頭下腳上的姿勢對於瑣骨下靜脈穿刺動脈是最好的


  Sept. 12, 2003--根據一篇發表於9月號Archives of Surgery的小型預期性比較研究指出,頭下腳上的姿勢及中立的肩膀和頭部,對於瑣骨下靜脈穿刺是最好的。
  
  紐約奧爾巴尼醫學院的John B.Fortune博士及Albany 醫學院的Paul Feustel博士表示,研究人員提倡許多位置可以促進瑣骨下靜脈穿刺,但是鮮少有人可以提出基本原理。
  
  傳統上較喜愛頭下腳上的姿勢以增加血管直徑,使空氣栓塞的危險減到最低,作者檢查了10位健康受試者的五種不同姿勢進行瑣骨下穿次:(1)平躺(或仰臥),頭和肩保持中立;(2)平躺,頭中立者,肩成拱形;(3)平躺,頭立直,肩成拱形;(4) 頭下腳上,頭直立,肩成拱形;以及(5) 頭下腳上,頭和肩中立。
  
  使用雙重掃描儀,研究人員以B-模式超音波、自鎖骨之位置及都普勒探針的流動速率,測量左邊瑣骨下靜脈的直徑。
  
  平均瑣骨下靜脈的直徑(SEM)在位置5(0.99[0.06] 釐米)和在位置 2(0.82[0.05] 釐米)是最大的,來自鎖骨的靜脈距離,在位置1是最大的(0.94[0.08] 釐米)在位置4是最小的(0.75[0.07] 釐米)。
  
  利用Dunnett 比較的方差分析,研究人員發現所有受試者的位置導致其靜脈明顯地較位置4和5更小時,靜脈明顯地更接近瑣骨。作者並未發現所有位置與流動速率之間的統計差異。
  
  「在不同的位置的靜脈面積差異可以達到 28%。在外傷或重病患者中,可能會出現血容量減少性休克和低中心靜脈壓,靜脈的擴張範圍較小。因此,在這種情況下,患者位置造成的靜脈大小之變化,是更重要的。」
  
  在邀集的評論文章中,喬治亞州的亞特蘭大的Karyn I.Butler博士表示,難以推斷患者和健康者之解剖學關係,因為重病患者的胸壁順應性較低,較可能發生血容量減少症及胸腔內的壓力增加。
  
  她補充說,這項研究中的資料可以促進解剖學、瑣骨下靜脈的尺寸、導管手術成功率及患者實際需要中央靜脈之順應性等,與身體位置關係的進一步研究。

Trendelenburg Position With Ne

By Mindy Hung, Medical Writer
Medscape Medical News

Sept. 12, 2003 — Placing patients in the Trendelenburg position with the shoulder and head in a neutral posture may facilitate subclavian vein puncture for intravenous access, according to results of a small prospective comparison study published in the September issue of the Archives of Surgery.

"While many positions have been strongly advocated to facilitate puncture of the subclavian vein, very little rationale can usually be given," write John B. Fortune, MD, from the Southern Illinois School of Medicine in Springfield, and Paul Feustel, PhD, from Albany Medical College in New York.

Traditional teaching favors the Trendelenburg position to increase vein diameter and minimize the risk of air embolism.

The authors examined 10 healthy volunteers placed in five different positions for subclavian vein puncture: (1) flat (or supine), head and shoulders neutral; (2) flat, head neutral, shoulders arched; (3) flat, head opposite, shoulders arched; (4) Trendelenburg, head opposite, shoulders arched; and (5) Trendelenburg, head and shoulders neutral.

Using a duplex scanner, investigators measured left subclavian vein diameter with B-mode ultrasonography, position from the clavicle, and flow rates with a Doppler probe.

Mean (SEM) diameter of the subclavian vein was largest in position 5 (0.99 [0.06] cm) and in position 2 (0.82 [0.05] cm). The distance of the vein from the clavicle was greatest in position 1 (0.94 [0.08] cm) and least in the position 4 (0.75 [0.07] cm).

Using analysis of variance with Dunnett's comparison, investigators found that all subject positions resulted in a significantly smaller size vein than in position 5. In position 4, the vein was significantly closer to the clavicle. The authors found no statistical differences in flow rates among all positions.

"The difference in vein area in various positions can be as great as 28%," the authors write. "In the patient who after trauma or with critical illness may have hypovolemic shock and low central venous pressures, the vein will probably be less distended than in our subjects. Therefore, in this situation, changes in vein size induced by patient position may be magnified and more important."

In an invited critique, Karyn I. Butler, MD, from Atlanta, Georgia, writes, "It is difficult to extrapolate anatomical relationships in healthy volunteers to critically ill patients who may have decreased chest wall compliance, hypovolemia, or increased intrathoracic pressure."

She adds, "Data presented in this study should prompt further investigation of the influence of body position on the anatomical relationship and size of the subclavian vein, the success rate of catheterization, and the rate of complications in actual patients in need of central venous access."

Arch Surg. 2003;138:996-1000, 1001

Reviewed by Gary D. Vogin, MD

    
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