1、陈锡明陈锡明2l先心病和其它大手术、重症监护治疗或某些慢性疾病的婴幼儿常需放置中心静脉导管l讨论婴幼儿中心静脉置管技术及其并发症的防治3l置管途径置管途径l超声辅助技术超声辅助技术l最佳置管深度最佳置管深度 l导管位置不当导管位置不当l并发症并发症l感染控制感染控制4l婴幼儿中心静脉置管难度较大 Finck 锁骨下静脉成功率u6个月 96%u45 否则颈内静脉与颈动脉重叠的机会增大l按压肝区使颈内静脉明显增粗，提高成功率91.High approach,midway between mastoid process and sternal notch.2,3.Middle approach us
2、ing apex of muscular triangle or cricoid cartilage.4.Low approach using jugular notch.5.Lateral approach to subclavian venipuncture.10颈内颈内静脉穿刺入路静脉穿刺入路111213141516穿刺方法穿刺方法17181920212223l静脉与体表标志相对恆定 成功率高 气胸也较高l导管进入对側头臂静脉约为5%-20%l首选右侧径路24l穿刺点在锁骨中点外1-2cml针尖指向胸骨上窝l紧贴锁骨下进针l呼气期进针可减少气胸发生l约半数在退针时见回血l穿刺的方向十分重
3、要偏向头部易致误入动脉偏后易致气胸穿刺过深可能刺入气管252627l穿刺点 位于腹股沟韧带下方1-2cm，股动脉旁0.5-1cml当无明显腹腔内压升高或下腔静梗阻情况时，经下腔静脉测得的静脉压与右房压相同2829l出生后3-5天内静脉导管未闭合经脐静脉一般可进入下腔静脉l若脐静脉导管已闭合经脐静脉插管进入肝静脉的分枝不能准确监测中心静脉压l置管后需X线，导管尖端的位置3031l并发症:门脉血栓形成感染心内膜炎门脉硬化心包填塞32l王晓东 周晓光:l22例极低出生体重儿的静脉营养l贵要、肘正中、头静脉、腋静脉置管l20/22例（90.9%)患儿成功置管l平均留置时间为13.26.4dl塞管1例、
4、导管末段细菌培养阳性3例lPICC使VLBW患儿顺利完成过度 王晓东 周晓光:外周导入中心静脉置管术在极低出生体重儿中的应用.中国当代儿科杂志.2002,4(3).-223-22433l崔其亮:l84例 新生儿 静脉营养通道 l贵要、肘正中l平均20天(最长80 天)l3例导管破裂,5例导管培养+崔其亮:外周穿刺中心静脉置管术在新生儿中的应用.新医学.2002,33(10).629-63034l在心肺转流的复温期置入各种导管右心房置管左心房置管l可经肺静脉置入左心房导管l经右心室流出道置入肺动脉导管35l超声波血管定位技术可以提高婴幼儿中心静脉置管的成功率。lValsawa手法、按压肝区和头低
5、足高位等方法均能使颈内静脉增粗，联合应用的效果更加 36lBratton:婴幼儿 生手操作 成功率97%(61/63)经典法62%(13.21)J Cardiothoracic&Vascular Anesthesia 1998,12:523-52637Audio Doppler-guided puncture of the internal jugular vein in an infant.38Two-dimensional ultrasound view of the internal jugular vein(larger circle,above and to the right of
6、 the smaller carotid artery).39The tip of the right internal jugular catheter is in the SVC,6 mm above the RA.40l经食道超声:导管尖端位于上腔静脉内经食道超声心动图技术有助于术中即刻观察到中心静脉导管的位置Andropoulos:J Cardiothoracic&Vascular Anesthesia 1999,13:320-321.41l .Andropoulos:Anesth Analg,1999:65-7042l尖端位于上腔静脉的上半部份上腔静脉位于心包反摺线之上即使静脉壁穿孔
7、，也无心包填塞危险l经食道超声心动图技术有助于术中即刻观察到中心静脉导管的位置l心电图引导中心静脉导管置管的深度4344l正确位置预测身高100cm 深度(cm)=身高(cm)/10-297%中心静脉导管位于上腔静脉与右房交界处45lAndropoulos:J Cardiothoracic&Vascular Anesthesia 1999,13:320-321.46体重(kg)置管深度(cm)22.9434.9556.9679.971012.981319.992029.9103039.9114049.9125059.9136069.9147079.91580100164748Postopera
8、tive chest radiograph with the tip of a right internal jugular vein catheter in the mid-superior vena cava.49lAlbrecht:l新鲜尸体解剖39例:心包反摺横跨上腔静脉l气管窿突位于反摺线之上8+-0.5mm,无一例位于其之下l气管窿突是可靠、简便的解剖标志 BJA 2004,92(1):75-77.50The carina is not a landmark for central venouscatheter placement in neonatesPediatric Anes
9、thesia 2007 17:96897151Age:postconceptional age(gestational age in weeks+weeks after delivery);distance:longitudinal distance between the carina and PR,positive distance means the PR is above the carina and negative distance means the PR is below the carina.PR,pericardial reflection;Pediatric Anesth
10、esia 2007 17:96897152l靠近右心房l胸骨-脐孔-穿刺点的长度l肾静脉以下l水平53cm 0.45kg+8.13R20.84.Correlation between the distance from the femoral insertion site tothe L3 level(the optimal insertion length)and the body weight ofthe patients(regression line and 95%confidence intervals).Pediatric Anesthesia，2005，15:12212454体重
11、（kg）颈内/锁骨下静脉股静脉708F双腔,16cm8F双腔,20cm5556Roth B.Anatomic relationship between the internal jugular vein and the carotid artery in preschool children an ultrasonographic study.Pediatric Anesthesia,2008,18:752756.Relationships between right(R)and left(L)internal jugular veins and homolateral carotid art
12、ery(CA).Figures are given in percent.The majority of internal jugular veins are at least partially covering the internal jugular veins.57Ultrasound image the internal jugular vein in its classic localization.58Ultrasound imagean uncommon internal vein localization.5960Age(months)LIJVRIJVMean60.990.1
13、31.000.130.990.137-18 0.890.110.910.130.900.1218-600.970.140.940.150.960.14Depth(cm)61Age(months)LIJVRIJVMean60.500.10*0.470.06*0.490.08*7-180.610.09*0.630.08*0.620.09*18-600.710.09*0.700.10*0.700.09*Diameter(cm)62l中心静脉导管 左上腔静脉 逆行进入颈内静脉 异位引流的肺静脉内 于静脉之外63l采用X线定位或心电图引导技术可以防止导管位置不当引起的严重并发症的发生l常规摄片以证实导管位置，然后才能开始使用化疗药物或静脉高营养l导管应位于气管隆突水平以上l摄片心影之外1-2cm的位置l必要时可经导管造影6465l最常见的有血栓形成与感染l心包填塞虽然罕见却可致命l长期植入的静脉装置的并发症可高达31%。l癌症病人经外周置入中心静脉导管（PICC）的并发症约为10.9%。lHIV感染患儿置入中心静脉导管的短期并发症约15%，明显高于非HIV患儿。66l与导管有关的感染发生率约为13.8/1000l抗菌素涂层或浸渍的导管有助于降低血内感染的发生率 Rifampine and Minocycline l一旦发现感染，应及时拔除中心静脉导管 6768谢谢
