1、超声引导下桡动脉穿刺置管优选超声引导下桡动脉穿刺置管提倡超声引导提倡超声引导提高效率提高效率 一次成功率提高一次成功率提高 总的穿刺次数降低总的穿刺次数降低 穿刺时间大幅度降低穿刺时间大幅度降低 失败率失败率降低并发症降低并发症 穿刺损伤（邻近肌腱、神经）穿刺损伤（邻近肌腱、神经）远端缺血（痉挛、血栓、夹层）远端缺血（痉挛、血栓、夹层）出血及其压迫（机化、粘连）出血及其压迫（机化、粘连）动脉特点动脉特点椭圆形椭圆形laterallateral diameter2.70laterallateral diameter2.70 0.40 mm 0.40 mmupforward diameter1.9
2、0upforward diameter1.90 0.26 mm 0.26 mmQh Zhou,Qh Zhou,动脉特点动脉特点The diameter of the radial artery was mean value of 2.2 0.4 mmcorrelation with body surface area(BSA)（Pearson correlation 0.292,P0.001）Ultrasound evaluation of the radial artery for arterial catheterization in healthy anesthetized patien
3、tsDongchul Lee.Ji Young Kim.et动脉特点动脉特点年龄年龄 年龄越小越细，三岁内，动脉平均直径年龄越小越细，三岁内，动脉平均直径1.0mm1.0mm（24G24G穿刺针是穿刺针是0.7mm0.7mm黄色）黄色）老年人动脉壁增厚，弹性差老年人动脉壁增厚，弹性差(尤其有动脉粥样尤其有动脉粥样硬化硬化)性别男性直径大于女性，长期从事体力活动的更粗性别男性直径大于女性，长期从事体力活动的更粗大大文献硬化的动脉更容易引起血管痉挛文献硬化的动脉更容易引起血管痉挛Saito S,et Influence of the ratio between Saito S,et Influen
4、ce of the ratio between radial artery inner diameter and sheath radial artery inner diameter and sheath outer diameter on radial artery flow after outer diameter on radial artery flow after transradial coronary intervention.Catheter transradial coronary intervention.Catheter Cardiovasc Interv 1999;4
5、6:1738.Cardiovasc Interv 1999;46:1738.血压血压正常血压情况下，动脉充盈、饱满容易触及或正常血压情况下，动脉充盈、饱满容易触及或显影显影血压低于血压低于80mmHg，动脉会变扁平，触摸法相，动脉会变扁平，触摸法相对困难，远端加压起到一个局部相对充盈的桡对困难，远端加压起到一个局部相对充盈的桡动脉动脉升压药？升压药？休克状态休克状态 相对血管扩张相对血管扩张最佳手腕位置最佳手腕位置最佳的手腕位置：最佳的手腕位置：45。Forty-five degree wrist angulation is optimal for ultrasound guided long
6、 axis radial artery cannulation in patientsover 60 years old:a randomized study.Ahmet Kucuk.et.J Clin Monit Comput(2014)28:567572穿刺置管时间(24 17 s vs.2010;28:3437.性别男性直径大于女性，长期从事体力活动的更粗大during ultrasoundguided vascular access:shortaxis vslongaxis approach.53 2.First attempt First attemptHeight(mm)3.Ult
7、rasoundguided radial arterial cannulation:long axis/inplane versus short axis/outofplane approaches?upforward diameter1.Height(mm)3.2010;17:113841.太浅无法起到引导的作用2010;17:113841.Derya Berk Yavuz Gurkan Alparslan Kus Halim Ulugol Mine Solak Kamil TokerUltrasoundguided radial arterial cannulation:long axis
8、/inplane versus short axis/outofplane approaches?适应各种类型的病人小儿、肥胖等53 2.during ultrasoundguided vascular access:shortaxis vslongaxis approach.桡动脉垂直直径桡动脉垂直直径 First attempt First attempt successful(n=75)failed(n=25)pHeight(mm)3.02 0.53 2.49 3.48 0.001Skin distance(mm)2.63 0.64 2.58 0.59 0.71Ahmet J Clin
