Keeb kwm ntawm central venous access
1. 1929: Tus kws phais neeg German Werner Forssmann tso lub tso zis tso zis los ntawm sab laug anterior cubital vein, thiab tau lees paub nrog X-ray tias lub catheter nkag mus rau sab xis atrium.
2. 1950: Central venous catheters yog tsim los ua ib qho kev xaiv tshiab rau hauv nruab nrab.
3. 1952: Aubaniac tau npaj subclavian vein puncture, Wilson tom qab tau npaj CVC catheterization raws li subclavian leeg
4. 1953: Sven-Ivar Seldinger tau npaj siab los hloov lub koob tawv nrog cov hlau qhia hlau qhia catheter rau peripheral venipuncture, thiab cov txheej txheem Seldinger tau los ua ib qho kev hloov kho tshuab rau hauv nruab nrab venous catheter tso.
5. 1956: Forssmann, Cournand, Richards yeej qhov Nobel nqi zog hauv tshuaj rau lawv txoj kev koom tes rau kev kho plawv catheterization
6. 1968: Thawj tsab ntawv ceeb toom ua lus Askiv ntawm sab hauv jugular venous nkag rau hauv nruab nrab venous siab xyuas
7. 1970: Lub tswv yim ntawm qhov catheter yog thawj zaug
8. 1978: Venous Doppler locator rau sab hauv jugular leeg lub cev nto npav
9. 1982: Kev siv ultrasound coj lub hauv paus venous nkag tau thawj zaug los ntawm Peters li al.
10. 1987: Wernecke li al thawj zaug qhia txog kev siv ultrasound los kuaj pneumothorax
11. 2001: Lub Chaw Haujlwm Saib Xyuas Kev Noj Qab Haus Huv thiab Cov Ntaub Ntawv Pov Thawj Ua Haujlwm tau teev npe hauv nruab nrab venous access point-of-care ultrasound raws li ib qho ntawm 11 cov kev coj ua tsim nyog ntawm kev txhawb nqa dav dav.
12. 2008: American College of Emergency Physicians teev ultrasound-guided central venous access as a "core or primary emergency ultrasound application"
13.2017: Amir et al hais tias ultrasound tuaj yeem siv los lees paub qhov chaw CVC thiab tsis suav nrog pneumothorax kom txuag sijhawm thiab xyuas kom raug
Txhais ntawm central venous access
1. CVC feem ntau yog hais txog kev tso ib lub catheter rau hauv cov hlab ntsha hauv nruab nrab los ntawm cov hlab ntsha sab hauv jugular, cov hlab ntsha subclavian thiab cov hlab ntsha femoral, feem ntau yog lub taub catheter nyob rau hauv lub superior vena cava, inferior vena cava, caval-atrial junction, txoj cai atrium los yog brachiocephalic vein, ntawm cov uas superior vena cava.Venous los yog kab noj hniav-atrial junction yog nyiam
2. Peripherally inserted central venous catheter yog PICC
3. Central venous access feem ntau yog siv rau:
a) Kev txhaj tshuaj ntau ntawm vasopressin, inositol, thiab lwm yam.
b) Loj-bore catheters rau infusion ntawm resuscitation kua thiab ntshav khoom
c) Loj bore catheter rau lub raum hloov kho los yog plasma exchange therapy
d) Parenteral noj zaub mov tswj
e) Kev siv tshuaj tua kab mob ntev ntev lossis kev kho tshuaj khomob
f) Cua txias catheter
g) Sheaths lossis catheters rau lwm cov kab, xws li pulmonary artery catheters, pacing wires thiab endovascular cov txheej txheem los yog rau cov txheej txheem plawv, thiab lwm yam.
Lub hauv paus ntsiab lus ntawm ultrasound-guided CVC qhov chaw
1.Assumptions ntawm tsoos CVC cannulation raws li anatomical landmarks: xav tau vascular anatomy thiab patency ntawm veins
2. Cov ntsiab lus ntawm Ultrasound Guidance
a) Anatomical variation: vein qhov chaw, lub cev nto anatomical cim lawv tus kheej;ultrasound tso cai rau pom lub sijhawm tiag tiag thiab kev ntsuas ntawm cov hlab ntsha thiab lub cev nyob ib sab
b) Vascular patency: Preoperative ultrasonography tuaj yeem kuaj pom thrombosis thiab stenosis hauv lub sijhawm (tshwj xeeb tshaj yog cov neeg mob hnyav uas muaj qhov tshwm sim ntawm cov hlab ntsha sib sib zog nqus)
c) Kev lees paub ntawm kev tso cov leeg thiab cov catheter tip positioning: real-time kev soj ntsuam ntawm guidewire nkag mus rau hauv cov hlab ntsha, brachiocephalic vein, inferior vena cava, txoj cai atrium los yog superior vena cava
d) Txo cov teeb meem: thrombosis, cardiac tamponade, arterial puncture, hemothorax, pneumothorax
Kev sojntsuam thiab khoom siv xaiv
1. Cov khoom nta: 2D duab yog lub hauv paus, xim Doppler thiab pulsed Doppler tuaj yeem paub qhov txawv ntawm cov hlab ntsha thiab cov hlab ntsha, kev tswj xyuas cov ntaub ntawv kho mob raws li ib feem ntawm cov ntaub ntawv kho mob, sterile sojntsuam npog / couplant kom tsis muaj menyuam nyob ib leeg.
