Mansfield P F, Hohn D C, Fornage B D, Gregurich M A, Ota D M
Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030.
N Engl J Med. 1994 Dec 29;331(26):1735-8. doi: 10.1056/NEJM199412293312602.
Although catheterization of the subclavian vein is a common procedure, the risk factors for complications and failures, with the exception of the physician's experience, are poorly understood. Ultrasonography has been recommended to help guide the placement of central venous catheters.
We conducted a prospective randomized trial of ultrasound-guided location of the subclavian vein as compared with standard insertion procedures. In the group of patients undergoing catheterization with ultrasound guidance, the site of the insertion was marked before the catheterization attempt; real-time ultrasound guidance was not used. The 821 eligible patients (411 in the ultrasound group and 410 in the control group) underwent catheterization in a single procedure suite under controlled nonemergency conditions, in most cases for the administration of chemotherapy.
Ultrasound guidance had no effect on the rate of complications or failures of subclavian-vein catheterization (risk ratio for complications, 1.00; 95 percent confidence interval, 0.66 to 1.52; risk ratio for failures, 1.04; 95 percent confidence interval, 0.72 to 1.50). In multivariate analyses, prior major surgery in the region (P = 0.002), a body-mass index (the weight in kilograms divided by the square of the height in meters) higher than 30 or lower than 20 (P = 0.009), and previous catheterization (P = 0.043) were associated with failed attempts. Complications were also associated with failed attempts: 52 of the 721 patients (7.2 percent) in whom catheterization was successful had complications, as compared with 28 of the 100 patients (28 percent) in whom physicians were unable to place catheters. The number of needle passes was strongly associated with the rates of failure and complications. The complication rate rose from 4.3 percent with one pass to 24.0 percent with more than two passes.
Ultrasound guidance of subclavian-vein catheterization, as used in this study, was not beneficial. In patients at highest risk for complications and failures, catheterization should be attempted by the most experienced physicians available.
尽管锁骨下静脉置管是一种常见操作，但除医生经验外，并发症和置管失败的危险因素尚不清楚。超声检查已被推荐用于辅助指导中心静脉导管的放置。
我们进行了一项前瞻性随机试验，比较超声引导下锁骨下静脉定位与标准置管程序。在超声引导下进行置管的患者组中，在尝试置管前标记插入部位；未使用实时超声引导。821例符合条件的患者（超声组411例，对照组410例）在单一操作室的非紧急控制条件下接受置管，大多数情况下是为了进行化疗。
超声引导对锁骨下静脉置管的并发症发生率或失败率没有影响（并发症风险比为1.00；95%置信区间为0.66至1.52；失败风险比为1.04；95%置信区间为0.72至1.50）。在多变量分析中，该区域既往有大手术史（P = 0.002）、体重指数（体重千克数除以身高米数的平方）高于30或低于20（P = 0.009）以及既往有置管史（P = 0.043）与置管失败相关。并发症也与置管失败相关：721例置管成功的患者中有52例（7.2%）发生并发症，而100例医生未能成功置管的患者中有28例（28%）发生并发症。穿刺次数与失败率和并发症发生率密切相关。并发症发生率从一次穿刺的4.3%上升至两次以上穿刺的24.0%。
本研究中使用的超声引导锁骨下静脉置管并无益处。对于并发症和失败风险最高的患者，应由经验最丰富的医生尝试进行置管。