9、Monit Comput(2014)28:567572皮肤至动脉浅壁的深度皮肤至动脉浅壁的深度太浅无法起到引导的作用太浅无法起到引导的作用T皮肤至动脉浅壁的深度皮肤至动脉浅壁的深度太深穿刺针血管外路径太长，缩短穿刺针管外太深穿刺针血管外路径太长，缩短穿刺针管外距离会增加针和血管的角度距离会增加针和血管的角度T皮肤与动脉浅层壁皮肤与动脉浅层壁A Novel Method for UltrasoundGuided Radial Arterial Catheterization in Pediatric PatientsYoshinobu Nakayama,MD,et.Society for Ped
10、iatric Anesthesia.May 2014；118，Number 5穿刺最佳深度穿刺最佳深度平面内外对照平面内外对照穿刺置管时间穿刺置管时间(24(24 17 s vs.47 17 s vs.47 34 s 34 s respectively,p0.05respectively,p0.05一次成功率一次成功率76%vs 51%76%vs 51%后壁破坏后壁破坏20%vs56%20%vs56%Ultrasoundguided radial arterial Ultrasoundguided radial arterial cannulation:long axis/inplane ve
11、rsus cannulation:long axis/inplane versus short axis/outofplane approaches?short axis/outofplane approaches?Derya Berk Derya Berk Yavuz Gurkan Yavuz Gurkan Alparslan Kus Alparslan Kus Halim Ulugol Halim Ulugol Mine Solak Mine Solak Kamil Toker Kamil TokerPublished online:16 February 2013 Published o
12、nline:16 February 2013 Springer Science+Business Media New York Springer Science+Business Media New York 20132013长轴平面内长轴平面内长轴平面内技术对针尖看的更清楚，穿刺更准长轴平面内技术对针尖看的更清楚，穿刺更准确，并发症更少。确，并发症更少。during ultrasoundguided vascular access:during ultrasoundguided vascular access:shortaxis vslongaxis approach.shortaxis v
13、slongaxis approach.Stone MB,Moon C,Sutijono D,Blaivas M.Stone MB,Moon C,Sutijono D,Blaivas M.Needle tip visualizationNeedle tip visualization Am J Emerg Med.2010;28:3437.Am J Emerg Med.2010;28:3437.只能看见一个切面，穿刺过程可能看见的并不是针尖The diameter of the radial artery was mean value of 2.47 34 s respectively,p0.可
14、以看到血管、穿刺进针全程，针尖、鞘管位置Yoshinobu Nakayama,MD,et.长轴平面内技术对针尖看的更清楚，穿刺更准确，并发症更少。失败率47 34 s respectively,p0.Society for Pediatric Anesthesia.First attempt First attemptHeight(mm)3.Dongchul Lee.一次成功率提高53 2.2010;17:113841.Incidence of posterior vessel wall puncture during ultrasoundguided vessel cannulation i
15、n a simulated model.Published online:16 February 2013 Springer Science+Business Media New York 201348 0.Ji Young Kim.Derya Berk Yavuz Gurkan Alparslan Kus Halim Ulugol Mine Solak Kamil Toker长轴平面内长轴平面内优点优点可以看到血管、穿刺进针可以看到血管、穿刺进针全程，针尖、鞘管位置全程，针尖、鞘管位置需要一段长而直的动脉需要一段长而直的动脉缺点缺点寻找定位时间长寻找定位时间长容易被探头的和皮肤角度容易被探头
