Mbiri ya chapakati venous mwayi
1. 1929: Dokotala wa opaleshoni Wachijeremani Werner Forssmann anaika katheta ya mkodzo kuchokera kumanzere kwa mtsempha wa m’kati mwa cubital wakumanzere, ndipo anatsimikizira ndi X-ray kuti catheteryo inalowa mu atrium yoyenera.
2. 1950: Ma catheter apakati amapangidwa mochuluka ngati njira yatsopano yofikira pakati.
3. 1952: Aubaniac akufuna kuphulika kwa mitsempha ya subclavia, Wilson pambuyo pake anapempha CVC catheterization yochokera ku subclavia vein.
4. 1953: Sven-Ivar Seldinger anaganiza zosintha singano yolimbayo ndi catheter yachitsulo yowongolera waya kuti pakhale zotumphukira, ndipo njira ya Seldinger idakhala ukadaulo wosinthira pakuyika kwapakati kwa venous catheter.
5. 1956: Forssmann, Cournand, Richards anapambana Mphotho ya Nobel mu Mankhwala chifukwa cha chithandizo chawo ku catheterization ya mtima.
6. 1968: Lipoti loyamba mu Chingerezi la mwayi wamkati wamkati wa venous wapakati pakuwunika kuthamanga kwa venous.
7. 1970: Lingaliro la catheter ya ngalande idaperekedwa koyamba
8. 1978: Venous Doppler locator wa mkati mwa jugular mtsempha wa thupi pamwamba chizindikiro
9. 1982: Kugwiritsiridwa ntchito kwa ultrasound kuti atsogolere mwayi wapakati wa venous kunanenedwa koyamba ndi Peters et al.
10. 1987: Wernecke et al poyamba adanena za kugwiritsa ntchito ultrasound kuti azindikire pneumothorax
11. 2001: The Bureau of Health Research and Quality Evidence Reporting imatchula malo apakati a venous access point-of-care ultrasound ngati imodzi mwazochita 11 zoyenera kukwezedwa kwambiri.
12. 2008: American College of Emergency Physicians imatchula mwayi wotsogozedwa ndi ultrasound wapakati ngati "core or primary emergency ultrasound application"
13.2017: Amir et al akuwonetsa kuti ultrasound ingagwiritsidwe ntchito kutsimikizira malo a CVC ndikupatula pneumothorax kuti asunge nthawi ndikuwonetsetsa kulondola.
Tanthauzo la mwayi wapakati wa venous
1. CVC nthawi zambiri imatanthawuza kulowetsa katheta mkati mwa mtsempha wapakati kudzera mu mtsempha wamkati wamkati, mtsempha wa subclavia ndi mtsempha wa chikazi, kawirikawiri nsonga ya catheter imakhala mu vena cava yapamwamba, pansi pa vena cava, caval-atrial junction, kumanzere kwa atrium kapena brachiocephalic mtsempha, womwe ndi wapamwamba kwambiri wa vena cava.Mpweya wa venous kapena cavity-atrial umayamikiridwa
2. Katheta wapakati wa venous ndi PICC
3. Kulowa kwa venous kwapakati kumagwiritsidwa ntchito kwambiri:
a) Jekeseni wokhazikika wa vasopressin, inositol, ndi zina.
b) Ma catheters obowola akulu othira madzi otsitsimutsa ndi zinthu zamagazi
c) Catheter yayikulu yochizira aimpso kapena kusinthana kwa plasma
d) Kasamalidwe ka kadyedwe ka makolo
e) Chithandizo cha nthawi yayitali cha maantibayotiki kapena chemotherapy
f) Kuziziritsa katheta
g) Ma sheath kapena ma catheter a mizere ina, monga ma catheters a pulmonary artery, mawaya oyenda ndi njira zama endovascular kapena njira zolowera mtima, ndi zina zambiri.
Mfundo zoyambira pakuyika kwa CVC motsogozedwa ndi ultrasound
1. Malingaliro a CVC cannulation yachikhalidwe kutengera zizindikiro za anatomical: kuyembekezeredwa kwa mitsempha yamagazi ndi patency ya mitsempha.
