紫绀及非紫绀型先天性心脏病患儿罗库溴铵药效学的比较

目的 比较紫绀及非紫绀型先天性心脏病(先心病)患儿罗库溴铵的药效学。方法 第一部分:选择非紫绀、轻度紫绀及重度紫绀型先心病患儿各12例,分别为非紫绀组、轻度紫绀组、重度紫绀组,测定0.6 mg／kg罗库溴铵的起效时间、作用时间及恢复指数。第二部分:40例先心病患儿,选择非紫绀、紫绀型先心病患儿各20例,分别为非紫绀组和紫绀组,每组患儿随机分为120、180、240、300μg／kg四个剂量组,用直线回归法建立罗库溴铵的量效曲线,计算罗库溴铵的ED50、ED90,及ED95。结果 第一部分:重度紫绀组起效时间较非紫绀组明显延长(P<0.05),三组间作用时间及恢复指数无差异。第二部分:紫绀组罗库溴铵的量效关系曲线较非紫绀组右移,紫绀组罗库溴铵ED50、ED90及ED95均较非紫绀组高(P<0.05)。结论 重度紫绀型先心病患儿罗库溴铵的起效时间延长,且对罗库溴铵的敏感性降低。     

超声定位在小儿颈内静脉穿刺置管中的应用

目的探讨超声定位在小儿颈内静脉穿刺置管中的应用效果。方法选择6月~6岁的先天性心脏病择期手术患儿80例,随机均分为两组:超声定位组(D组):使用便携式B超仪在颈部以二维超声图像确定颈内静脉位置进行穿刺;对照组(C组):以传统的颈内动脉搏动的外侧为标志进行穿刺。记录首次穿刺成功率、总穿刺成功率、穿刺次数、穿刺时间和并发症发生率;观察D组超声图像的颈内静脉走向与同侧乳头的关系。结果 D组首次穿刺成功率、总穿刺成功率显著高于C组(P<0.05),穿刺次数和操作时间显著少于C组(P<0.01),误穿颈动脉并发症显著低于C组(P<0.05)。结论超声定位在小儿颈内静脉穿刺置管中的应用,可以显著提高首次穿刺成功率和总穿刺成功率,明显减少穿刺次数和缩短穿刺时间,降低并发症的发生率。     

手术患儿屈膝45°外展位行大隐静脉留置针输液效果探讨

目的提高手术患儿大隐静脉穿刺置管成功率,减轻患儿的痛苦。方法将100例手术患儿随机分对照组和观察组各50例,观察组采用屈膝45°外展位行大隐静脉穿刺置管,对照组采用传统方法穿刺置管。结果观察组一次性静脉穿刺置管成功率显著高于对照组(P0.05)。结论患儿采用屈膝45°外展位行大隐静脉穿刺,可提高一次性静脉刺置管成功率,提高护士工作效率,减轻手术患儿痛苦。     

紫绀与非紫绀型先天性心脏病患者PETCO2与PaCO2的相关性

目的探讨先天性心脏病患者PETCO2与PaCO2测定值的相关性.方法42例全身麻醉下手术患儿分为紫绀组、非紫绀组和对照组.结果三组PETCO2均无显著性差异.非紫绀组与对照组比较,PaCO2、Pa-ETCO2无显著性差异.紫绀组与对照组及非紫绀组比较,PaCO2与PaETCO2显著升高(P<0.01).三组PETCO2与PaCO2的线性相关系数分别为对照组0.96,非紫绀组0.86,紫绀组0.40.相关系数比较,非紫绀组与对照组无显著性差异(P>0.05),而紫绀组显著低于对照组及非紫绀组(P分别<0.01和<0.05).结论非紫绀型先天性心脏病不影响PETCO2测定值,而紫绀型先天性心脏病PETCO2显著低于非紫绀型先天性心脏病,不能准确反映PaCO2.     

