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首页> 外文期刊>The Internet Journal of Medical Simulation >A Needle Guide Device is Better than a Free Hand Technique for Ultrasound Guided Cannulation of the Internal Jugular Vein: Results from a Simulation Study
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A Needle Guide Device is Better than a Free Hand Technique for Ultrasound Guided Cannulation of the Internal Jugular Vein: Results from a Simulation Study

机译：超声引导下颈内静脉插管的针头引导装置优于徒手技术：模拟研究的结果

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Background: Ultrasound is becoming the standard of care for the placement of central venous lines. Several studies have shown a reduction of needle passes and improved success rates when ultrasound is used over traditional blind techniques. There are no studies to date comparing the use of a needle guide to a freehand technique with ultrasound.Methods: Practitioners ranging from medical students to attending anesthesiologists were randomized to either a needle guide (NG) or freehand (FH) group. Each subject was asked to insert an 18-gauge needle into the internal jugular vein of a patient simulator. Outcomes were time to completion, number of needle attempts, and major complications defined as either cannulation of the carotid or inserting the needle far enough to potentially cause a pneumothorax. Odds ratios (OR) were estimated using unadjusted chi-squared tests and adjustment for patient covariates were performed using logistic regression.Results: 61 practitioners were randomized. Only 16% of subjects in the NG group needed more than one attempt compared with 83% in the FH group (OR 0.04, 95% CI 0.0 to 0.15, p<.001); Similarly, 6.5% of subjects in the FH group took longer than 30 seconds compared with 27.6% for the NG group (OR 0.18, 95% CI 0.0 to 0.85, p<.001). There were four complications in the FH group and none in the NH group (OR 0.0, 95% CI 0.0 to 0.83, p=0.03). Previous experience, based on a lifetime estimate of the number of central lines inserted with and without ultrasound, was not associated with either a reduction in the number of attempts or in the time to successfully cannulate the internal jugular vein.Conclusion: In this simulation, the use of a needle guide improves the placement of central venous catheters by reducing time to successful cannulation, by reducing the number of attempts, and by reducing the number of complications. This advantage is not modified by prior experience. Introduction The placement of central venous catheters is a common anesthesia practice with an estimated 5 million central lines being placed per a year (1). The placement of a central venous catheter represents an opportunity for significant iatrogenic injury, including pneumothorax and carotid puncture (2). The use of ultrasound to facilitate the performance of central venous access has been suggested to represent a potential standard of care (2,3,4). Several studies have shown the benefit of ultrasound when used in placing central lines, mainly in the reduction of needle passes and the reduction of complications when compared to traditional “blind” anatomical techniques (3,4,5,6). These benefits have been demonstrated in several studies to be further amplified in novice practitioners when compared with experts (1,4,5) and have lead to the recommendation by several national committees that ultrasound should be used for all central venous access procedures whenever available (2,4). However, the best practice model for the use of ultrasound has yet to be determined. A common technique for central line placement entails the real-time use of ultrasound in which the needle is guided toward and visualized entering into the short axis image of the IJ. In regional anesthesia techniques and central venous access, two approaches have emerged regarding the orientation of the needle with respect to the ultrasound beam.) The in-plane approach generates a long-axis view of the needle, allowing full visualization of the shaft and tip of the needle. The out-of-plane view generates a short axis view of the needle. With the out-of-plane view, the operator can not confirm that the needle tip is being imaged (rather than part of the shaft), and, therefore, the needle location is often inferred from tissue movement. The in-plane approach tends to be favored for single injections (such as nerve blocks), with the out-of-plane technique facilitating catheter placement.When using the real-time out-of-plane view, the operator must decide between the use
机译：背景：超声正成为中心静脉线放置的护理标准。多项研究表明，与传统的盲目技术相比，使用超声波可减少针通过次数并提高成功率。迄今为止，尚无研究将针头引导器与徒手技术与超声相比较。方法：从医学生到主治麻醉师的医师被随机分为针头引导（NG）或徒手（FH）组。要求每个受试者将18号针头插入患者模拟器的颈内静脉。结果是完成时间，尝试穿刺针的次数以及主要并发症，这些并发症定义为颈动脉插管或插入针头的距离足以引起气胸。使用未调整的卡方检验估计赔率（OR），并使用logistic回归进行患者协变量调整。结果：61名从业者被随机分配。 NG组中只有16％的受试者需要一次以上的尝试，而FH组中只有83％（OR 0.04，95％CI 0.0至0.15，p <.001）;同样，FH组中有6.5％的受试者花费了超过30秒的时间，而NG组中为27.6％（OR 0.18，95％CI 0.0至0.85，p <.001）。 FH组有4种并发症，而NH组则没有（OR 0.0，95％CI 0.0至0.83，p = 0.03）。基于对使用和不使用超声的情况下插入的中心线的寿命进行估算的先前经验，与成功插管颈内静脉的尝试次数或时间减少均无关。结论：在此模拟中，针引导器的使用通过减少成功插管的时间，减少尝试次数和减少并发症的次数，改善了中心静脉导管的放置。先前的经验并不能改变这一优势。简介中心静脉导管的放置是一种常见的麻醉方法，估计每年放置500万条中心线（1）。中央静脉导管的放置代表了严重的医源性伤害的机会，包括气胸和颈动脉穿刺（2）。有人建议使用超声来促进中心静脉通路的表现，这代表了一种潜在的护理标准（2、3、4）。几项研究表明，与传统的“盲”解剖技术相比，使用超声波放置中心线的好处主要在于减少了穿刺针的次数和并发症的减少（3、4、5、6）。与专家相比（1,4,5），这些益处已在多项研究中得到证明，可以在新手执业者中进一步放大（1,4,5），并导致一些国家委员会建议，只要有可能，就应在所有中央静脉通路中使用超声检查（ 2,4）。但是，尚未确定使用超声波的最佳实践模型。用于中心线放置的常见技术需要实时使用超声，在超声中，将针引导向并可视化进入IJ的短轴图像。在区域麻醉技术和中心静脉通路中，出现了两种关于针头相对于超声波束的方向的方法。）平面内方法可生成针头的长轴视图，从而可以完全观察到轴和尖端的针。平面外视图生成针的短轴视图。在平面外视图下，操作员无法确认正在对针尖进行成像（而不是轴的一部分），因此，通常可以从组织运动中推断出针的位置。平面内方法通常倾向于单次注射（例如神经阻滞），而平面外技术可方便放置导管。使用实时平面外视图时，操作员必须在使用

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