超聲引導(dǎo)下橈動(dòng)脈穿刺置管課件

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〕

動(dòng)脈特點(diǎn)橢圓形lateral-lateraldiameter：2.70±0.40mmup-forwarddiameter：1.90±0.26mmQhZhou,動(dòng)脈特點(diǎn)Thediameteroftheradialarterywasmeanvalueof2.2±0.4mmcorrelationwithbodysurfacearea(BSA)〔Pearsoncorrelation0.292,P\0.001〕UltrasoundevaluationoftheradialarteryforarterialcatheterizationinhealthyanesthetizedpatientsDongchulLee.JiYoungKim.etJClinMonitComputDOI10.1007/s10877-015-9704-9.SpringerScience+BusinessMediaNewYork2021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.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)張最正確手腕位置最佳的手腕位置：45°。Forty-fivedegreewristangulationisoptimalforultrasoundguidedlongaxisradialarterycannulationinpatientsover60yearsold:arandomizedstudy.AhmetKucuk.et.JClinMonitComput(2014)28:567–572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±0.590.71AhmetKucuk.et.Forty-fivedegreewristangulationisoptimalforultrasoundguidedlongaxisradialarterycannulationinpatientsover60yearsold:arandomizedstudy.JClinMonitComput(2021)28:567–572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)脈淺壁的深度太深：穿刺針血管外路徑太長，縮短穿刺針管外距離會(huì)增加針和血管的角度T

皮膚與動(dòng)脈淺層壁ANovelMethodforUltrasound-GuidedRadialArterialCatheterizationinPediatricPatientsYoshinobuNakayama,MD,et.SocietyforPediatricAnesthesia.May2021；118，Number5穿刺最正確深度平面內(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%Ultrasound-guidedradialarterialcannulation:longaxis/in-planeversusshortaxis/out-of-planeapproaches?DeryaBerk?YavuzGurkan?AlparslanKus?HalimUlugol?MineSolak?KamilTokerPublishedonline:16February2021SpringerScience+BusinessMediaNewYork2021長軸平面內(nèi)長軸平面內(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。duringultrasound-guidedvascularaccess:short-axisvslong-axisapproach.StoneMB,MoonC,SutijonoD,BlaivasM.NeedletipvisualizationAmJEmergMed.2021;28:343–7.長軸平面內(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而直的動(dòng)脈缺點(diǎn)尋找定位時(shí)間長容易被探頭的和皮膚角度影響AA探頭探頭長軸平面內(nèi)AT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)歷A探頭操作水平直接與成功率、穿刺次數(shù)相關(guān)后壁破壞：20%vs56%最佳的手腕位置：45°。2021;17:1138–41.Forty-fivedegreewristangulationisoptimalforultrasoundguidedlongaxisradialarterycannulationinpatientsover60yearsold:arandomizedstudy.一次成功率：76%vs51%1007/s10877-015-9704-9.AhmetKucuk.correlationwithbodysurfacearea(BSA)〔Pearsoncorrelation0.CatheterCardiovascInterv1999;46:173–8.長軸平面內(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。SpringerScience+BusinessMediaNewYork2021JClinMonitComputDOI10.SocietyforPediatricAnesthesia.操作者的經(jīng)歷：重要因素successful(n=75)failed(n=25)p型號(hào)直徑*長度針尖與套管尖距離FirstattemptFirstattempt平面內(nèi)外對(duì)照不同穿刺針對(duì)照

型號(hào)直徑*長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操作者的經(jīng)歷：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、方向的迅速區(qū)分、超聲的引導(dǎo)能力橈動(dòng)脈后壁破壞后壁破壞率〔平面內(nèi)和平面外總體：〕34%Incidenceofposteriorvesselwall