Fournil Céline, Boulet Nicolas, Bastide Sophie, Louart Benjamin, Ambert Audrey, Boutin Caroline, Lefrant Jean-Yves, Muller Laurent, Roger Claire
Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France.
Laboratoire de Biostatistique, Epidémiologie Clinique, Santé Publique Innovation et Méthodologie (BESPIM), Pôle Pharmacie, Santé Publique, Nîmes University Hospital, University of Montpellier, France.
J Clin Ultrasound. 2023 Jan;51(1):158-166. doi: 10.1002/jcu.23383. Epub 2022 Nov 17.
Ultrasound (US)-guided axillary vein (AV) catheterization has been considered as the preferred site of insertion to minimize catheter-related infections. Given its difficulty of realization, internal jugular vein (IJV) access remains, thus, the first choice of catheter insertion site. This descriptive study was aimed to assess the success and complication rates of in-plane short axis approach of IJV in the lower neck and the AV approach under US-guidance.
In a prospective randomized controlled open-label pilot trial, all patients requiring central venous catheterization (CVC) in intensive care unit or operating room were randomly assigned to low IJV or AV groups. The primary objective was to estimate the overall success rate of both approaches. The secondary objectives were immediate complication rates, procedure durations, success rate after the first puncture, late complication rates (i.e., thrombosis, catheter colonization, and catheter-related infections), and nurse satisfaction regarding insertion site dressings.
One hundred and seventy-three out of two hundred and ten included patients were fully analyzed (90 and 83 in the IJV and AV approach groups, respectively). Overall success rates for IJV and AV sites were 96% (95% confidence interval (CI) [90-99]) and 89% (95% CI [81-94]) respectively. First puncture success rates were 90% and 80% respectively. The median overall procedure duration from US pre-procedural screening to guidewire insertion was 8 and 10 min in IJV and AV groups. Overall immediate complications rates for IJV and AV sites were 11.6% and 14.6%, respectively. Incidence of catheter colonization were 7.9% and 6.8% and catheter-related infection rate were 2.6% and 0%, respectively.
In this pilot study, US-guided low IJV and AV approaches are safe and efficient techniques for CVC insertion associated with high success and low complications rates. Duration for guidewire insertion seemed to be shorter in the short axis in-plane IJV approach. It provides the basis for a future randomized trial comparing these two approaches.
超声（US）引导下的腋静脉（AV）置管被认为是将导管相关感染降至最低的首选插入部位。鉴于其实施难度，颈内静脉（IJV）穿刺仍是导管插入部位的首选。本描述性研究旨在评估超声引导下在下颈部采用IJV平面内短轴进针法和AV进针法的成功率及并发症发生率。
在一项前瞻性随机对照开放标签试验中，所有在重症监护病房或手术室需要中心静脉置管（CVC）的患者被随机分配至低位IJV组或AV组。主要目标是评估两种方法的总体成功率。次要目标包括即时并发症发生率、操作时间、首次穿刺成功率、晚期并发症发生率（即血栓形成、导管定植和导管相关感染）以及护士对穿刺部位敷料的满意度。
纳入的210例患者中有173例进行了全面分析（IJV进针法组90例，AV进针法组83例）。IJV和AV部位的总体成功率分别为96%（95%置信区间[CI][90 - 99]）和89%（95%CI[81 - 94]）。首次穿刺成功率分别为90%和80%。从超声术前筛查到导丝插入的总体操作时间中位数在IJV组和AV组分别为8分钟和10分钟。IJV和AV部位的总体即时并发症发生率分别为11.6%和14.6%。导管定植发生率分别为7.9%和6.8%，导管相关感染率分别为2.6%和0%。
在本初步研究中，超声引导下的低位IJV和AV进针法是安全有效的CVC插入技术，成功率高且并发症发生率低。平面内短轴IJV进针法的导丝插入时间似乎更短。这为未来比较这两种方法的随机试验提供了依据。
