【有奖翻译】经锁骨下中心静脉置管术《新英格兰杂志》-（欢迎认领）

绿茵场

各位朋友：

中心静脉相关血流感染（CVC-BSI）是最常见的医院感染之一，其中被证实有效的预防措施之一就是尽量选择锁骨下静脉部位穿刺，这里提供一篇由新英格兰杂志提供的“经锁骨下中心静脉置管术”文章。

注意到大家平时较忙，同时为了让更多的朋友参与其中，现将文章分成五部分，欢迎认领（可重复认领）。

认领后请于一周内完成。对于完成者视翻译质量和速度予以奖励（经验+金钱：10-20不等）

资料来源：http://www.nejm.org/multimedia/medical-videos

友情提供：会员 蓝鱼o_0

https://bbs.sific.com.cn/viewthread.php?tid=52331&rpid=587981&ordertype=0&page=1#pid587981

绿茵场

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Central Venous Catheterization — Subclavian Vein
经锁骨下中心静脉置管术《新英格兰杂志》
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绿茵场

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Indications

Central venous catheterization provides for the administration of caustic and critical medications as well as allowing sampling of blood and measurement of central venous pressure. Recent evidence and Institute for Healthcare Improvement bundled guidelines1 suggest that the subclavian vein is the preferred choice for placement of a central venous catheter.

Contraindications

General contraindications for placement of a central venous catheter include infection of the area overlying the target vein and thrombosis of the target vein. Specific contraindications to the subclavian approach include fracture of the ipsilateral clavicle or anterior proximal ribs, which can distort the anatomy and make placement difficult. Greater caution should be used when placing a central venous catheter in coagulopathic patients. The location of the artery (beneath the clavicle) makes application of direct pressure nearly impossible in attempts to control bleeding.

中文翻译 见17楼（认领人：绿茵场）

绿茵场

回复 1# 绿茵场

Equipment

Most of the necessary equipment can be found in commercially available kits. These kits typically include skin-preparation solution and a drape, lidocaine, sterile gauze, non-Luer lock syringes, a scalpel, a catheter, a dilator, several needles, and a guidewire. You will also need a sterile gown, sterile gloves, a surgical cap, a mask with a face shield, and drapes to cover the patient’s entire body. Flush solution is also not commonly found in the kits. Determine the catheter length and depth of placement by referring to the patient’s external landmarks. The tip of the catheter should

reach the junction of the superior vena cava and the right atrium. Common catheters used range from 4-French catheters for infants to 7-French catheters for adults; 11.5-French catheters may be used for dialysis. Because the risk of infection increases with an increasing number of lumens, a catheter with the fewest number of lumens required should be used.

绿茵场

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Preparation

Explain the procedure to the patient and obtain written informed consent. Wear a sterile gown and gloves, a mask with face shield, and a surgical cap. Examine the patient to be sure that there are no contraindications. Place the patient in the 15-degree Trendelenburg position, which will engorge the vein. If you place a rolled towel or similar object under the spine to help identify the patient’s external land-marks, be aware that propping the shoulder or turning the head has been shown to decrease the size of the vein on ultrasonography.2 Scrub the area thoroughly with chlorhexidine. Drape the area, covering the patient’s entire body.

     Next, identify anatomic landmarks, beginning with the middle third of the clavicle. Follow this laterally to the point where the clavicle deviates from the proximal ribs (Fig. 1). Just medial to this point, the subclavian vein and artery run just inferior to the clavicle. This is where most successful catheterization occurs. The insertion site should be somewhat remote from the clavicle, so that the path of the needle ultimately stays parallel to and just under the clavicle. Typically, the point of insertion is 2 cm lateral to and 2 cm caudal to the middle third of the clavicle (Fig. 2). Local anesthesia with 1 to 2 ml of 1 percent lidocaine or equiva-lent should be used in this area.

中文翻译 见19楼（认领人：mickeypank）

绿茵场

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Ultrasound Guidance

Several recent articles suggest that ultrasonography can increase the likelihood of successful placement of a subclavian catheter, despite the presence of bony land-marks.3,4 Because of the greater difficulty in identifying the vein by compression, Doppler flow should be used to distinguish between the artery and the vein.