2. Mfundo za Ultrasound Guide
a) Kusintha kwa anatomical: malo a mitsempha, zolembera za thupi pawokha;ultrasound imalola kuwona zenizeni zenizeni ndikuwunika zotengera ndi ma anatomy oyandikana nawo
b) Vascular patency: Preoperative ultrasonography imatha kuzindikira thrombosis ndi stenosis pakapita nthawi (makamaka mwa odwala omwe ali ndi vuto lalikulu la thrombosis yakuya)
c) Chitsimikizo cha kuyika kwa mtsempha ndi catheter nsonga: kuyang'ana nthawi yeniyeni yolowera mumtsempha, brachiocephalic vein, inferior vena cava, atrium yakumanja kapena superior vena cava.
d) Kuchepetsa zovuta: thrombosis, tamponade ya mtima, kubaya kwa mitsempha, hemothorax, pneumothorax
Kusankha kwa Probe ndi Zida
1. Zida zida: Chithunzi cha 2D ndicho maziko, mtundu wa Doppler ndi pulsed Doppler umatha kusiyanitsa pakati pa mitsempha ndi mitsempha, kasamalidwe ka mbiri yachipatala monga gawo la zolemba zachipatala za odwala, chivundikiro cha kafukufuku wosabala / kupopera kumatsimikizira kudzipatula kosabala.
2. Kusankha kafukufuku:
a) Kulowa: Mitsempha yamkati yamkati ndi yachikazi nthawi zambiri imakhala 1-4 cm pansi pa khungu, ndipo mtsempha wa subclavia umafunika 4-7 cm.
b) kusamvana koyenera ndi kuyang'ana kosinthika
c) Kufufuza kwakung'ono: 2 ~ 4cm mulifupi, kosavuta kuwona nkhwangwa zazitali komanso zazifupi zamitsempha, zosavuta kuyika kafukufuku ndi singano
d) 7 ~ 12MHz gulu laling'ono laling'ono limagwiritsidwa ntchito;yaing'ono otukukira pansi pansi pa clavicle, ana hockey ndodo kafukufuku
Njira yafupikitsa ndi njira yotalikirapo
Ubale pakati pa probe ndi singano umatsimikizira ngati ili mu ndege kapena kunja kwa ndege
1. Nsonga ya singano siingakhoze kuwonedwa panthawi ya opaleshoni, ndipo malo a nsonga ya singano ayenera kutsimikiziridwa ndi kusuntha kwa kafukufuku;ubwino: kuphunzira pang'ono pamapindikira, kuyang'ana bwino kwa perivascular minofu, ndi kuyika kosavuta kwa kafukufuku wa anthu onenepa ndi khosi lalifupi;
2. Thupi lathunthu la singano ndi nsonga ya singano zitha kuwoneka panthawi ya opaleshoni;ndizovuta kusunga mitsempha ya magazi ndi singano mu ndege ya ultrasound imaging nthawi zonse
static ndi mphamvu
1. Njira yosasunthika, ultrasound imangogwiritsidwa ntchito poyesa kuyesa ndikusankha mfundo zoyika singano
2. Njira yamphamvu: nthawi yeniyeni yotsogozedwa ndi ultrasound
3. Njira yolembera pamwamba pa thupi < static method < dynamic njira
Kubowola kwa CVC motsogozedwa ndi Ultrasound ndi catheterization
1. Kukonzekera kusanachitike opaleshoni
a) Kulembetsa zambiri za odwala kuti azisunga ma chart
b) Jambulani malowo kuti akhomedwe kuti atsimikizire zamoyo wamagazi ndi patency, ndikuzindikira dongosolo la opaleshoni.
c) Sinthani kupindula kwa chithunzi, kuya, ndi zina zambiri kuti mupeze chithunzi chabwino kwambiri
d) Ikani zida za ultrasound kuti muwonetsetse kuti malo okhomerera, kafukufuku, zenera ndi mzere wowonera ndi collinear
2. Maluso opangira opaleshoni
a) Saline yakuthupi imagwiritsidwa ntchito pakhungu m'malo mwa couplant kuti couplant isalowe m'thupi la munthu.
b) Dzanja losakhala lamphamvu limagwira kafukufuku mopepuka ndikutsamira pang'onopang'ono kwa wodwalayo kuti akhazikike.
c) Yang'anani maso anu pazenera la ultrasound, ndipo mumve kupsinjika komwe kumatumizidwa ndi singano ndi manja anu (kudzimva kulephera)
d) Kufotokozera waya wolondolera: Wolemba amalimbikitsa kuti waya wolondolera osachepera 5 cm aikidwe mu chotengera chapakati cha venous (ie, waya wolondolerayo ukhale wosachepera 15 cm kuchokera pampando wa singano);Ayenera kulowa 20 ~ 30cm, koma waya wowongolera amalowa mozama kwambiri, ndizosavuta kuyambitsa arrhythmia.