操作频度对超声消融子宫肌瘤学习曲线的影响

目的探讨医生操作频度对超声消融子宫肌瘤学习曲线的影响。方法回顾性分析2名已完成超声消融培训的医生(A医生、B医生)分别在各自单位初始独立开展41例(A组)及39例(B组)超声消融治疗的患者资料。采用累积求和法(CUSUM)评估2组的学习曲线。比较2名医生的操作频度是否对学习曲线存在影响。结果 A组手术室时间和手术时间明显长于B组(P0.05);两组患者子宫肌瘤消融率差异无统计学意义(P0.05),平均每月完成操作A医生为2例、B医生为7例。A医生CUSUM曲线在可接受失败率(H0)和不可接受失败率(H1)之间波动,从23例开始出现下降趋势,但未跨过H0。B医生CUSUM曲线呈现连续下降趋势,在13例时曲线跨过H0。结论操作频度是学习曲线的重要评价指标。超声消融治疗子宫肌瘤有着严格、复杂的程序,连续的操作实践是迅速完成学习曲线的必要前提。     

超声引导下颈内静脉置管在婴儿心脏手术中的应用

目的 探讨超声引导下颈内静脉置管术在婴儿心脏手术中的临床应用.方法 选择年龄30d～1岁,体重3.70～12.0 kg行先天性心脏病手术的患儿40例,随机均分为两组.观察组(A组)在超声引导下将颈内静脉置于屏幕中央,用18G BD静脉留置针穿刺血管,置静脉外套管后,放入引导钢丝,然后置入中心静脉导管;对照组(B组)选择右颈内静脉中路或后路,用18G BD静脉留置针穿刺,回血通畅后经静脉外套管置入引导钢丝,最后置入中心静脉导管.记录两组穿刺置管时间、穿刺总成功率、一次穿刺成功率、失败率及并发症.结果 A组穿刺置管时间明显短于B组(P＜0.05).A组穿刺总成功率100%,明显高于B组的80%(P＜0.05);A组一次穿刺成功率90%,显著高于B组的65%(P＜0.01);A组无失败病例,B组失败率20%;A组的穿刺并发症低于B组,但差异无统计学意义.结论 超声引导下婴儿颈内静脉穿刺置管,提高了成功率,能有效降低并发症,并缩短穿刺置管时间,有较高的临床应用价值.     

七氟醚吸入诱导在小儿心脏手术麻醉中的应用

本文总结在大流量氧时吸入高浓度七氟醚在小儿先天性心脏病麻醉诱导中的应用。先天性心脏病患儿30例(紫绀型7例),心功能～级,平均年龄(2.5±1.3)岁,体重(11.6±3.12)kg。不给术前药,面罩吸入氧(5L/min) 8%七氟醚诱导。待疼痛反射消失后,开放静脉,停吸七氟醚,静脉给予阿托品、芬太尼、潘龙,2分钟后气管内插管。记录睫毛反射、疼痛反射消失时间、入室时、睫毛反射消失时、静脉给药前和气管插管后BP、HP、SpO2。观察诱导中患儿合作情况,有无呛咳、呕吐、呼吸抑制、喉痉挛、分泌物增多、躁动及心律失常。随机抽取7例非紫绀型小儿作为非紫绀组…     

先天性心脏病儿童铁缺乏症的高危因素研究

目的研究铁缺乏症(ID)在先天性心脏病(CHD)儿童中的患病情况,寻找在CHD儿童中合并ID的高危因素。方法回顾性分析2016年2~6月于我科住院诊治的227例CHD患儿,根据铁代谢(以血清铁蛋白12μg/L为ID的诊断标准)的结果,分析ID的发生率。根据CHD的类型,将这些患儿分为紫绀型和非紫绀型两组,比较患儿的年龄、性别、生长发育状况和血常规等数据。结果 19.8%的CHD儿童合并ID。紫绀型患儿ID发生率高于非紫绀型患儿(31.0%vs.17.3%,P=0.045)。ID患儿均表现出年龄小,贫血比例高,平均红细胞体积(MCV)、平均红细胞血红蛋白含量(MCH)和平均红细胞血红蛋白浓度(MCHC)降低(红细胞体积缩小),以及红细胞体积分布宽度(RDW)增加(红细胞大小不等)的特点。结论紫绀型,低龄,贫血,MCV、MCH、MCHC降低(红细胞体积缩小),RDW增加(红细胞大小不等)是CHD患儿合并ID的高危因素。     

超声引导下桡动脉穿刺中短轴与长轴方法的应用

目的比较超声引导下桡动脉穿刺中短轴与长轴方法的临床效果。方法选择择期手术拟行桡动脉穿刺患者140例,ASAⅠ~Ⅲ级,性别不限,年龄32~78岁,体重54~83kg。按照随机数字表法将患者分为两组:短轴组和长轴组,每组70例,在局部麻醉下行超声引导桡动脉穿刺。记录超声定位时间、首次穿刺成功率、穿刺失败率及并发症发生情况。结果与短轴组比较,长轴组超声定位时间明显延长(P0.01),首次穿刺成功率明显增加(P0.05)。结论与短轴方法相比,长轴方法在超声引导下桡动脉穿刺时超声定位时间延长,但首次穿刺成功率延高。     