The Procedure

Starting 2 cm lateral to the bend of the clavicle and approximately 2 cm caudal, insert the catheterization needle through the skin at a 30-degree angle toward the sternal notch. Place a finger of your nondominant hand in the sternal notch to help find the landmark. Once the needle is under the skin, lower the needle and syringe to run parallel to but beneath (posterior to) the clavicle (Fig. 3). Access to the vein typically occurs just beneath the clavicle, but it may involve a depth of several centimeters under the skin.

      Once you have obtained venous access, carefully stabilize the needle and re-move the syringe. Introduce the J-tipped end of the guidewire into the needle. The wire should thread easily and without resistance until well beyond the end of the needle. If you notice ectopic cardiac beats on the monitor, pull the wire back until the ectopic beats disappear. Then remove the needle, leaving the wire in place. Maintain control of the wire. A small, 1-to-2-mm incision should be made in the skin at the insertion point to facilitate dilator passage. Advance the dilator over the wire into and through the skin and then into the vessel. Once the vessel is dilated, the dilator can be removed. Use a gauze pad to control increased bleeding, which usually occurs after dilation. Advance the line over the guidewire, maintaining control of the wire before passing the catheter into the skin. Remove the guidewire, check for blood return from all ports, flush all ports, and secure the catheter in place. Apply a sterile dressing before removing the drapes (Fig. 4).

中文翻译 见16楼（认领人：xuziqin ）

绿茵场

Complications

Specific complications associated temporally with placement of a subclavian line include hemothorax and pneumothorax, air embolism, inadvertent arterial puncture, and aortic perforation. Obtain a chest radiograph after placement to assess for complications and for correct placement of the catheter. Common malplacement locations include placement transverse to the contralateral subclavian vein, retrograde into the ipsilateral internal jugular vein, or potentially the contralateral internal jugular vein.

Longer-term complications include thrombosis of the vein and infection. Data suggest that subclavian placement mitigates but does not eliminate the risk of infection. Adherence to the Institute for Healthcare Improvement guidelines, including the use of proper hand hygiene, the use of maximal barrier precautions during placement, the use of chlorhexidine skin antisepsis, and daily review of need for the catheter, will help to decrease the risk of infection.

中文翻译 见15楼（认领人：Adler007）

蓝鱼o_0

【Lumbar Puncture】腰穿——认领

toto

回复 8# 蓝鱼o_0


   你全部认领了吧

绿茵场

回复 9# toto
能者多劳，希望是如此，但相信 蓝鱼 忙不过来哦！
最好还是能发挥大家的力量哈！

绿茵场

回复 3# 绿茵场
我先抛砖引玉吧，认领第一部分。
希望老师们积极认领！

细雨润竹

回复 8# 蓝鱼o_0
相信你的能力，期待早日看到杰作

蓝鱼o_0

回复 12# 细雨润竹


细雨老师，感谢您的信任。我尽力而为。

蓝鱼o_0

回复 9# toto

呵呵，TOTO版主，谢谢您的支持。不过我真的能力有限时间也有限。

Adler007

【第五部分】
Complications
Specific complications associated temporally with placement of a subclavian line include hemothorax and pneumothorax, air embolism, inadvertent arterial puncture, and aortic perforation. Obtain a chest radiograph after placement to assess for complications and for correct placement of the catheter. Common malplacement locations include placement transverse to the contralateral subclavian vein, retrograde into the ipsilateral internal jugular vein, or potentially the contralateral internal jugular vein.
Longer-term complications include thrombosis of the vein and infection. Data suggest that subclavian placement mitigates but does not eliminate the risk of infection. Adherence to the Institute for Healthcare Improvement guidelines, including the use of proper hand hygiene, the use of maximal barrier precautions during placement, the use of chlorhexidine skin antisepsis, and daily review of need for the catheter, will help to decrease the risk of infection.

