超聲引導(dǎo)下橈動(dòng)脈穿刺置管優(yōu)質(zhì)課件

超聲引導(dǎo)下橈動(dòng)脈穿刺置管超聲引導(dǎo)下橈動(dòng)脈穿刺置管1優(yōu)選超聲引導(dǎo)下橈動(dòng)脈穿刺置管優(yōu)選超聲引導(dǎo)下橈動(dòng)脈穿刺置管提倡超聲引導(dǎo)提高效率一次成功率提高總的穿刺次數(shù)降低穿刺時(shí)間大幅度降低失敗率降低并發(fā)癥穿刺損傷（鄰近肌腱、神經(jīng)）遠(yuǎn)端缺血（痙攣、血栓、夾層）出血及其壓迫（機(jī)化、粘連）

提倡超聲引導(dǎo)提高效率動(dòng)脈特點(diǎn)橢圓形laterallateraldiameter2.70±0.40mmupforwarddiameter1.90±0.26mmQhZhou,動(dòng)脈特點(diǎn)橢圓形動(dòng)脈特點(diǎn)Thediameteroftheradialarterywasmeanvalueof2.2±0.4mmcorrelationwithbodysurfacearea(BSA)（Pearsoncorrelation0.292,P\0.001）UltrasoundevaluationoftheradialarteryforarterialcatheterizationinhealthyanesthetizedpatientsDongchulLee.JiYoungKim.et動(dòng)脈特點(diǎn)Thediameteroftheradial動(dòng)脈特點(diǎn)年齡年齡越小越細(xì)，三歲內(nèi)，動(dòng)脈平均直徑1.0mm（24G穿刺針是0.7mm黃色）老年人動(dòng)脈壁增厚，彈性差(尤其有動(dòng)脈粥樣硬化)性別男性直徑大于女性，長(zhǎng)期從事體力活動(dòng)的更粗大文獻(xiàn)硬化的動(dòng)脈更容易引起血管痙攣SaitoS,etInfluenceoftheratiobetweenradialarteryinnerdiameterandsheathouterdiameteronradialarteryflowaftertransradialcoronaryintervention.CatheterCardiovascInterv1999;46:173–8.動(dòng)脈特點(diǎn)年齡年齡越小越細(xì)，三歲內(nèi)，動(dòng)脈平均直徑1.0mm（血壓正常血壓情況下，動(dòng)脈充盈、飽滿容易觸及或顯影血壓低于80mmHg，動(dòng)脈會(huì)變扁平，觸摸法相對(duì)困難，遠(yuǎn)端加壓起到一個(gè)局部相對(duì)充盈的橈動(dòng)脈升壓藥？

休克狀態(tài)

相對(duì)血管擴(kuò)張血壓正常血壓情況下，動(dòng)脈充盈、飽滿容易觸及或顯影最佳手腕位置最佳的手腕位置：45°。Forty-fivedegreewristangulationisoptimalforultrasoundguidedlongaxisradialarterycannulationinpatientsover60yearsold:arandomizedstudy.AhmetKucuk.et.JClinMonitComput(2014)28:567–572最佳手腕位置最佳的手腕位置：45°。穿刺置管時(shí)間(24±17svs.2010;28:343–7.性別男性直徑大于女性，長(zhǎng)期從事體力活動(dòng)的更粗大duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.532.FirstattemptFirstattemptHeight(mm)3.Ultrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?upforwarddiameter1.Height(mm)3.2010;17:1138–41.太淺無法起到引導(dǎo)的作用2010;17:1138–41.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilTokerUltrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?適應(yīng)各種類型的病人小兒、肥胖等532.duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.橈動(dòng)脈垂直直徑FirstattemptFirstattemptsuccessful(n=75)failed(n=25)pHeight(mm)3.02±0.532.49±3.48<0.001Skindistance(mm)2.63±0.642.58±0.590.71AhmetJClinMonitComput(2014)28:567–572穿刺置管時(shí)間(24±17svs.橈動(dòng)脈垂直直徑皮膚至動(dòng)脈淺壁的深度太淺無法起到引導(dǎo)的作用T皮膚至動(dòng)脈淺壁的深度T皮膚至動(dòng)脈淺壁的深度太深穿刺針血管外路徑太長(zhǎng)，縮短穿刺針管外距離會(huì)增加針和血管的角度T皮膚至動(dòng)脈淺壁的深度太深穿刺針血管外路徑太長(zhǎng)，縮短穿刺針管外

皮膚與動(dòng)脈淺層壁ANovelMethodforUltrasoundGuidedRadialArterialCatheterizationinPediatricPatientsYoshinobuNakayama,MD,et.SocietyforPediatricAnesthesia.May2014；118，Number5

