患儿进行了一项前瞻性随机研究。根据功效分析确定患者入组。排除标准包括已知中心静脉不通或凝血功能障碍。随机分组后，患者被分配至超声引导下颈内静脉入路或基于体表标志的锁骨下/颈内静脉入路。主要结局指标为静脉穿刺尝试次数。次要结局指标包括：置管时间、动脉穿刺次数和其他并发症。连续变量采用双尾学生 t 检验进行比较。离散变量采用卡方检验进行分析。p<0.05 为差异有统计学意义。
2008 年 4 月至 2011 年 9 月期间共纳入 150 例患者。两组患者的人口统计学数据无差异。超声组首次尝试成功率为 65%，而体表标志组为 45%（p=0.021）。超声组 3 次内成功率为 95%，而体表标志组为 74%（p=0.0001）。
超声引导可减少中心静脉置管所需的穿刺尝试次数。这表明在小儿外科医生中使用超声可以降低并发症的风险。
