Glen H, Lang I, Christie L
Consultant Anaesthetist/Intensivist, Intensive Care Unit, Wishaw General Hospital, Wishaw, UK.
Consultant, Anaesthesia/Intensive Care Medicine, Intensive Care Unit, Wishaw General Hospital, Wishaw, UK.
Anaesth Intensive Care. 2015 Sep;43(5):635-40. doi: 10.1177/0310057X1504300513.
Central venous catheter (CVC) insertion is commonly undertaken in the ICU. The use of ultrasound (US) to facilitate CVC insertion is standard and is supported by guidelines. Because the subclavian vein cannot be insonated where it underlies the clavicle, its use as a CVC site is now less common. The axillary vein, however, can be seen on US just distal to the subclavian vein and placement of a CVC at this site gives a result which is functionally indistinguishable from a subclavian CVC. We evaluated placement of US-guided axillary CVCs in mechanically ventilated intensive care patients. Data were collected for 125 consecutive US-guided axillary CVC procedures in ventilated patients in an adult intensive care setting. All lines were inserted using real-time US guidance with an out-of-plane technique. One hundred and twenty-five procedures occurred in 119 patients. Successful line placement was achieved in 117 out of 125 (94%) procedures. Complications included four procedures that required repeating due to catheter malposition and one arterial puncture. The median number of attempts per procedure was one (IQR 1 to 2). Thirty-nine (31%) patients had a body mass index of 30 or above, 43 (34%) patients had a coagulopathy and 70 (56%) patients had significant ventilator dependence (FiO2 of 0.5 or above, or positive end expiratory pressure 10 cmH20 or above). The technique of US-guided axillary CVC access can be undertaken successfully in ventilated intensive care patients, even in challenging circumstances. Taken together with existing work on the utility and safety of this technique, we suggest that it be adopted more widely in the intensive care population.
中心静脉导管（CVC）置入术在重症监护病房（ICU）中很常见。使用超声（US）辅助CVC置入是标准操作且有指南支持。由于锁骨下静脉在锁骨下方无法被超声探测到，因此现在将其作为CVC置入部位的情况已不那么常见。然而，腋静脉在超声下可在锁骨下静脉远端看到，在此部位置入CVC的效果在功能上与锁骨下CVC无异。我们评估了在机械通气的重症监护患者中超声引导下腋静脉CVC置入情况。在成人重症监护环境中，对连续125例接受超声引导下腋静脉CVC操作的通气患者收集了数据。所有导管均采用平面外技术在实时超声引导下置入。119例患者进行了125次操作。125例操作中有117例（94%）成功置入导管。并发症包括4例因导管位置不当需重新操作的情况和1例动脉穿刺。每次操作的中位尝试次数为1次（四分位间距为1至2次）。39例（31%）患者体重指数为30或以上，43例（34%）患者有凝血功能障碍，70例（56%）患者有显著的呼吸机依赖（吸入氧分数为0.5或以上，或呼气末正压为10 cmH₂O或以上）。超声引导下腋静脉CVC置入技术即使在具有挑战性的情况下，也能在通气的重症监护患者中成功实施。结合关于该技术实用性和安全性的现有研究，我们建议在重症监护人群中更广泛地采用该技术。