皮膚與動(dòng)脈淺層壁12穿刺最佳深度穿刺最佳深度平面內(nèi)外對(duì)照穿刺置管時(shí)間(24±17svs.47±34srespectively,p<0.05一次成功率76%vs51%后壁破壞20%vs56%Ultrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilTokerPublishedonline:16February2013SpringerScience+BusinessMediaNewYork2013平面內(nèi)外對(duì)照穿刺置管時(shí)間(24±17svs.47長(zhǎng)軸平面內(nèi)長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥更少。duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.StoneMB,MoonC,SutijonoD,BlaivasM.NeedletipvisualizationAmJEmergMed.2010;28:343–7.長(zhǎng)軸平面內(nèi)長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖Thediameteroftheradialarterywasmeanvalueof2.47±34srespectively,p<0.可以看到血管、穿刺進(jìn)針全程，針尖、鞘管位置YoshinobuNakayama,MD,et.長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥更少。失敗率47±34srespectively,p<0.SocietyforPediatricAnesthesia.FirstattemptFirstattemptHeight(mm)3.DongchulLee.一次成功率提高532.2010;17:1138–41.Incidenceofposteriorvesselwallpunctureduringultrasoundguidedvesselcannulationinasimulatedmodel.Publishedonline:16February2013SpringerScience+BusinessMediaNewYork201348<0.JiYoungKim.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilToker長(zhǎng)軸平面內(nèi)優(yōu)點(diǎn)可以看到血管、穿刺進(jìn)針全程，針尖、鞘管位置需要一段長(zhǎng)而直的動(dòng)脈缺點(diǎn)尋找定位時(shí)間長(zhǎng)容易被探頭的和皮膚角度影響AA探頭探頭只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖長(zhǎng)軸平面內(nèi)優(yōu)16長(zhǎng)軸平面內(nèi)AT長(zhǎng)軸平面內(nèi)AT17短軸平面外超聲尋找定位時(shí)間短可以看清楚動(dòng)脈和周圍組織的相互比鄰關(guān)系，穿刺針正對(duì)著動(dòng)脈正中（沿著動(dòng)脈直徑穿刺）只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖需要一定的經(jīng)驗(yàn)A探頭短軸平面外超聲尋找定位時(shí)間短A探頭18平面內(nèi)外對(duì)照平面內(nèi)外對(duì)照不同穿刺針對(duì)照

型號(hào)直徑*長(zhǎng)度針尖與套管尖距離18G綠1.3*453mm20G紅1.1*322mm22G藍(lán)0.9*251.5mm24G黃0.7*21.2mm不同穿刺針對(duì)照型號(hào)直徑*長(zhǎng)度針尖與套操作者的經(jīng)驗(yàn)重要因素操作水平直接與成功率、穿刺次數(shù)相關(guān)操作前要反復(fù)訓(xùn)練、熟悉適應(yīng)各種類型的病人小兒、肥胖等熟悉超聲機(jī)器的各種參數(shù)增益、深度、方向的迅速辨別、超聲的引導(dǎo)能力操作者的經(jīng)驗(yàn)重要因素操作水平直接與成功率、穿刺次數(shù)相關(guān)橈動(dòng)脈后壁破壞后壁破壞率（平面內(nèi)和平面外總體）34%Incidenceofposteriorvesselwallpunctureduringultrasoundguidedvesselcannulationinasimulatedmodel.MoonCH,BleharD,ShearMA,etal.AcadEmergMed.2010;17:1138–41.橈動(dòng)脈后壁破壞后壁破壞率（平面內(nèi)和平面外總體）34%JiYoungKim.AmJEmergMed.正常血壓情況下，動(dòng)脈充盈、飽滿容易觸及或顯影SocietyforPediatricAnesthesia.StoneMB,MoonC,SutijonoD,BlaivasM.2010;17:1138–41.性別男性直徑大于女性，長(zhǎng)期從事體力活動(dòng)的更粗大duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.總的穿刺次數(shù)降低休克狀態(tài)Ultrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?ANovelMethodforUltrasoundGuidedRadialArterialCatheterizationinPediatricPatients118，Number5一次成功率76%vs51%Incidenceofposteriorvesselwallpunctureduringultrasoundguidedvesselcannulationinasimulatedmodel.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilToker優(yōu)選超聲引導(dǎo)下橈動(dòng)脈穿刺置管SocietyforPediatricAnesthesia.Forty-fivedegreewristangulationisoptimalforultrasoundguidedlongaxisradialarterycannulationinpatientsAmJEmergMed.適應(yīng)各種類型的病人小兒、肥胖等長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥更少。（沿著動(dòng)脈直徑穿刺）JiYoungKim.Incidenceofposteriorvesselwallpunctureduringultrasoundguidedvesselcannulationinasimulatedmodel.AhmetJClinMonitComput(2014)28:567–572Height(mm)3.只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖532.后壁破壞率（平面內(nèi)和平面外總體）34%Thediameteroftheradialarterywasmeanvalueof2.YoshinobuNakayama,MD,et.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilToker47±34srespectively,p<0.2010;17:1138–41.correlationwithbodysurfacearea(BSA)（Pearsoncorrelation0.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilToker熟悉超聲機(jī)器的各種參數(shù)增益、深度、方向的迅速辨別、超聲的引導(dǎo)能力7*21.送管失敗導(dǎo)致動(dòng)脈穿失敗最多的一個(gè)通暢回血針芯和鞘的關(guān)系建議在送管進(jìn)入的同時(shí)，仍然流暢的回血！JiYoungKim.Forty-fivedegree超聲引導(dǎo)下橈動(dòng)脈穿刺置管超聲引導(dǎo)下橈動(dòng)脈穿刺置管24優(yōu)選超聲引導(dǎo)下橈動(dòng)脈穿刺置管優(yōu)選超聲引導(dǎo)下橈動(dòng)脈穿刺置管提倡超聲引導(dǎo)提高效率一次成功率提高總的穿刺次數(shù)降低穿刺時(shí)間大幅度降低失敗率降低并發(fā)癥穿刺損傷（鄰近肌腱、神經(jīng)）遠(yuǎn)端缺血（痙攣、血栓、夾層）出血及其壓迫（機(jī)化、粘連）

