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桡动脉穿刺置管是麻醉科最常用的临床操作之一,实时动脉测压技术在危重、复杂、长时间手术中广泛应用。肥胖病人往往合并有高血压、糖尿病,术中血流动力学波动较大,动脉穿刺测压能大大提高围手术期安全性。传统的穿刺技术是靠操作者的手感,穿刺成功率不能保证,临床上经常遇到穿刺困难,有时候因为动脉穿刺困难延误时间达1 h甚至更长。超声在临床应用越来越普及,几乎所有的三级医院麻醉科均配备超声仪器,超声引导进行神经阻滞、动静脉穿刺、容量评估及肺超声、食管超声等,让围手术期的管理越来越精准。对于超声引导下动静脉穿刺技术,有报道[1]短轴平面外优于长轴平面内,也有报道[2]2种方法成功率类似,长轴平面内并发症更少。随着近年来高频超声的广泛应用,浅表超声技术大大提高了超声的清晰度,超声实时引导穿刺技术是一种趋势。根据本研究团队近年来大量进行超声引导下神经阻滞操作的经验,平面内操作通常优于平面外操作,尤其在安全性上。本研究通过随机对照研究比较超声引导下桡动脉长轴平面内穿刺和短轴平面外穿刺技术的优缺点,希望总结经验指导临床。现作报道。
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本研究通过安徽医科大学第二附属医院医学伦理委员会批准,收集2019年6月至2020年5月需要进行动脉测压成年肥胖病人[体质量指数(BMI)≥28 kg/m2]100例,ASA Ⅰ~Ⅲ级,排除Allen试验阳性,尺动脉闭塞、外周血管疾病病人。随机分为超声引导短轴(S)组和超声引导长轴(L)组,2组病人年龄、性别比例、BMI、手术类别一般资料差异均无统计学意义(P>0.05)(见表 1),具有可比性。
分组 年龄/岁 男 女 BMI/(kg/m2) 手术类型 减重手术 非减重手术 S组 35±10 28 22 41.3±6.2 37 13 L组 37±13 31 19 42.0±7.7 41 9 t 0.86 0.37 0.50 0.93 P >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组病人一般资料比较(x±s)
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所有病人进入手术室首先进行信息核查确认,监护氧饱和度、心率、血压。心理关怀病人,告知操作事项,对于紧张病人静脉推注舒芬太尼5 μg,咪达唑仑1 mg。病人平卧位,穿刺侧上肢外展置于支架上,手腕处垫薄枕,固定手掌使腕部屈曲,掌心向上。超声探头(美国索诺声Edge Ⅱ,探头为6~13 MHz线阵探头)表面均有涂抹适量耦合剂,无菌透明贴膜包住超声探头,确保无菌操作。2D模式超声扫查桡动脉和尺动脉未见明显狭窄后继续操作;超声引导下S组:将探头放置桡骨茎突近端2~3 cm扫查到桡动脉,根据动脉的波动性识别桡动脉(见图 1),然后利用Color模式进行确定(见图 2),选择最清晰处穿刺,利用M模式确定中点,将M线对准动脉最宽处(见图 3),将探头的左右方向与超声显示屏左右一致,进针点离开探头0.5 cm 30°左右平面外进针,穿刺过程中可以在2D、M及Color不同模式之间切换,尽量使穿刺针在显示屏中间。超声引导下L组:利用相同方法确定动脉短轴中点后,缓慢旋转探头90°,保持动脉在视野中,通过轻微向桡侧或尺侧平移探头获取最宽的动脉图像后固定探头(见图 4、5),进针点离开探头0.5 cm 0°~30°平面内进针,全程确保针尖和针体可见(见图 6)。
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比较2组穿刺一次成功率、穿刺时间(自穿刺点消毒至穿刺套管针置入完成), 使用穿刺针数量、穿刺次数(进针到皮肤至退针出皮肤定义为穿刺一次)以及穿刺部位血肿发生情况。
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采用t检验、χ2检验和秩和检验。
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L组穿刺一次成功率高于S组(P < 0.05);S组4例出现穿刺部位血肿,均更换对侧桡动脉穿刺成功,L组未发生穿刺部位血肿,2组差异有统计学意义(P < 0.05);2组病人穿刺时间、穿刺次数、穿刺针使用数量差异均无统计学意义(P>0.05)(见表 2)。2组穿刺时间变异系数,S组为37.5 %,L组为16.7%。
分组 n 穿刺一次成功 穿刺时间/s 穿刺次数
M50(M25, M75)穿刺针数量
M50(M25, M75)/根穿刺部位血肿 S组 50 27(54.00) 48.3±18.1 1(1, 4) 1(1, 3) 4(8.00) L组 50 39(78.00) 52.4±9.0 1(1, 3) 1(1, 3) 0(0.00) t — 6.42* 1.43 — — 4.16* P — < 0.05 >0.05 >0.05 >0.05 < 0.05 *示χ2值 表 2 2组病人穿刺相关指标比较(x±s)
超声引导全程可视化桡动脉穿刺置管方法在肥胖病人麻醉中的应用
Application value of ultrasound-guided whole-process visualization of radial artery puncture and catheterization in anesthesia of obese patients
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摘要:
目的评价超声引导全程可视化桡动脉穿刺置管方法在肥胖病人麻醉中的临床应用效果。 方法选择体质量指数≥28 kg/m2拟行手术,需要动脉穿刺置管病人100例,随机分为超声引导长轴平面内组(L组)和超声引导短轴平面外组(S组);比较穿刺一次成功率、穿刺时间、穿刺次数、穿刺并发症等。 结果L组穿刺一次成功率高于S组(P < 0.05);S组4例出现穿刺部位血肿,均更换对侧桡动脉穿刺成功,L组未发生穿刺部位血肿,2组差异有统计学意义(P < 0.05);2组病人穿刺时间、穿刺次数、穿刺针使用数量差异均无统计学意义(P>0.05)。 结论超声引导长轴全程可视化桡动脉穿刺置管操作成功率高于超声引导短轴平面外技术。 Abstract:ObjectiveTo evaluate the clinical effectiveness of ultrasound-guided whole-process visualization of radial artery puncture catheterization in anesthesia of obese patients. MethodsOne hundred patients with body mass index ≥28 kg/m2 through arterial puncture catheterization were randomly divided into the group L(n=50, radial arterial cannulation with whole-process visible ultrasound-guided long-axis in-plane technique) and group S(n=50, radial arterial cannulation with ultrasound-guided short-axis out-of-plane technique).The success rate at first-time attempt, puncture time, puncture times and puncture complications were compared between two groups. ResultsThe success rate at first-time attempt in group L was significantly higher than that in group S(P < 0.05).In group S, 4 patients with hematoma at the puncture site were found, and the contralateral radial artery puncture were successful in all patients, no hematoma at the puncture site in group L was found, and the difference of which between two groups was statistically significant(P < 0.05).The differences of the puncture time, number of puncture and number of puncture needles between two groups were not statistically significant(P>0.05). ConclusionsThe success rate of ultrasound-guided long-axis whole-process visualization of radial artery puncture and catheterizationis higher than that of ultrasound-guided short-axis out-of-plane technique. -
Key words:
- anesthesia /
- radial artery puncture and catheterization /
- ultrasound /
- obesity /
- visualization
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表 1 2组病人一般资料比较(x±s)
分组 年龄/岁 男 女 BMI/(kg/m2) 手术类型 减重手术 非减重手术 S组 35±10 28 22 41.3±6.2 37 13 L组 37±13 31 19 42.0±7.7 41 9 t 0.86 0.37 0.50 0.93 P >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组病人穿刺相关指标比较(x±s)
分组 n 穿刺一次成功 穿刺时间/s 穿刺次数
M50(M25, M75)穿刺针数量
M50(M25, M75)/根穿刺部位血肿 S组 50 27(54.00) 48.3±18.1 1(1, 4) 1(1, 3) 4(8.00) L组 50 39(78.00) 52.4±9.0 1(1, 3) 1(1, 3) 0(0.00) t — 6.42* 1.43 — — 4.16* P — < 0.05 >0.05 >0.05 >0.05 < 0.05 *示χ2值 -
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