2. Kev sojntsuam xaiv:
a) Kev nkag mus: Sab hauv cov hlab ntsha thiab cov leeg femoral feem ntau yog 1-4 cm tob hauv qab ntawm daim tawv nqaij, thiab cov leeg subclavian xav tau 4-7 cm.
b) tsim nyog daws teeb meem thiab adjustable tsom
c) Kev sojntsuam me me: 2 ~ 4cm dav, yooj yim los soj ntsuam qhov ntev thiab luv axes ntawm cov hlab ntsha, yooj yim rau qhov chaw sojntsuam thiab koob
d) 7 ~ 12MHz me me linear array feem ntau yog siv;me convex nyob rau hauv lub clavicle, me nyuam hockey stick sojntsuam
Txoj kev luv-axis thiab txoj kev ntev-axis
Kev sib raug zoo ntawm qhov kev sojntsuam thiab rab koob txiav txim siab seb nws puas nyob hauv lub dav hlau lossis tawm ntawm lub dav hlau
1. Lub koob lub taub hau tsis tuaj yeem pom thaum lub sijhawm ua haujlwm, thiab txoj haujlwm ntawm rab koob yuav tsum tau txiav txim siab los ntawm kev sib tw dynamically viav vias sojntsuam;qhov zoo: luv luv kev kawm nkhaus, kev soj ntsuam zoo ntawm cov ntaub so ntswg perivascular, thiab yooj yim tso rau ntawm kev sojntsuam rau cov neeg rog rog thiab caj dab luv;
2. Lub cev koob thiab rab koob tuaj yeem pom thaum lub sijhawm ua haujlwm;Nws yog ib qho nyuaj kom khaws cov hlab ntsha thiab cov koob hauv lub dav hlau ultrasound txhua lub sijhawm
static thiab dynamic
1. Txoj kev zoo li qub, ultrasound tsuas yog siv rau kev ntsuam xyuas ua ntej thiab xaiv cov ntsiab lus ntawm cov koob txhaj tshuaj
2. Dynamic method: real-time ultrasound-guided puncture
3. Lub cev nto cim txoj kev < static method < dynamic method
Ultrasound-guided CVC puncture thiab catheterization
1. Kev npaj ua ntej
a) Cov ntaub ntawv sau npe rau tus neeg mob kom khaws cov ntaub ntawv teev tseg
b) Tshawb xyuas qhov chaw yuav tsum tau punctured kom paub meej tias vascular anatomy thiab patency, thiab txiav txim siab txog kev phais
c) Kho cov duab nce, qhov tob, thiab lwm yam kom tau txais cov duab zoo tshaj plaws
d) Muab cov khoom siv ultrasound los xyuas kom meej tias qhov puncture point, sojntsuam, tshuaj ntsuam thiab kab pom yog collinear
2. Kev txawj ua haujlwm
a) Physiological saline yog siv rau ntawm daim tawv nqaij es tsis txhob ntawm couplant los tiv thaiv cov couplant los ntawm kev nkag mus rau tib neeg lub cev.
b) Lub tes tsis muaj zog tuav qhov kev sojntsuam maj mam thiab leans maj mam tawm tsam tus neeg mob kom ruaj khov
c) Khaws koj ob lub qhov muag ntawm lub vijtsam ultrasound, thiab hnov qhov kev hloov siab xa rov qab los ntawm rab koob nrog koj txhais tes (xav tias tsis ua haujlwm)
d) Qhia cov xov hlau qhia: Tus sau xav kom tsawg kawg 5 cm ntawm cov lus qhia xaim yuav tsum muab tso rau hauv lub hauv paus venous hlab ntsha (piv txwv li, cov lus qhia hlau yuav tsum yog tsawg kawg 15 cm ntawm lub rooj zaum koob);Yuav tsum tau nkag mus rau 20 ~ 30cm, tab sis cov lus qhia xaim nkag mus tob, nws yooj yim ua rau arrhythmia.