紫绀型先天性心脏病心肌侧枝血管形成机制的探讨

目的探讨紫绀型先天性心脏病心肌侧枝血管形成的机制。方法以22例紫绀型先天性心脏病(cyanoticcongenitalheartdisease,C鄄CHD)和24例非紫绀型先天性心脏病(acyanoticcongenitalheartdisease,A鄄CHD)患者为研究对象,取右心耳和血清为标本,采用双抗体夹心ELISA法测定术前、术后24h、术后72h血清VEGF(Vascularendothelialgrowthfactor)水平变化;并采用链霉菌抗生物素蛋白鄄过氧化酶免疫组化染色超敏法行心肌组织VEGF蛋白表达的测定,图像分析方法求出其PU(positiveunit)值。结果(1)术前血清VEGF表达C鄄CHD组明显比A鄄CHD组高(946.30±371.38vs289.00±32.18,P<0.001);(2)在C鄄CHD组,术后1天血清VEGF含量比术前显著降低(607.97±335.18vs946.30±371.38,P<0.001);(3)C鄄CHD组心肌VEGF表达显著高于A鄄CHD组(8.75±3.04vs4.55±2.06,P<0.001)。结论紫绀型先天性心脏病心肌侧枝血管形成可能为VEGF所介导。     

Ultrasound-guided infraclavicular axillary vein cannulation

Background and objectivePercutaneous central venous cannulation is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. We wanted to evaluate an ultrasound-guided technique for the axillary vein cannulation, looking specifically at the ease of use, success rate and decreased complications.MethodsSixty consecutive surgical patients scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding an in plane puncture of axillary vein was used. After locating the vessels, an echo-guided sterile procedure was performed to cannulate the vein.ResultsCannulation was successful in all patients, and there were no complications during insertion of the catheters. Both axillary veins were cannulated, and the vein was punctured successfully at first attempt in 95% of the patients. The median time from the start of the first puncture (of the skin) until the aspiration of blood was 15 (7– 135) seconds.ConclusionThis ultrasound-guided technique for inserting central venous catheters in axillary vein was easy to apply. This procedure could increase precision and safety in patients undergoing axillary vein cannulation.     

Transillumination by light‐emitting diode facilitates peripheral venous cannulations in infants and small children

Background: Transillumination facilitates the visualization of peripheral veins in infants and children. The clinical usefulness of light‐emitting diode (LED)‐powered devices has not been thoroughly studied. Methods: We randomly assigned 136 infants and children weighing <15 kg, undergoing general anesthesia, to red LED‐powered transillumination (TM group, n=67) vs. the usual method (UM group, n=69) of peripheral venous cannulations. Venous puncture was performed following anesthesia induction with sevoflurane and nitrous oxide. The primary and secondary study endpoints were the rate of successful cannulations at initial attempt, and the duration of insertion attempts, respectively. Results: The median score of the estimated cannulation difficulty before attempted puncture was similar in both groups. The success rates at first attempt were 75% and 61% (NS) and mean±SD times to successful venous access were 47±34 and 68±66 s (NS) in the TM and UM groups, respectively. The cannulation procedures were completed significantly earlier in the TM group than in the UM group (hazard ratio, 1.59; 95% confidence interval, 1.03–2.47; P=0.03). In the subgroup of infants and children <2 years old, venous cannulation was successful at first attempt in 73% and 49% in the TM group (n=44) and in the UM group (n=47), respectively (P=0.03). Conclusions: LED‐powered transillumination devices facilitated peripheral venous cannulations in small infants and children.     

老年患者超声引导下锁骨下静脉与腋静脉穿刺的比较

目的比较老年患者超声引导下锁骨下静脉与腋静脉穿刺置管的效果。方法需要放置中心静脉导管的患者99例,男68例,女31例,年龄65岁,随机分为两组:锁骨下静脉穿刺组(SV组,n=49)和腋静脉穿刺组(AV组,n=50)。记录锁骨下静脉和腋静脉超声定位时间、静脉深度、静脉最大内径,计算静脉塌陷率。记录深静脉一次穿刺成功、二次穿刺成功、总穿刺成功例数和穿刺时间。记录误穿动脉、气胸等并发症的发生情况。结果与AV组比较,SV组超声定位时间明显缩短(P0.01),静脉深度、静脉最大内径明显增大(P0.01),呼吸塌陷率明显降低(P0.01),一次穿刺成功率和总穿刺成功率明显升高(P0.05)。两组二次穿刺成功率、穿刺时间差异无统计学意义。两组均无误穿动脉、气胸等并发症。结论老年患者超声引导下锁骨下静脉穿刺较腋静脉穿刺成功率高。     

