超声引导下桡动脉穿刺置管.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,六院超声学组,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,六院超声学组,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,超声引导下桡动脉穿刺置管,第一页，共23页。,优选超声引导下桡动脉穿刺置管,第二页，共23页。,倡导超声引导,提高效率：,一次成功率提高,总的穿刺次数减少,穿刺时间大幅度减少,失败率,减少并发症,穿刺损伤（邻近肌腱、神经）,远端缺血（痉挛、血栓、夹层）,出血及其压迫（机化、粘连）,第三页，共23页。,动脉特点,椭圆形,lateral-lateral diameter,：,2.70 0.40 mm,up-forward diameter,：,1.90 0.26 mm,Qh Zhou,第四页，共23页。,动脉特点,The diameter of the radial artery was mean value of 2.2 0.4 mm,correlation with body surface area(BSA)（Pearson correlation 0.292,P0.001）,Ultrasound evaluation of the radial artery for arterial catheterization in healthy anesthetized patients,Dongchul Lee.Ji Young Kim.et,J Clin Monit Comput DOI 10.1007/s10877-015-9704-9.Springer Science+Business Media New York,第五页，共23页。,动脉特点,年龄：年龄越小越细，三岁内，动脉平均直径1.0mm（24G穿刺针是0.7mm黄色）,老年人动脉壁增厚，弹性差(尤其有动脉粥样硬化),性别：男性直径不小于女性，长期从事体力活动的更粗大,文献：硬化的动脉更轻易引起血管痉挛,Saito S,et Influence of the ratio between radial artery inner diameter and sheath outer diameter on radial artery flow after transradial coronary intervention.Catheter Cardiovasc Interv 1999;46:1738.,第六页，共23页。,血压,正常血压状况下，动脉充盈、饱满轻易触及或显影,血压低于80mmHg，动脉会变扁平，触摸法相对困难，远端加压起到一种局部相对充盈的桡动脉,升压药？,休克状态,相对血管扩张,第七页，共23页。,最佳手腕位置,最佳的手腕位置：45。,Forty-five degree wrist angulation is optimal for ultrasound guided long axis radial artery cannulation in patients,over 60 years old:a randomized study.Ahmet Kucuk.et.,J Clin Monit Comput()28:567572,第八页，共23页。,桡动脉垂直直径,First attempt First attempt,successful(n=75)failed(n=25)p,Height(mm)3.02 0.53 2.49 3.48 0.001,Skin distance(mm)2.63 0.64 2.58 0.59 0.71,Ahmet J Clin Monit Comput()28:567572,第九页，共23页。,皮肤至动脉浅壁的深度,太浅：无法起到引导的作用,T,第十页，共23页。,皮肤至动脉浅壁的深度,太深：穿刺针血管外途径太长，缩短穿刺针管外距离会增长针和血管的角度,T,第十一页，共23页。,皮肤与动脉浅层壁,A Novel Method for Ultrasound-Guided Radial Arterial Catheterization in Pediatric Patients,Yoshinobu Nakayama,MD,et.Society for Pediatric Anesthesia.May ；118，Number 5,第十二页，共23页。,穿刺最佳深度,第十三页，共23页。,平面内外对照,穿刺置管时间：(24 17 s vs.47 34 s respectively,p0.05,一次成功率：76%vs 51%,后壁破坏：20%vs56%,Ultrasound-guided radial arterial cannulation:long axis/in-plane versus short axis/out-of-plane approaches?,Derya Berk Yavuz Gurkan Alparslan Kus Halim Ulugol Mine Solak Kamil Toker,Published online:16 February Springer Science+Business Media New York,第十四页，共23页。,长轴平面内,长轴平面内技术对针尖看的更清晰，穿刺更精确，并发症更少。,during ultrasound-guided vascular access:short-axis vslong-axis approach.,Stone MB,Moon C,Sutijono D,Blaivas M.Needle tip visualization,Am J Emerg Med.;28:3437.,第十五页，共23页。,长轴平面内,长处：,可以看到血管、穿刺进针全程，针尖、鞘管位置,需要一段长而直的动脉,缺陷,寻找定位时间长,轻易被探头的和皮肤角度影响,A,A,探头,探头,第十六页，共23页。,长轴平面内,A,T,第十七页，共23页。,短轴平面外,超声寻找定位时间短,可以看清晰动脉和周围组织的互相比邻关系，穿刺针正对着动脉正中,（沿着动脉直径穿刺）,只能看见一种切面，穿刺过程也许看见的并不是针尖,需要一定的经验,A,探头,第十八页，共23页。,平面内外对照,第十九页，共23页。,不一样穿刺针对照,型号 直径*长度 针尖与套管尖距离,18G,绿,1.3,*,45 3mm,20G,红,1.1*32 2mm,22G,蓝,0.9*25 1.5mm,24G,黄,0.7,*,2 1.2mm,第二十页，共23页。,操作者的经验：重要原因,操作水平直接与成功率、穿刺次数有关,操作前要反复训练、熟悉,适应多种类型的病人：小儿、肥胖等,熟悉超声机器的多种参数：增益、深度、方向的迅速辨别、超声的引导能力,第二十一页，共23页。,桡动脉后壁破坏,后壁破坏率（平面内和平面外总体：）34%,Incidence of posterior vessel wall puncture during ultrasound-guided vessel cannulation in a simulated model.,Moon CH,Blehar D,Shear MA,et al.Acad Emerg Med.;17:113841.,第二十二页，共23页。,送管失败,导致动脉穿失败最多的,一种畅通回血,针芯和鞘的关系,提议：在送管进入的同步，,仍然流畅的回血！,第二十三页，共23页。,