e) Kev lees paub ntawm txoj haujlwm ntawm cov ntawv qhia xaim: Tshawb xyuas raws lub axis luv thiab tom qab ntawd lub axis ntev ntawm cov hlab ntsha los ntawm qhov kawg ntawm qhov kawg, thiab taug qab txoj hauj lwm ntawm cov ntawv qhia hlau.Piv txwv li, thaum cov hlab ntsha sab hauv jugular yog punctured, nws yog ib qho tsim nyog kom paub meej tias cov ntawv qhia xaim nkag mus rau hauv cov hlab ntsha brachiocephalic.
f) Ua ib qho me me nrog lub scalpel ua ntej dilation, lub dilator mus dhau tag nrho cov ntaub so ntswg nyob rau hauv pem hauv ntej ntawm cov hlab ntsha, tab sis tsis txhob punctures cov hlab ntsha.
3. Internal Jugular Vein Cannulation Trap
a) Kev sib raug zoo ntawm cov hlab ntsha carotid thiab cov hlab ntsha sab hauv jugular: Anatomically, cov hlab ntsha hauv jugular feem ntau nyob rau sab nraud ntawm cov hlab ntsha.Thaum lub sij hawm luv-axis scanning, vim lub caj dab yog puag ncig, scanning ntawm ntau txoj hauj lwm sib txawv cov ces kaum, thiab overlapping leeg thiab cov hlab ntsha yuav tshwm sim.Phem.
b) Kev xaiv ntawm rab koob nkag nkag: qhov sib npaug ntawm txoj kab uas hla yog qhov loj, tab sis nws nyob ze rau ntawm lub ntsws, thiab qhov kev pheej hmoo ntawm pneumothorax yog siab;Nws raug nquahu kom kuaj xyuas kom paub meej tias cov hlab ntsha ntawm lub koob nkag mus yog 1 ~ 2cm tob ntawm daim tawv nqaij.
c) Tshawb xyuas tag nrho cov leeg hauv cov leeg ua ntej, ntsuas lub cev thiab patency ntawm cov hlab ntsha, tsis txhob thrombus thiab stenosis ntawm qhov taw tes thiab cais nws ntawm cov hlab ntsha carotid.
d) Tsis txhob muaj carotid artery puncture: Ua ntej vasodilation, qhov puncture point thiab txoj hauj lwm ntawm cov ntawv qhia hlau yuav tsum tau lees paub nyob rau hauv qhov ntev thiab luv axis views.Rau kev nyab xeeb vim li cas, daim duab ntev axis ntawm cov ntawv qhia xaim yuav tsum pom nyob rau hauv cov hlab ntsha brachiocephalic.
e) Tig lub taub hau: Cov txheej txheem kev kos npe ib txwm pom zoo kom tig lub taub hau kom pom cov leeg nqaij sternocleidomastoid thiab nthuav tawm thiab kho cov hlab ntsha sab hauv, tab sis tig lub taub hau 30 degrees yuav ua rau cov leeg sab hauv jugular thiab cov hlab ntsha carotid sib tshooj ntau dua. 54%, thiab ultrasound-guided puncture tsis tau.Nws raug nquahu kom tig
4.Subclavian leeg catheterization
a) Nws yuav tsum tau muab sau tseg tias ultrasound scan ntawm cov hlab ntsha subclavian yog me ntsis nyuaj
b) Qhov zoo: Lub anatomical txoj hauj lwm ntawm cov hlab ntsha yog tus txhim khu kev qha, uas yog yooj yim rau hauv-dav hlau puncture
c) Kev txawj ntse: Qhov kev sojntsuam tau muab tso rau hauv lub clavicle hauv fossa hauv qab nws, qhia qhov luv-axis saib, thiab qhov kev sojntsuam maj mam swb rau nruab nrab;technically, axillary leeg yog punctured ntawm no;tig qhov kev sojntsuam 90 degrees kom pom qhov ntev-axis saib ntawm cov hlab ntsha, qhov kev sojntsuam yog me ntsis qaij ntawm lub taub hau;Tom qab qhov kev sojntsuam tau ruaj khov, lub koob yog punctured los ntawm qhov nruab nrab ntawm qhov kev sojntsuam sab, thiab rab koob tau muab tso rau hauv cov lus qhia ntawm lub sijhawm ntawm ultrasound.
d) Tsis ntev los no, me me microconvex puncture nrog me ntsis qis zaus tau siv los coj, thiab qhov kev sojntsuam me dua thiab tuaj yeem pom tob dua
5. Femoral leeg catheterization
a) Qhov zoo: Khaws kom deb ntawm txoj hlab pa thiab cov cuab yeej saib xyuas, tsis muaj kev pheej hmoo ntawm pneumothorax thiab hemothorax
b) Tsis muaj ntau cov ntaub ntawv ntawm ultrasound-guided puncture.Qee tus neeg xav tias nws yog qhov txhim khu kev qha heev rau puncture lub cev nto nrog cov cim pom tseeb, tab sis ultrasound tsis muaj txiaj ntsig.Ultrasound kev taw qhia yog heev haum rau FV anatomical variation thiab plawv nres.