16、的和皮肤角度影响影响AA探头探头探头探头长轴平面内长轴平面内AT短轴平面外短轴平面外超声寻找定位时间短超声寻找定位时间短可以看清楚动脉和周围组可以看清楚动脉和周围组织的相互比邻关系，穿刺织的相互比邻关系，穿刺针正对着动脉正中针正对着动脉正中 （沿着动脉直径穿刺）（沿着动脉直径穿刺）只能看见一个切面只能看见一个切面，穿，穿刺过程可能看见的并不是刺过程可能看见的并不是针尖针尖需要一定的经验需要一定的经验A探头探头平面内外对照平面内外对照不同穿刺针对照不同穿刺针对照 型号型号 直径直径*长度长度 针尖与套管针尖与套管尖距离尖距离 18G 绿绿 1.3*45 3mm20G 红红 1.1*32 2mm2
17、2G 蓝蓝 0.9*25 1.5mm24G 黄黄 0.7*2 1.2mm操作者的经验重要因素操作者的经验重要因素操作水平直接与成功率、穿刺次数相关操作水平直接与成功率、穿刺次数相关操作前要反复训练、熟悉操作前要反复训练、熟悉适应各种类型的病人小儿、肥胖等适应各种类型的病人小儿、肥胖等熟悉超声机器的各种参数增益、深度、方向的熟悉超声机器的各种参数增益、深度、方向的迅速辨别、超声的引导能力迅速辨别、超声的引导能力桡动脉后壁破坏桡动脉后壁破坏后壁破坏率（平面内和平面外总体）后壁破坏率（平面内和平面外总体）34%34%Incidence of posterior vessel wall Inciden
18、ce of posterior vessel wall puncture during ultrasoundguided vessel puncture during ultrasoundguided vessel cannulation in a simulated model.cannulation in a simulated model.Moon CH,Blehar D,Shear MA,et al.Moon CH,Blehar D,Shear MA,et al.Acad Emerg Med.2010;17:113841.Acad Emerg Med.2010;17:113841.Ji
19、 Young Kim.Am J Emerg Med.正常血压情况下，动脉充盈、饱满容易触及或显影Society for Pediatric Anesthesia.Stone MB,Moon C,Sutijono D,Blaivas M.2010;17:113841.性别男性直径大于女性，长期从事体力活动的更粗大during ultrasoundguided vascular access:shortaxis vslongaxis approach.总的穿刺次数降低休克状态Ultrasoundguided radial arterial cannulation:long axis/inplane
20、 versus short axis/outofplane approaches?A Novel Method for UltrasoundGuided Radial Arterial Catheterization in Pediatric Patients118，Number 5一次成功率76%vs 51%Incidence of posterior vessel wall puncture during ultrasoundguided vessel cannulation in a simulated model.Derya Berk Yavuz Gurkan Alparslan Ku
21、s Halim Ulugol Mine Solak Kamil Toker优选超声引导下桡动脉穿刺置管Society for Pediatric Anesthesia.Forty-five degree wrist angulation is optimal for ultrasound guided long axis radial artery cannulation in patientsAm J Emerg Med.适应各种类型的病人小儿、肥胖等长轴平面内技术对针尖看的更清楚，穿刺更准确，并发症更少。（沿着动脉直径穿刺）Ji Young Kim.Incidence of posteri
22、or vessel wall puncture during ultrasoundguided vessel cannulation in a simulated model.Ahmet J Clin Monit Comput(2014)28:567572Height(mm)3.只能看见一个切面，穿刺过程可能看见的并不是针尖53 2.后壁破坏率（平面内和平面外总体）34%The diameter of the radial artery was mean value of 2.Yoshinobu Nakayama,MD,et.Derya Berk Yavuz Gurkan Alparslan
23、Kus Halim Ulugol Mine Solak Kamil Toker47 34 s respectively,p0.2010;17:113841.correlation with body surface area(BSA)（Pearson correlation 0.Derya Berk Yavuz Gurkan Alparslan Kus Halim Ulugol Mine Solak Kamil Toker熟悉超声机器的各种参数增益、深度、方向的迅速辨别、超声的引导能力7*2 1.送管失败送管失败导致动脉穿失败最多的导致动脉穿失败最多的一个通畅回血一个通畅回血针芯和鞘的关系针芯和鞘的关系建议在送管进入的同时，建议在送管进入的同时，仍然流畅的回血！仍然流畅的回血！
