Vogel Jody A, Haukoos Jason S, Erickson Catherine L, Liao Michael M, Theoret Jonathan, Sanz Geoffrey E, Kendall John
1Department of Emergency Medicine, Denver Health Medical Center, Denver, CO. 2Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. 3Department of Epidemiology, Colorado School of Public Health, Aurora, CO. 4Department of Emergency Medicine, Oregon Health and Science University, Portland, OR. 5Department of Emergency Medicine, North Suburban Medical Center, Thornton, CO. 6Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada. 7Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
Crit Care Med. 2015 Apr;43(4):832-9. doi: 10.1097/CCM.0000000000000823.
To evaluate whether using long-axis or short-axis view during ultrasound-guided internal jugular and subclavian central venous catheterization results in fewer skin breaks, decreased time to cannulation, and fewer posterior wall penetrations.
Prospective, randomized crossover study.
Urban emergency department with approximate annual census of 60,000.
Emergency medicine resident physicians at the Denver Health Residency in Emergency Medicine, a postgraduate year 1-4 training program.
Resident physicians blinded to the study hypothesis used ultrasound guidance to cannulate the internal jugular and subclavian of a human torso mannequin using the long-axis and short-axis views at each site.
An ultrasound fellow recorded skin breaks, redirections, and time to cannulation. An experienced ultrasound fellow or attending used a convex 8-4 MHz transducer during cannulation to monitor the needle path and determine posterior wall penetration. Generalized linear mixed models with a random subject effect were used to compare time to cannulation, number of skin breaks and redirections, and posterior wall penetration of the long axis and short axis at each cannulation site. Twenty-eight resident physicians participated: eight postgraduate year 1, eight postgraduate year 2, five postgraduate year 3, and seven postgraduate year 4. The median (interquartile range) number of total internal jugular central venous catheters placed was 27 (interquartile range, 9-42) and subclavian was six catheters (interquartile range, 2-20). The median number of previous ultrasound-guided internal jugular catheters was 25 (interquartile range, 9-40), and ultrasound-guided subclavian catheters were three (interquartile range, 0-5). The long-axis view was associated with a significant decrease in the number of redirections at the internal jugular and subclavian sites, relative risk 0.4 (95% CI, 0.2-0.9) and relative risk 0.5 (95% CI, 0.3-0.7), respectively. There was no significant difference in the number of skin breaks between the long axis and short axis at the subclavian and internal jugular sites. The long-axis view for subclavian was associated with decreased time to cannulation; there was no significant difference in time between the short-axis and long-axis views at the internal jugular site. The prevalence of posterior wall penetration was internal jugular short axis 25%, internal jugular long axis 21%, subclavian short axis 64%, and subclavian long axis 39%. The odds of posterior wall penetration were significantly less in the subclavian long axis (odds ratio, 0.3; 95% CI, 0.1-0.9).
The long-axis view for the internal jugular was more efficient than the short-axis view with fewer redirections. The long-axis view for subclavian central venous catheterization was also more efficient with decreased time to cannulation and fewer redirections. The long-axis approach to subclavian central venous catheterization is also associated with fewer posterior wall penetrations. Using the long-axis view for subclavian central venous catheterization and avoiding posterior wall penetrations may result in fewer central venous catheter-related complications.
评估在超声引导下进行颈内静脉和锁骨下静脉中心静脉置管时，采用长轴视图还是短轴视图是否能减少皮肤破损、缩短置管时间并减少后壁穿刺情况。
前瞻性随机交叉研究。
年接诊量约60000人次的城市急诊科。
丹佛健康急诊医学住院医师培训项目（1 - 4年级研究生培训项目）的急诊医学住院医师。
对研究假设不知情的住院医师使用超声引导，在人体躯干模型的每个部位分别采用长轴视图和短轴视图对颈内静脉和锁骨下静脉进行置管。
一名超声科医师记录皮肤破损、重新穿刺情况及置管时间。一名经验丰富的超声科医师或主治医师在置管过程中使用凸阵8 - 4MHz探头监测针道并确定后壁穿刺情况。采用具有随机受试者效应的广义线性混合模型比较每个置管部位长轴视图和短轴视图的置管时间、皮肤破损和重新穿刺次数以及后壁穿刺情况。28名住院医师参与研究：1年级研究生8名，2年级研究生8名，3年级研究生5名，4年级研究生7名。颈内静脉中心静脉置管的总数中位数（四分位数间距）为27（四分位数间距，9 - 42），锁骨下静脉为6根导管（四分位数间距，2 - 20）。既往超声引导下颈内静脉置管的中位数为25（四分位数间距，9 - 40），超声引导下锁骨下静脉置管为3根（四分位数间距，0 - 5）。长轴视图与颈内静脉和锁骨下静脉部位的重新穿刺次数显著减少相关，相对风险分别为0.4（95%CI，0.2 - 0.9）和0.5（95%CI，0.3 - 0.7）。锁骨下静脉和颈内静脉部位长轴视图和短轴视图的皮肤破损次数无显著差异。锁骨下静脉长轴视图与置管时间缩短相关；颈内静脉部位短轴视图和长轴视图的时间无显著差异。后壁穿刺发生率为：颈内静脉短轴25%，颈内静脉长轴21%，锁骨下静脉短轴64%，锁骨下静脉长轴39%。锁骨下静脉长轴的后壁穿刺几率显著更低（优势比，0.3；95%CI，0.1 - 0.9）。
颈内静脉长轴视图比短轴视图更高效，重新穿刺次数更少。锁骨下静脉中心静脉置管的长轴视图也更高效，置管时间缩短且重新穿刺次数减少。锁骨下静脉中心静脉置管的长轴方法还与后壁穿刺次数减少相关。采用锁骨下静脉中心静脉置管的长轴视图并避免后壁穿刺可能会减少中心静脉导管相关并发症。
