Department of Anesthesiology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan, ROC.
J Chin Med Assoc. 2013 Jul;76(7):401-6. doi: 10.1016/j.jcma.2013.03.014. Epub 2013 May 9.
The Trendelenburg position has been suggested for right internal jugular vein (RIJV) catheterization. However, this position can sometimes be functionally intolerable for chronic kidney disease patients. We conducted an ultrasound study to further investigate the efficacy of the use of the Trendelenburg position during tunneled dialysis catheter insertion via the RIJV in chronic kidney disease patients.
We recruited into our study patients without a history of prior tunneled dialysis catheter insertion or neck surgery. Those patients with stenosis or thrombus in the RIJV were excluded. Serial ultrasound images were acquired with patients in the supine position, with the head rotated 30° to the left: Stage 0, table flat; Stage T, Trendelenburg tilt. Then, measurements of patient RIJV transverse diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) were obtained.
Fifty dialysis patients and 40 healthy volunteers completed the study. There were no significant differences in the lateral diameter, AP diameter, or AP/lateral diameter ratio between the dialysis patients and healthy volunteers, whether in the supine or the Trendelenburg position. However, the CSA of the RIJV of the healthy volunteers in the Trendelenburg position was significantly larger than that in dialysis patients. The change in CSA from the supine to the Trendelenburg position was also significantly different between the two groups.
In contrast to healthy volunteers, there was no enlargement of the RIJV when dialysis patients were in the Trendelenburg position. The reason for this phenomenon may be multifactorial, with diastolic dysfunction being the most likely cause, and further investigation is required to clarify the cause. Our investigation suggests that the supine position for central venous catheterization in dialysis patients is superior to the Trendelenburg position.
头高脚低位被建议用于右颈内静脉（RIJV）置管。然而，对于慢性肾脏病患者，这种体位有时在功能上是无法耐受的。我们进行了一项超声研究，以进一步探讨在慢性肾脏病患者中经 RIJV 隧道式透析导管插入时使用头高脚低位的效果。
我们招募了既往无隧道式透析导管插入或颈部手术史的患者。RIJV 狭窄或血栓形成的患者被排除在外。患者取仰卧位，头向左侧旋转 30°，进行连续超声检查：0 期，水平位；T 期，头高脚低位。然后，测量患者 RIJV 横径、前后径（AP）和横截面积（CSA）。
50 例透析患者和 40 名健康志愿者完成了这项研究。在仰卧位和头高脚低位时，透析患者与健康志愿者的 RIJV 外侧直径、AP 直径或 AP/外侧直径比值均无显著差异。然而，健康志愿者在头高脚低位时 RIJV 的 CSA 明显大于透析患者。两组患者从仰卧位到头高脚低位时 CSA 的变化也有显著差异。
与健康志愿者相比，透析患者处于头高脚低位时 RIJV 没有增大。这种现象的原因可能是多因素的，舒张功能障碍最有可能是原因，需要进一步研究以阐明原因。我们的研究表明，在透析患者中，中心静脉置管的仰卧位优于头高脚低位。