e) Kutsimikizira malo a waya wolondolera: Jambulani motsatira nsonga yaifupi ndiyeno tsinde lalitali la mtsempha wamagazi kuchokera kumalekezero akutali, ndikutsata pomwe waya wolondolerayo.Mwachitsanzo, mtsempha wamkati wa jugular ukadulidwa, ndikofunikira kutsimikizira kuti waya wowongolera amalowa mumtsempha wa brachiocephalic.
f) Pangani choboola pang'ono ndi scalpel musanatambasule, dilator imadutsa m'mitsempha yonse yomwe ili kutsogolo kwa mtsempha wamagazi, koma pewani kuboola mtsempha wamagazi.
3. Internal Jugular Vein Cannulation Trap
a) Ubale pakati pa mtsempha wa carotid ndi mtsempha wamkati wamkati: Mwachizoloŵezi, mtsempha wamkati wa jugular nthawi zambiri umakhala kunja kwa mtsempha.Pakuwunika kwakanthawi kochepa, chifukwa khosi ndi lozungulira, kupanga sikani m'malo osiyanasiyana kumapanga makona osiyanasiyana, ndipo mitsempha ndi mitsempha imatha kuchitika.Zodabwitsa.
b) Kusankhidwa kwa singano yolowera: kutalika kwa chubu ndi kwakukulu, koma kuli pafupi ndi mapapo, ndipo chiopsezo cha pneumothorax ndi chachikulu;tikulimbikitsidwa kusanthula kuti mutsimikizire kuti chotengera chamagazi chomwe chili pachiwopsezo cha singano ndi 1 ~ 2cm kuchokera pakhungu.
c) Jambulani mtsempha wamkati wamkati pasadakhale, yang'anani momwe mtsempha wamagazi ulili komanso patency, pewani thrombus ndi stenosis pamalo opumira ndikulekanitsa ndi mtsempha wa carotid.
d) Pewani kuphulika kwa mtsempha wa carotid: Musanayambe vasodilation, malo otsekemera ndi malo a waya wotsogolera ayenera kutsimikiziridwa muzowona zazitali komanso zazifupi.Pazifukwa zachitetezo, chithunzi chachitali cha axis cha waya wowongolera chiyenera kuwonedwa mumtsempha wa brachiocephalic.
e) Kutembenuza mutu: Njira yachikhalidwe yokhomerera chizindikiro imalimbikitsa kutembenuza mutu kuwunikira chizindikiro cha minofu ya sternocleidomastoid ndikuwonetsa ndikukonza mtsempha wamkati wamkati, koma kutembenuza mutu madigiri 30 kungapangitse kuti mtsempha wamkati wamkati ndi mtsempha wa carotid ugwirizane mopitilira. 54%, ndipo kutsogozedwa ndi ultrasound sikutheka.Ndikoyenera kutembenuka
4.Subclavian vein catheterization
a) Dziwani kuti ultrasound jambulani subclavia mtsempha ndi penapake zovuta
b) Ubwino: Maonekedwe a mtsempha ndi odalirika, omwe ndi osavuta kupunthwa mu ndege.
c) Maluso: Kufufuza kumayikidwa pambali pa clavicle mu fossa yomwe ili pansi pake, kusonyeza mawonekedwe afupikitsa, ndipo kafukufukuyo amatsika pang'onopang'ono pakati;mwaukadaulo, mtsempha wa axillary wakhomedwa apa;tembenuzirani kafukufukuyu madigiri 90 kuti muwonetse mawonekedwe akutali kwa chotengera chamagazi, kafukufukuyo amapendekeka pang'ono kumutu;kafukufukuyo atakhazikika, singanoyo imakhomeredwa pakati pa mbali ya kafukufukuyo, ndipo singanoyo imayikidwa pansi pa chiwongolero chenicheni cha ultrasound.
d) Posachedwapa, puncture yaying'ono ya microconvex yokhala ndi ma frequency otsika pang'ono yagwiritsidwa ntchito kutsogolera, ndipo kafukufukuyo ndi wocheperako ndipo amatha kuwona mozama.
