Calvache Jose-Andres, Rodríguez Maria-Virginia, Trochez Adolfo, Klimek Markus, Stolker Robert-Jan, Lesaffre Emmanuel
Department of Anaesthesiology, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands Department of Biostatistics, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands Departamento de Anestesiología, Universidad del Cauca, Popayán, Cauca, Colombia
Clínica La Estancia, Intensive Care Unit, Popayán, Cauca, Colombia.
J Intensive Care Med. 2016 Jul;31(6):397-402. doi: 10.1177/0885066614541407. Epub 2014 Jul 2.
Central venous catheterization is a standard procedure in intensive care therapy. In developing countries, this intervention is frequently performed by physicians in training and without the availability of ultrasound guidance. Purpose of this study was to determine the incidence and potential risk factors for mechanical complications during central venous catheterization in an intensive care setting performed by a mixed group of practitioners without the use of adjunct ultrasound.
Prospective observational cohort study in a university teaching hospital. Three hundred critically ill patients requiring their first central venous catheter insertion were enrolled. All patients were observed for 24 hours for mechanical complications (pneumothorax, hemothorax, arterial puncture, incorrect tip position, cardiac dysrhythmia, and/or subcutaneous hematoma). Potential associations with mechanical complications were adjusted using multivariable analysis. Main outcome was the cumulative incidence of mechanical complications.
The incidence of mechanical complications was 17% (n = 51). After covariate adjustment, the number of punctures was significantly related to mechanical complications. Compared with 1 puncture, 3 or more attempts were significantly associated with mechanical complications (odds ratio 3.62 [95% confidence interval 1.34-9.8]; P = .011). Experience of the operator was not associated with mechanical complications.
The incidence of mechanical complications is affected by the number of punctures performed. After adjustment, the risk increases substantially with more than 3 attempts. Limiting the number of attempts, appropriate supervision and the use of ultrasound guidance when available are recommended for the further reduction in mechanical complications of central venous catheterization.
中心静脉置管是重症监护治疗中的一项标准操作。在发展中国家，这项操作常常由正在接受培训的医生进行，且没有超声引导。本研究的目的是确定在重症监护环境中，由一组混合的从业者在不使用辅助超声的情况下进行中心静脉置管时机械并发症的发生率及潜在风险因素。
在一所大学教学医院进行前瞻性观察队列研究。纳入300例需要首次进行中心静脉置管的危重症患者。所有患者均被观察24小时，以观察机械并发症（气胸、血胸、动脉穿刺、尖端位置不正确、心律失常和/或皮下血肿）。使用多变量分析调整与机械并发症的潜在关联。主要结局是机械并发症的累积发生率。
机械并发症的发生率为17%（n = 51）。在进行协变量调整后，穿刺次数与机械并发症显著相关。与1次穿刺相比，3次或更多次尝试与机械并发症显著相关（比值比3.62 [95%置信区间1.34 - 9.8]；P = 0.011）。操作者的经验与机械并发症无关。
机械并发症的发生率受穿刺次数的影响。调整后，超过3次尝试时风险会大幅增加。建议限制尝试次数、进行适当监督并在可用时使用超声引导，以进一步降低中心静脉置管的机械并发症。
