| ObjectiveTo describe the shape of axillary-subclavian vein, anatomical position, Identify the relationship between subclavian vein and surrounding tissues via ultrasound. Discuss the selection for insertion site of right axillary-subclavian vein catheterization and placement of probe as well as evaluate the ultrasound-guided technique for the cannulation of axillary-subclavian vein.MethodsPart one:Two hundred and eight patients which included one hundred and twenty male patients and eighty eight female patients were scheduled for selective operations, aged19to86years old, ASA Ⅰ-Ⅲ, with the body mass index between18to29kg·m-2. We use a portable ultrasound systems with a linear6to13MHz transducer. The clavicle sternal end was marked point A, the clavicle acromial end as point B. Show the best short axis of vein in foreign two-third of clavicular line translated from the distal to proximal axillary vein. Ultrasonic measurement vein’s diameter, depth, visualization rate of pleura,distance between the two vessels and distance between subclavian-axillary vein and pleura in foreign two-third of clavicular line, midclavicular line and junction of the subclavian vein and clavicle and mark the vein on body surface, connection of the markers is basic shape of vein. Mark the junction of the subclavian vein and clavicle as point C. Find out the best long axis of vein in above three positions and measure the included angle between coronal plane of ultrasound probe and human and Horizontal included angle of subclavian vein and the lower border of the clavicle, describe the relationship of distance from point C to the clavicle sternum end and clavicle length (AB).Part two:A total of one hundred and five patients which included sixty four male patients and forty one female patients who intended to receive central venous catherization puncture, aged19to85years old, ASA Ⅰ-Ⅲ, with the body mass index between19to 28kg·m2, were randomly divided into three groups:blind puncture of body-surface localization(Group AL); oriented with ultrasound-assistance,then took puncture(Group AU); real-time ultrasound-guided puncture(Group US). The number of puncture, puncture time, failure ratio and the first achievement ratio, the included angle between catheter and the long axis of vein.complications within24h postprocedure were recorded. Review catheter position with ultrasound and observe whether strayed into the internal jugular vein. Measure the distance between the insertion point of the Group US and the traditional infraclavicular access.ResultPart one:Vein’s diameter in foreign two-third of clavicular line was smaller, depth was deeper than junction of the subclavian vein and clavicle (P<0.05). This difference between junction of the subclavian vein and clavicle and midclavicular line was not observed(P>0.05). In junction of the subclavian vein and clavicle artery and subclavian vein is almost overlapping, There was no significant difference in distance between the two vessels in midclavicular line and foreign two-third of clavicular line (P>0.05).In junction of the subclavian vein and clavicle vein is close to pleural. Pleural is not visible in ultrasonic image in foreign two-third of clavicular line.In different body mass index, There was no significant difference in vein’s diameter, distance between the two vessels. Vein’s depth in BMI≥28kg·m-2was deeper than BMI≤20kg·m-2(P<0.05). All above Measurement index were not statistically different between the sexes (P>0.05). Compared with junction of the subclavian vein and clavicle, significant difference was detected in the included angle between coronal plane of ultrasound probe in the midclavicular line and foreign two-third of clavicular line(P<0.05). Ratio of distance between point C and the sternoclavicular joint and length of the clavicle for male was0.37±0.03, female was0.35±0.02. Horizontal included angle of subclavian vein and the lower border of the clavicle for male was37±3°, for female was36±3°.Part two:No significant difference in the demographic characteristics such as age, the height, the weight, the body mass index was observed among three groups (P>0.05). Puncture time in three groups was statistically different(P<0.05).In Group AL, Group AU and Group US, the average number of puncture respectively were1.28,1.17,1.03; the first achievement ratio were77.14%,91.42%,97.14%; failure ratio were8.57%,2.86%,0%; cases for early complication were3,2,1; the included angle between the needle and skin were28±4°,30±6°,31±5°. Intravascular placement of cather in Group AL, Group AU was mostly concentrated in the subclavian vein, the Group US was mainly located in the axillary vein. In Group US94%of the insert site point falls into the circle which was granted for characteristics of the point2cm below the clavicle midpoint as a center and1cm as radius.ConclusionPart one:Subclavian-axillary vein in the medial clavicle midpoint is superficial, but close to the pleura and arterial. Depth of vein in the lateral clavicle midpoint is deep, not conducive to ultrasonic image and operations. Therefore, Determination in this study mock puncture point should be close to clavicular midpoint is appropriate.Part two:(1) By comparisons of three methodCannulation time was significantly shortest and the successful rate by real-time ultrasound-guidance. ultrasound-assisted orientiaton puncture gained a higher success rate and less time than traditional method.(2) Vascular puncture point is mostly located in subclavian vein by the traditional puncture and ultrasound-assistance puncture, mainly in axillary vein with real-time ultrasound guidance;(3) Although complications are reduced with real-time ultrasound guidance, there was no statistical difference in three groups.To comfirm these findings,we may need a bigger sample size. |
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