Collier P E, Goodman G B
Department of Surgery, Sewickley Valley Hospital, PA 15143, USA.
J Am Coll Surg. 1995 Nov;181(5):459-63.
Pericardial tamponade caused by central venous catheter perforation of the heart is a catastrophic complication that can be prevented by attention to proper positioning of the catheter tip proximal to the cardiac silhouette. This study was performed to determine awareness of this potential complication among physicians and to suggest measures to minimize the incidence of this problem.
Clinical and radiologic features of 11 cases were evaluated. House officers and attending staff who frequently pass central venous catheters and train junior physicians to place these catheters were questioned specifically to test their awareness of this complication and their knowledge of optimal catheter tip positioning. Attending radiology staff physicians were questioned similarly. The written protocols of local community hospitals with respect to central venous catheter placement were reviewed to determine their criteria for optimal catheter placement.
Ten of the 11 cases reviewed resulted in death; the 11th case resulted in severe anoxic brain insult with a persistent vegetative state. In the ten cases that had radiologic studies available for review, the central venous catheter tip was seen to lie malpositioned within the cardiac silhouette. Questioning of house officers and attending staff as well as attending radiology staff revealed a lack of awareness of this problem generally and a lack of knowledge of optimal catheter tip positioning specifically. The protocols of area hospitals revealed similar findings with respect to this potential complication.
Pericardial tamponade resulting from central venous catheter perforation of the heart can be avoided by adherence to proper technique in the placement of these catheters, ensuring that the catheter tip lies proximal to the cardiac silhouette, optimally in the superior vena cava, 2 cm proximal to the pericardial reflection. Physicians who place these catheters and train others to do so must be aware of this issue and they must educate their trainees as well. Radiologists responsible for interpreting the roentgenographs of the chest obtained after catheter placement should be alert to catheter malposition and communicate this information promptly. Hospital protocols should deal with this issue explicitly and insist on repositioning of catheters if catheter tips are seen to lodge in suboptimal positions.
中心静脉导管穿破心脏导致的心包填塞是一种灾难性并发症，通过注意将导管尖端置于心脏轮廓近端可预防该并发症。本研究旨在确定医生对这一潜在并发症的认知情况，并提出将该问题发生率降至最低的措施。
评估了11例患者的临床和放射学特征。专门询问了经常置入中心静脉导管并培训初级医生放置这些导管的住院医师和主治医生，以测试他们对该并发症的认知以及对导管尖端最佳位置的了解。对放射科主治医生也进行了类似询问。审查了当地社区医院关于中心静脉导管置入的书面规程，以确定其最佳导管置入标准。
11例接受审查的病例中有10例死亡；第11例导致严重缺氧性脑损伤并持续处于植物状态。在有放射学检查可供审查的10例病例中，可见中心静脉导管尖端位置不当，位于心脏轮廓内。对住院医师、主治医生以及放射科主治医生的询问显示，总体上对该问题缺乏认知，特别是对导管尖端最佳位置缺乏了解。地区医院的规程在这一潜在并发症方面也有类似发现。
通过在放置这些导管时遵循正确技术，确保导管尖端位于心脏轮廓近端，最佳位置是在上腔静脉内、心包折返处近端2厘米处，可避免中心静脉导管穿破心脏导致的心包填塞。放置这些导管并培训他人放置的医生必须了解这一问题，并且必须对其学员进行教育。负责解读导管置入后胸部X线片的放射科医生应警惕导管位置不当，并及时传达这一信息。医院规程应明确处理这一问题，并在导管尖端位置不佳时坚持重新放置导管。