并发症
   锁骨下静脉穿刺的急性相关并发症包括血胸、气胸、空气栓塞、疏忽的动脉刺穿和大动脉的穿孔。放置后行胸片拍摄可以评估并发症及导管放置是否正确。一般错误的静脉穿刺点包括锁骨下静脉对侧的头臂静脉,同侧颈内静脉、或在对侧颈内静脉。
   长期的并发症包括静脉血栓形成的和感染。锁骨下静脉穿刺的数据表明不能消除感染的风险。遵守合适的放置、手卫生,在置管期间最大程度的防护措施、使用洗必泰皮肤擦浴及每天置管需要性的评估的研究指南,将有助于降低感染的风险

紫陌红尘

第四部分        
超声引导        

  近期的一些文章表明,尽管锁骨下有骨性标志的存在3 4，使用超声仍可以增加锁骨下导管的成功率。因为通过按压来辨识静脉存在更多的困难，因此多普勒血流应被用来区分动脉和静脉。        
操作步骤        

在平行于锁骨弯曲处的2CM，距锁骨末端约2CM处，（一手持穿刺针），经皮肤，以30度角指向胸骨颈静脉切迹插入穿刺针。另一只手的手指置于胸骨切迹来帮助定位。一旦穿刺针穿至皮肤下,降低穿刺针的角度，使注射器平行但在锁骨下（后）(图3)。        静脉通常正好在锁骨下,但它可能在皮肤下数厘米处。一旦你找到静脉,小心稳住穿刺针，并脱开注射器。将具J-型末端的导丝引入穿刺针。引入导丝应容易和无阻力,直到超出穿刺针头。如果你观察到监护仪上有异位心律，退回导丝，直至异位心律消失。然后拔出穿刺针,留下导丝并稳住导丝。在皮肤穿刺点上应做一个1-2mm小切口，以便扩皮器导入。 将扩皮器沿导丝推进皮肤,随后进入血管。一旦血管被扩开,移去扩皮器。使用纱布垫来控制增加的出血,这通常发生在扩皮器使用后。将导管导入导丝，稳住导丝，直至导管穿入皮肤。拔出导丝，检查所有接口是否有回血,并冲洗所有接口，确保导管在位。除去洞巾前使用无菌敷料(图4)。

绿茵场

回复 3# 绿茵场
【第一部分】翻译（供参考）

适应症

中心静脉置管在为心脏缺损和危重病人提供治疗的同时，也提供血液标本取样及中心静脉血压的监测。最新证据和健康促进机构的综合指南认定锁骨下是中心静脉置管的最佳部位。

禁忌症

中心静脉置管的一般禁忌症包括静脉炎症和静脉血栓。特殊禁忌症则包括同侧锁骨骨折或胸骨端肋骨骨折，原因是能改变静脉位置使得置管困难。在为凝血障碍的患者进行中心静脉置管时则需要特别谨慎。在直接血压监测的解剖位置（锁骨下）几乎不可能止血。

米奇朋克

回复 5# 绿茵场
我看了下第三部分还没有认领,我领下喽~~

米奇朋克

【第三部分】
准备
     向患者解释穿刺术的过程并签署书面知情同意书。穿无菌手术衣，戴无菌手套，可遮住面部的口罩及外科手术帽。给患者做检查以确保其没有穿刺禁忌症。让患者呈15度垂头仰卧位，这个体位能使静脉充盈。如果操作人员在脊柱下方垫一条卷毛巾或其他类似的物体是为了帮助确定患者的体表标记，那么他们必须意识到被支撑住的肩膀和转动的头颅都会缩小超声引导下静脉的管径。用洗必泰消毒剂彻底擦洗穿刺部位皮肤。铺单必须覆盖患者整个身躯。
     接下来要确定解剖学上的体表标记，首先从锁骨中间三分之一这个位置开始。沿着这个位置向旁侧移向另一个点，在这个点上锁骨与邻近的肋骨分离(图1)。该点内侧恰是锁骨下静脉和动脉经过的地方，当然也是成功率最高的置管位置。穿刺的进针点应该稍微远离锁骨以便穿刺针的管路最终停留在锁骨下方与其平行的位置。通常情况下，进针点在锁骨中间三分之一这个位置旁开2厘米(图2)。穿刺点的局麻应使用1%的利多卡因1~2毫升或其他等效的麻醉剂。

图1和图2

绿茵场

目前仅剩下第二部分了，加油哦！