c) Qav ceg taw txo qis qhov sib tshooj ntawm sab saum toj ntawm FV nrog FA, tsa lub taub hau thiab nthuav ob txhais ceg sab nraud kom nthuav dav lub lumen.
d) Cov txheej txheem yog tib yam li rau sab hauv jugular vein puncture
Cardiac ultrasound qhia xaim positioning
1. TEE cardiac ultrasound muaj qhov tseeb tshaj plaws txoj hauj lwm, tab sis nws yog kev puas tsuaj thiab tsis tuaj yeem siv niaj hnub
2. Txoj kev sib txawv ntawm qhov sib txawv: siv cov microbubbles nyob rau hauv kev co ib txwm saline raws li tus neeg sawv cev zoo sib xws, thiab nkag mus rau sab xis atrium li ntawm 2 vib nas this tom qab laminar flow ejection ntawm lub catheter taub.
3. Yuav tsum muaj kev paub dhau los hauv kev kuaj mob plawv ultrasound, tab sis tuaj yeem kuaj xyuas lub sijhawm tiag tiag, txaus nyiam
Lub ntsws ultrasound scan los txiav txim pneumothorax
1. Ultrasound-guided central venous puncture tsis tsuas yog txo qhov tshwm sim ntawm pneumothorax, tab sis kuj muaj siab rhiab heev thiab tshwj xeeb rau kev kuaj pneumothorax (siab dua hauv siab X-ray)
2. Nws raug nquahu kom muab nws tso rau hauv cov txheej txheem tom qab kev pom zoo, uas tuaj yeem tshawb xyuas sai thiab raug ntawm lub txaj.Yog tias nws tau koom ua ke nrog ntu dhau los ntawm kev mob plawv ultrasound, nws yuav tsum ua kom luv lub sijhawm tos rau kev siv catheter.
3. Lub ntsws ultrasound: (cov ntaub ntawv ntxiv rau sab nraud, rau kev siv xwb)
Cov duab ntawm lub ntsws li qub:
Kab A: Lub pleural hyperechoic kab uas swb nrog ua pa, ua raws li los ntawm ntau cov kab uas tig mus rau nws, equidistant, thiab attenuated nrog qhov tob, uas yog, lub ntsws zawv zawg.
M-ultrasound qhia tau hais tias cov kab hyperechoic reciprocating nyob rau hauv cov kev taw qhia ntawm kev sojntsuam nrog kev ua pa yog zoo li lub hiav txwv, thiab pectoral pwm kab yog xuab zeb, uas yog, lub puam kos npe rau.
Hauv qee tus neeg ib txwm muaj, qhov chaw nruab nrab ntawm qhov kawg ntawm lub diaphragm tuaj yeem kuaj pom tsawg dua 3 laser beam zoo li cov duab los ntawm kab pectoral pwm, txuas mus rau hauv qab ntawm lub vijtsam, thiab rov ua pa - B kab.
Pneumothorax Duab:
B kab ploj lawm, lub ntsws zawv zawg ploj, thiab lub puam kos npe yog hloov los ntawm barcode kos npe.Tsis tas li ntawd, lub ntsws taw tes kos npe yog siv los txiav txim seb qhov twg ntawm pneumothorax, thiab lub ntsws taw qhia pom qhov twg lub puam kos npe thiab cov cim barcode hloov pauv.
Kev cob qhia Ultrasound-Guided CVC
1. Tsis muaj kev pom zoo rau kev cob qhia thiab cov qauv ntawv pov thawj
2. Qhov kev nkag siab tias qhov muag tsis pom cov tswv yim ploj hauv kev kawm ultrasound muaj nyob;Txawm li cas los xij, raws li cov txheej txheem ultrasound tau dhau los ua ntau dua, kev xaiv ntawm tus neeg mob kev nyab xeeb thiab kev saib xyuas cov txheej txheem uas yuav tsis tshua siv yuav tsum tau txiav txim siab.
3. Kev soj ntsuam ntawm kev muaj peev xwm kho mob yuav tsum tau qhab nia los ntawm kev soj ntsuam kev soj ntsuam es tsis yog tso siab rau cov txheej txheem ntau lawm
nyob rau hauv xaus
Tus yuam sij rau kev ua tau zoo thiab muaj kev nyab xeeb ntawm ultrasound-guided CVC yog kev paub txog cov pitfalls thiab kev txwv ntawm cov txheej txheem no ntxiv rau kev cob qhia kom raug.
Post lub sij hawm: Nov-26-2022
