临床操作：动脉穿刺新方法

本文由“小麻哥的日常"授权转载

⛳️摘要译文⛳️

动态针尖定位法在老年患者超声引导动脉穿刺置管中的应用：

一项随机对照试验

👉背景：

由于年龄相关的形态学改变，老年患者动脉穿刺置管困难。

应用动态针尖定位（dynamic needle tip positioning，DNTP）方法，引导导管充分定位在血管内，可能有助于成功置管。

👉方法：

这项前瞻性研究招募了70岁以上的患者，他们计划在全身麻醉和动脉置管下进行择期手术。

将患者随机分为DNTP组（D组，n=76）或常规短轴视图组（C组，n=75）。

穿刺前使用超声评估动脉深度、直径和动脉状况（钙化、节段狭窄和弯曲）。

我们记录了首次尝试成功率、插管时间、尝试次数和插管相关并发症。

👉结果：

共有151名患者入选本研究。

D组的首次尝试成功率显著高于C组（89%对72%；P=0.0168）。

D组与C组的最后一次插管时间中位数分别为25秒与30秒（P=0.0001），总插管时间分别为25与35秒（P=0.0001）。

D组最后一次尝试动脉插管和总插管时间较短。

C组尝试次数较高（P=0.0038）。

D组的血肿发生率明显较低（16%对47%，相对风险=3.0，P=0.0001）。

👉结论：

DNTP方法可提高70岁以上老年患者首次动脉插管成功率，减少并发症。

图1.两种超声引导的桡动脉穿刺置管方法的图示。

A、 常规方法

（a）在超声屏幕上确认动脉内腔中心的针尖可视化。在确认血液已被吸入导管毂后，在减小穿刺角度的同时稍微推进针，并将外部导管插入动脉。然后，在移除内引导针之后，如果没有观察到血液回流，则依次执行（b）和（c）过程。

（b） 通过施加负压拔出外导管，直到再次观察到血液抽吸，

（c）如果继续血液抽吸，则将外导管插入动脉。

B、 DNTP（动态针尖定位）方法

（a）穿刺皮肤和桡动脉，针尖位于动脉内腔中心。

（b） 探头略微向前移动，直到针尖消失在动脉内腔中。

（c） 针尖稍微向前移动后再次看到针尖。

重复步骤（a）-（c）2次或多次，以确保外套管的整个导管进入动脉。

图2.CONSORT流程图。

图3.整体导管插入术成功时间的Kaplan–Meier曲线。

D：D组，动态针尖定位法。C：C组，常规短轴法。

时间（x轴）定义为从第一次尝试期间开始超声扫描到监视器上出现动脉波形的时间。

如果在10分钟后使用指定方法插管不成功，则定义为插管失败。

⛳️原文摘要

Application of the dynamic needle tip positioning method for ultrasound-guided arterial catheterization in elderly patients: A randomized controlled trial

Background: Arterial cannulation in elderly patients is difficult because of age-related morphological changes. Applying dynamic needle tip positioning (DNTP) that guides the catheter to position inside the vessel sufficiently may aid in successful cannulation.

Methods: This prospective study enrolled patients aged over 70 years, who were scheduled for elective surgery under general anaesthesia with arterial cannulation. The patients were randomly assigned to the DNTP (group D, n = 76) or the conventional short-axis view(group C, n = 75) group. The arterial depth, diameter, and arterial conditions(calcification, segmental stenosis, and tortuosity) were evaluated using ultrasound, before puncture. We recorded the first attempt success, cannulation time, the number of attempts, and cannulation-related complications.

Results: A total of 151 patients were enrolled in this study. The first attempt success rate in group D was significantly higher than that in group C (89% versus 72%; P = 0.0168). The median cannulation time per last attempt in group D versus group C was 25 versus 30 sec(P = 0.0001), and the overall cannulation time was 25 versus 35 sec(P = 0.0001), respectively. Arterial cannulation per last attempt and overall cannulation time were shorter in group D. The number of attempts was higher in group C (P = 0.0038). The occurrence rate of hematoma was significantly lower in group D (16% versus 47%, relative risk = 3.0, P = 0.0001).

Conclusions: The DNTP method may improve the first attempt success rate of arterial cannulation and reduce complications in elderly patients over 70 years of age.

Fig 1. Illustrations for two ultrasound-guided radial artery cannulation methods. A. Conventional method (a) Confirmation of needle tip visualization in the centre of intra-arterial lumen on the ultrasound screen. After confirming that blood has been aspirated into the catheter hub, the needle is advanced slightly whilst reducing the puncture angle, and an external catheter was inserted into the artery. Then, after the inner guide needle is removed, the (b)and (c) process are performed sequentially if the blood return is not observed. (b) The outer catheter was withdrawn by applying negative pressure until the blood aspiration is observed again, (c)If blood aspiration continued, an outer- catheter is inserted into the artery. B. DNTP (dynamic needle tip positioning) method (a) The skin and radial artery are punctured, and the tip of the needle is seen in the centre of the intra-arterial lumen. (b) The probe is moved forward slightly until the needle tip disappears in the intra-arterial lumen. (c) The needle tip is slightly advanced tip of the needle. Repeat steps (a)-(c) 2 or more times to ensure that the entire catheter of the outer cannula is advanced into the artery.

Fig 2. CONSORT flow diagram.

Fig 3. Kaplan–Meier curves for the overall catheterization success time. D: Group D, dynamic needle tip positioning method. C: Group C, conventional short-axis method. Time(x-axis) is defined as the time from the start of ultrasound scanning during the first attempt to the appearance of an arterial waveform on the monitor. If cannulation was not successful with the assigned method after 10 min, it was defined as cannulation failure.

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