Ultrasound-guided cannulation versus the landmark-guided technique for acute haemodialysis access

Background. The correct placement of large-bore venous catheters plays an important role in the management of haemodialysis patients. Whilst the procedure for landmark-based placement of these catheters is well known, the technique is not without significant morbidity and mortality. Complications include arterial puncture, haematoma, and pneumothorax. The procedure may be further complicated in these patients by venous thrombosis and abnormal vein position from multiple previous attempts at venous access. Methods. Data on the use of ultrasound guidance versus anatomical landmarks for the placement of internal jugular vein (n=69) and femoral vein (n=30) dialysis access was retrospectively analysed over a 13-month period. Data collected included age, sex, duration on dialysis, number of vein cannulation sets required, number of attempts for successful cannulation, salvage of failed cannulation using landmark-based technique by ultrasound guidance, and the complication rate. Results. Internal jugular vein cannulation using ultrasound was ultimately successful in 96.67% compared to 82% in the landmark group. The vein was entered on the first attempt in 83.3% of patients with ultrasound compared to 35.9% of the landmark group (P<0.0001). Seven patients in whom the landmark technique was unsuccessful had access placed under ultrasound guidance. There were fewer carotid artery punctures in the ultrasound group (7.7 versus 0%, P=n.s.). In the femoral vein group, the vein was entered on the first attempt in 85.7% of patients with ultrasound compared to 56.25% of the landmark group. (P=n.s.). Conclusions. The use of ultrasound guidance is associated with fewer complications and is more likely to lead to cannulation of the vein at the first attempt in haemodialysis patients.     

Real‐time ultrasound‐guided axillary vein cannulation in children: a randomised controlled trial

The axillary vein is a good site for ultrasound‐guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real‐time ultrasound‐guided axillary vein cannulation with conventional infraclavicular landmark‐guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound‐guided axillary vein (axillary group) or landmark‐guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first‐attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25–6.48, p = 0.010). The first‐attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real‐time ultrasound‐guided in‐plane technique is useful and effective in paediatric patients.     

Ultrasound-guided central venous cannulation in infants and children

BACKGROUND: Percutaneous central venous cannulation in infants and children is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. An ultrasound-guided technique is now available and we wanted to evaluate this method in children and infants, looking specifically at the ease of use, success rate and complications. METHODS: Forty-two consecutive infants and children (median 16.5 [0-177] months and 10 [3-45] kg) scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding puncture of vessels was used. After locating the puncture site, a sterile procedure was performed using an accompanying kit to aid puncture of the vessel. RESULTS: Cannulation was successful in all patients and we had no complications during insertion of the catheters. The right internal jugular vein was preferred in most patients, and in 95% of the patients the vein was punctured at the first attempt. The median time from start of puncture to aspiration of blood was 12 (3-180) seconds. CONCLUSION: The ultrasound-guided technique for placement of central venous catheters was easy to apply in infants and children. It is our impression that it increased the precision and safety of the procedure in this group of patients.     

Saphenous Vein Cannulation in Re‐Redo Cardiac Surgery

Abstract The widely used peripheral vein site of cannulation (i.e., the femoral vein) cannot always be employed in the setting of re‐redo procedures. We propose a safe and simple surgical technique for a femoral vein cannulation using the greater saphenous vein as the inflow tract for the venous drainage in the setting of redo cardiac surgery. (J Card Surg 2012;27:676‐677)     

Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Prospective randomized comparison with landmark-guided puncture in ventilated patients