提倡超聲引導(dǎo)提高效率動(dòng)脈特點(diǎn)橢圓形laterallateraldiameter2.70±0.40mmupforwarddiameter1.90±0.26mmQhZhou,動(dòng)脈特點(diǎn)橢圓形動(dòng)脈特點(diǎn)Thediameteroftheradialarterywasmeanvalueof2.2±0.4mmcorrelationwithbodysurfacearea(BSA)（Pearsoncorrelation0.292,P\0.001）UltrasoundevaluationoftheradialarteryforarterialcatheterizationinhealthyanesthetizedpatientsDongchulLee.JiYoungKim.et動(dòng)脈特點(diǎn)Thediameteroftheradial動(dòng)脈特點(diǎn)年齡年齡越小越細(xì)，三歲內(nèi)，動(dòng)脈平均直徑1.0mm（24G穿刺針是0.7mm黃色）老年人動(dòng)脈壁增厚，彈性差(尤其有動(dòng)脈粥樣硬化)性別男性直徑大于女性，長(zhǎng)期從事體力活動(dòng)的更粗大文獻(xiàn)硬化的動(dòng)脈更容易引起血管痙攣SaitoS,etInfluenceoftheratiobetweenradialarteryinnerdiameterandsheathouterdiameteronradialarteryflowaftertransradialcoronaryintervention.CatheterCardiovascInterv1999;46:173–8.動(dòng)脈特點(diǎn)年齡年齡越小越細(xì)，三歲內(nèi)，動(dòng)脈平均直徑1.0mm（血壓正常血壓情況下，動(dòng)脈充盈、飽滿容易觸及或顯影血壓低于80mmHg，動(dòng)脈會(huì)變扁平，觸摸法相對(duì)困難，遠(yuǎn)端加壓起到一個(gè)局部相對(duì)充盈的橈動(dòng)脈升壓藥？

休克狀態(tài)

相對(duì)血管擴(kuò)張血壓正常血壓情況下，動(dòng)脈充盈、飽滿容易觸及或顯影最佳手腕位置最佳的手腕位置：45°。Forty-fivedegreewristangulationisoptimalforultrasoundguidedlongaxisradialarterycannulationinpatientsover60yearsold:arandomizedstudy.AhmetKucuk.et.JClinMonitComput(2014)28:567–572最佳手腕位置最佳的手腕位置：45°。穿刺置管時(shí)間(24±17svs.2010;28:343–7.性別男性直徑大于女性，長(zhǎng)期從事體力活動(dòng)的更粗大duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.532.FirstattemptFirstattemptHeight(mm)3.Ultrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?upforwarddiameter1.Height(mm)3.2010;17:1138–41.太淺無法起到引導(dǎo)的作用2010;17:1138–41.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilTokerUltrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?適應(yīng)各種類型的病人小兒、肥胖等532.duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.橈動(dòng)脈垂直直徑FirstattemptFirstattemptsuccessful(n=75)failed(n=25)pHeight(mm)3.02±0.532.49±3.48<0.001Skindistance(mm)2.63±0.642.58±0.590.71AhmetJClinMonitComput(2014)28:567–572穿刺置管時(shí)間(24±17svs.橈動(dòng)脈垂直直徑皮膚至動(dòng)脈淺壁的深度太淺無法起到引導(dǎo)的作用T皮膚至動(dòng)脈淺壁的深度T皮膚至動(dòng)脈淺壁的深度太深穿刺針血管外路徑太長(zhǎng)，縮短穿刺針管外距離會(huì)增加針和血管的角度T皮膚至動(dòng)脈淺壁的深度太深穿刺針血管外路徑太長(zhǎng)，縮短穿刺針管外