5. Catheterization ya mtsempha wa chikazi
a) Ubwino: Khalani kutali ndi thirakiti la kupuma ndi zida zowunikira, palibe chiopsezo cha pneumothorax ndi hemothorax
b) Palibe mabuku ambiri okhudza kuwombera motsogozedwa ndi ultrasound.Anthu ena amaganiza kuti ndikodalirika kwambiri kuboola thupi ndi zolembera zodziwikiratu, koma ultrasound ndiyosakwanira.Kuwongolera kwa Ultrasound ndikoyenera kwambiri kusinthasintha kwa FV ndi kumangidwa kwa mtima.
c) Kukhazikika kwa mwendo wa chule kumachepetsa kuphatikizika kwa pamwamba pa FV ndi FA, kumakweza mutu ndikukulitsa miyendo yakunja kuti ikulitse lumen ya venous.
d) Njirayi ndi yofanana ndi yoboola mtsempha wamkati wa jugular
Cardiac ultrasound guide wire positioning
1. TEE cardiac ultrasound ili ndi nsonga yolondola kwambiri, koma imawononga ndipo singagwiritsidwe ntchito mwachizolowezi.
2. Njira yowonjezera kusiyanitsa: gwiritsani ntchito ma microbubbles mu saline yogwedezeka ngati chinthu chosiyanitsa, ndipo lowetsani atrium yoyenera mkati mwa masekondi a 2 pambuyo potulutsa laminar kuchokera ku nsonga ya catheter.
3. Pamafunika chidziwitso chambiri pakuwunika kwamtima kwa ultrasound, koma zitha kutsimikiziridwa munthawi yeniyeni, zokongola
Lung ultrasound scan kuti athetse pneumothorax
1. Ultrasound-guided central venous puncture sikuti imangochepetsa chiwerengero cha pneumothorax, komanso imakhala ndi chidziwitso chapamwamba komanso chodziwika bwino cha pneumothorax (chapamwamba kuposa chifuwa X-ray)
2. Ndibwino kuti muphatikize mu ndondomeko yotsimikizira pambuyo pa opaleshoni, yomwe ingayang'ane mofulumira ndi molondola pa bedi.Ngati ikuphatikizidwa ndi gawo lapitalo la ultrasound ya mtima, ikuyembekezeka kufupikitsa nthawi yodikira kuti catheter igwiritsidwe ntchito.
3. Lung ultrasound: (zakunja zowonjezera, zongotengera zokha)
Chithunzi cha mapapo abwinobwino:
Mzere A: Mzere wa pleural hyperechoic umene umatsetsereka ndi kupuma, kutsatiridwa ndi mizere ingapo yofanana ndi iyo, yofanana, ndi yofupikitsidwa ndi kuya, ndiko kuti, kutsetsereka kwamapapu.
M-ultrasound inasonyeza kuti mzere wa hyperechoic womwe umabwereranso kumbali ya kafukufuku ndi kupuma unali ngati nyanja, ndipo mzere wa pectoral nkhungu unali ngati mchenga, ndiko kuti, chizindikiro cha gombe.
Kwa anthu ena abwinobwino, malo omaliza omwe ali pamwamba pa diaphragm amatha kuzindikira zithunzi zosakwana 3 zonga mtengo wa laser zochokera pamzere wa nkhungu wa pectoral, kufalikira pansi pa chinsalu, ndikubwerezanso kupuma - B line.
Chithunzi cha Pneumothorax:
Mzere wa B umatha, kutsetsereka kwa mapapo kumatha, ndipo chizindikiro cha m'mphepete mwa nyanja chimasinthidwa ndi chizindikiro cha barcode.Kuphatikiza apo, chizindikiro cha m'mapapo chimagwiritsidwa ntchito kudziwa kukula kwa pneumothorax, ndipo mapapu amawonekera pomwe chizindikiro cha m'mphepete mwa nyanja ndi chizindikiro cha barcode chimawonekera.
Maphunziro a CVC otsogozedwa ndi Ultrasound
1. Kusamvana pamiyezo ya maphunziro ndi ziphaso
2. Lingaliro lakuti njira zowonongeka zakhungu zimatayika pophunzira njira za ultrasound zilipo;komabe, pamene njira za ultrasound zikufala kwambiri, kusankha pakati pa chitetezo cha odwala ndi kukonza njira zomwe sizingagwiritsidwe ntchito ziyenera kuganiziridwa.
3. Kuunika kwa luso lachipatala kuyenera kuwerengedwa poyang'anira zochitika zachipatala osati kudalira kuchuluka kwa njira
Pomaliza
Chinsinsi cha CVC yotsogozedwa ndi ultrasound yothandiza komanso yotetezeka ndikuzindikira zovuta ndi zolephera za njirayi kuphatikiza pamaphunziro oyenera.
Nthawi yotumiza: Nov-26-2022