OBJECTIVE: To investigate whether prepuncture ultrasound evaluation of vascular anatomy facilitates internal jugular vein cannulation compared with landmark-guided puncture. DESIGN: Prospective randomized study. SETTING: Single community hospital. PARTICIPANTS: Adult patients undergoing general anesthesia (n = 240). INTERVENTIONS: The right internal jugular vein was cannulated using either anatomic landmarks or prepuncture ultrasound (3.75/7.5 MHz) guidance. In the landmark group, respiratory jugular venodilation was used as the primary landmark for locating the vein. Results of cannulation and the incidence of complications were compared. MEASUREMENTS AND MAIN RESULTS: Patients were randomly assigned to the ultrasound or landmark group. Respiratory jugular venodilation was identified in 188 patients (78.3%), in whom results of cannulation did not differ between the 2 techniques with respect to the venous access rate (cannulated at the first attempt: 83.5% in the landmark v 85.7% in the ultrasound group), the success rate (cannulated within 3 attempts: 96.9% v 95.6%), and the incidence of arterial puncture (1.0% v 3.3%). In the remaining 52 respiratory jugular venodilation-unidentified patients, the access rate (30.4% v 86.2%, p < 0.001) and the success rate (78.3 v 100%, p < 0.05) were significantly better in the ultrasound group, and no arterial puncture was recorded in the ultrasound group, whereas the incidence was 13.0% in the landmark group. The results were similar regardless of the ultrasound frequency used. CONCLUSION: Prepuncture ultrasound evaluation did not improve the result of right internal jugular vein cannulation compared with the respiratory jugular venodilation-guided approach. When the landmark was not observed, however, the prepuncture ultrasound guidance was helpful in facilitating the cannulation.     

Physiologic dead space, venous admixture, and the arterial to end-tidal carbon dioxide difference in infants and children undergoing cardiac surgery

End-tidal CO2 (PETCO2), arterial CO2 (PaCO2), mixed expired CO2 (PECO2), arterial and mixed venous oxygen contents were measured and the PaCO2 to PETCO2 difference (delta PCO2), physiologic dead space to tidal volume ratios (VD/VT) and venous admixture (Qs/Qt) were calculated in 41 anesthetized infants and children undergoing repair of congenital cardiac lesions. Eighteen children were acyanotic; 9 with normal pulmonary blood flow (PBF) and normal intracardiac anatomy (normal group); and 9 with increased PBF (acyanotic group). Twenty-three children were cyanotic; 14 with right to left intracardiac shunts and decreased PBF (cyanotic (D) group); and 9 with mixing lesions with normal or increased PBF (cyanotic (I) group). Correlations between PaCO2 and PETCO2 in the four groups of children were carried out and the relationship of delta PCO2 to VD/VT and Qs/Qt was determined. PETCO2 correlated closely with the PaCO2 in the normal and acyanotic groups (r2 = 0.97 and 0.91, respectively) and the lines of regression for the relationship between PaCO2 and PETCO2 for both groups did not differ from the line of identity (P less than or equal to 0.05). Mean +/- SD VD/VT for the normal and acyanotic groups were 0.35 +/- 0.17 and 0.39 +/- 0.19, respectively (NS). Corresponding values for the cyanotic (D) group and cyanotic (I) group were 0.38 +/- 0.16 and 0.55 +/- 0.16, respectively (NS), and were significantly greater than those from the normal and acyanotic groups (P less than 0.05). The relationship of delta PCO2 to VD/VT and Qs/Qt demonstrated that VD/VT was the most important determinant of delta PCO2, but in instances where Qs/Qt were large (e.g., cyanotic congenital heart disease) the percentage contribution of Qs/Qt to the delta PCO2 can be considerable.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dynamic ultrasound‐guided short‐axis needle tip navigation technique vs. landmark technique for difficult saphenous vein access in children: a randomised study

Dynamic ultrasound‐guided short‐axis needle tip navigation is a novel technique for vascular access. After venipuncture, the needle and catheter are further advanced within the vessel lumen under real‐time ultrasound guidance with constant visualisation of the needle tip in the short‐axis view. This can minimise the risk of transfixing the cannulated vessel. We compared two techniques for non‐visible saphenous vein cannulation under general anaesthesia in children weighing ≥ 3 kg and less than four years of age: dynamic ultrasound‐guided short‐axis needle tip navigation technique (ultrasound group) vs. landmark technique. Venous cannulation was performed by three experienced anaesthetists. The primary outcome measure was first‐attempt success rate. Success rate within 10 min was a secondary outcome. A total of 102 patients were randomly allocated to either the ultrasound group or the landmark group. First‐attempt success rate was 90% in the ultrasound group compared with 51% in the landmark group, p<0.001, difference 39%, 95% confidence interval (CI) of the difference 23–55%. Success rate within 10 min was 92% in the ultrasound group compared with 63% in the landmark group, p = 0.001, difference 29%, 95%CI of the difference 14–45%. We conclude that, when performed by experienced anaesthetists, the dynamic ultrasound‐guided short‐axis needle tip navigation technique improved non‐visible saphenous vein cannulation in children compared with the landmark technique.