皮膚與動(dòng)脈淺層壁ANovelMethodforUltrasoundGuidedRadialArterialCatheterizationinPediatricPatientsYoshinobuNakayama,MD,et.SocietyforPediatricAnesthesia.May2014；118，Number5

皮膚與動(dòng)脈淺層壁35穿刺最佳深度穿刺最佳深度平面內(nèi)外對(duì)照穿刺置管時(shí)間(24±17svs.47±34srespectively,p<0.05一次成功率76%vs51%后壁破壞20%vs56%Ultrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/outofplaneapproaches?DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilTokerPublishedonline:16February2013SpringerScience+BusinessMediaNewYork2013平面內(nèi)外對(duì)照穿刺置管時(shí)間(24±17svs.47長(zhǎng)軸平面內(nèi)長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥更少。duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.StoneMB,MoonC,SutijonoD,BlaivasM.NeedletipvisualizationAmJEmergMed.2010;28:343–7.長(zhǎng)軸平面內(nèi)長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖Thediameteroftheradialarterywasmeanvalueof2.47±34srespectively,p<0.可以看到血管、穿刺進(jìn)針全程，針尖、鞘管位置YoshinobuNakayama,MD,et.長(zhǎng)軸平面內(nèi)技術(shù)對(duì)針尖看的更清楚，穿刺更準(zhǔn)確，并發(fā)癥更少。失敗率47±34srespectively,p<0.SocietyforPediatricAnesthesia.FirstattemptFirstattemptHeight(mm)3.DongchulLee.一次成功率提高532.2010;17:1138–41.Incidenceofposteriorvesselwallpunctureduringultrasoundguidedvesselcannulationinasimulatedmodel.Publishedonline:16February2013SpringerScience+BusinessMediaNewYork201348<0.JiYoungKim.DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilToker長(zhǎng)軸平面內(nèi)優(yōu)點(diǎn)可以看到血管、穿刺進(jìn)針全程，針尖、鞘管位置需要一段長(zhǎng)而直的動(dòng)脈缺點(diǎn)尋找定位時(shí)間長(zhǎng)容易被探頭的和皮膚角度影響AA探頭探頭只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖長(zhǎng)軸平面內(nèi)優(yōu)39長(zhǎng)軸平面內(nèi)AT長(zhǎng)軸平面內(nèi)AT40短軸平面外超聲尋找定位時(shí)間短可以看清楚動(dòng)脈和周圍組織的相互比鄰關(guān)系，穿刺針正對(duì)著動(dòng)脈正中（沿著動(dòng)脈直徑穿刺）只能看見一個(gè)切面，穿刺過程可能看見的并不是針尖需要一定的經(jīng)驗(yàn)A探頭短軸平面外超聲尋找定位時(shí)間短A探頭41平面內(nèi)外對(duì)照平面內(nèi)外對(duì)照不同穿刺針對(duì)照

型號(hào)直徑*長(zhǎng)度針尖與套管尖距離18G綠1.3*453mm20G紅1.1*322mm22G藍(lán)0.9*251.5mm24G黃0.7*21.2mm不同穿刺針對(duì)照型號(hào)直徑*長(zhǎng)度針尖與套操作者的經(jīng)驗(yàn)重要因素操作水平直接與成功率、穿刺次數(shù)相關(guān)操作前要反復(fù)訓(xùn)練、熟悉適應(yīng)各種類型的病人小兒、肥胖等熟悉超聲機(jī)器的各種參數(shù)增益、深度、方向的迅速辨別、超聲的引導(dǎo)能力操作者的經(jīng)驗(yàn)重要因素操作水平直接與成功率、穿刺次數(shù)相關(guān)橈動(dòng)脈后壁破壞后壁破壞率（平面內(nèi)和平面外總體）34%Incidenceofposteriorvesselwallpunctureduringultrasoundguidedvesselcannulationinasimulatedmodel.MoonCH,BleharD,ShearMA,etal.AcadEmergMed.2010;17:1138–41.橈動(dòng)脈后壁破壞后壁破壞率（平面內(nèi)和平面外總體）34%JiYoungKim.AmJEmergMed.正常血壓情況下，動(dòng)脈充盈、飽滿容易觸及或顯影SocietyforPediatricAnesthesia.StoneMB,MoonC,SutijonoD,BlaivasM.2010;17:1138–41.性別男性直徑大于女性，長(zhǎng)期從事體力活動(dòng)的更粗大duringultrasoundguidedvascularaccess:shortaxisvslongaxisapproach.總的穿刺次數(shù)降低休克狀態(tài)Ultrasoundguidedradialarterialcannulation:longaxis/inplaneversusshortaxis/out