自己翻译了下新英格兰关于超声引导下桡动脉穿刺的视频，由于最近没有太多时间为原视频加上字幕，先将中英字幕对照发个文字版出来。如有翻译不当的地方，欢迎大家共同交流！原视频可见我投稿。

下附原文章地址

https://www.nejm.org/doi/full/10.1056/NEJMvcm1213181

- This is a video in clinical medicine from the New England Journal of Medicine.这是一个来自《新英格兰杂志》的临床医学视频 

- 1  overview 概述

- Insertion of an arterial catheter is a common procedure in critical care units.Ultrasonography  may be used to ensure safe and successful insertion of an arterial catheter.动脉穿刺置管在ICU是一个常规操作。超声技术可用于确保动脉穿刺置管的安全性和成功率。

- This video will demonstrate the use of ultrasound guidance for the insertion of a radial arterial catheter in adults.这个视频会展示在超声引导下对成人进行动脉穿刺置管技术。

- 2 indication指示

- Arterial catheterization allows for the continuous recording of arterial pressure measurements and can be used to adjust the doses of vasoactive drugs动脉导管能够确保连续动脉压力的测量，也可用于调整血管活性药物的剂量。

- that are administered for hemodynamic support in critically ill patients.来为危重病人提供血流动力学的支持

- Arterial catheterization also provides easy and convenient access to arterial blood when arterial blood-gas sampling and other laboratory tests need to be performed.动脉导管也为获取动脉血液用于血气分析样本和其他检验提供简单方便的途径。

- Ultrasound guidance can be more effective than palpation for the insertion of an arterial catheter in patients with obesity, edema, hypotension,超声引导下的动脉穿刺置管较于触及动脉搏动的方式更高效，尤其是对于有肥胖、水肿、高血压

- or vascular abnormalities，such as tortouous vessels.或是血管异常，比如弯曲血管的病人。

- In general, the use of ultrasound guidance for the insertion of a radial arterial catheter is faster than the palpation method and has a higher success rate.总的来说，使用超声引导下动脉穿刺置管较触及动脉搏动的方法来说更快且有更高的成功率。

- Also, successful insertion is achieved after fewer attempts, which means that there are fewer attempted sites of insertion, thereby minimizing patient discomfort.而且，成功的插入会经过更少次的尝试，这也意味着更少的穿刺尝试点，也就能尽可能减少病人的不适感。

- 3 contraindications禁忌证

- there are no contraindications to the use of ultrasound guidance.对于超声引导使用方面没有禁忌证

- However, radial arterial catheterization is contraindicated in patients with infection of the skin or soft tissue at the insertion site,但是在穿刺点有皮肤或软组织感染的病人是禁忌做动脉穿刺置管的

- severe peripheral vascular  disease,  impaired collateral circulation , or  severe  coagulopathy.严重的周围血管疾病，侧支循环受损或是严重的凝血障碍。

- 4 equipment and  preparation 设备准备

- After obtaining  the patient’s consent  of  the  procedure, gather  the  necessary  equipment.在获得病人对操作的同意后，准备好必要的材料设备。

- You will need two pairs of sterile gloves, a mask, a sterile gown, a skin-preparation solution such as chlorhexidine, sterile drapes, 1% lidocaine without epinephrine, a 5-cc syringe你将需要两双无菌手套、一个口罩、一个无菌手术衣、 消毒皮肤准备氯己定、无菌布、不含肾上腺素的浓度1%利多卡因、一个5-cc的注射器

- and a 25-gauge needle for delivery of the local anesthetic, and angiocatheters.一个25号针头用来进行局部麻醉以及血管导管

- radial arterial catheterization can be performed with standard angiocatheters or with safety angiocatheters.桡动脉的动脉穿刺置管可用标准血管导管或是安全血管导管。

- Use the equipment that complies with the safety practices at your institution. 使用符合你机构安全标准的材料设备。

- You will need materials for dressing and securing the catheter, sterile gauze, and a sterile ultrasound probe cover with sterile gel. 你将需要用于包扎和固定导管的材料，无菌纱布，以及带有无菌凝胶的无菌超声探头。

- You will also need a pressure bag, a pressure transducer, and a monitor that is Appropriate for arterial catheter transduction. In order to assess the vasculature, 你还需要一个压力袋、一个压力传感器和一个适合监测动脉压力的监护仪。为了评估脉管系统，

- you will need a linear-array transducer ultrasound probe with a frequency range of 5 to 13 MHz.你还需要一个频率范围为5至13兆赫的线性阵列换能器超声探头。

- Wash your hands before touching the patient, and put on the mask.在触碰病人前洗手并戴上口罩。

- Position the patient's wrist such that the forearm is flat. Put on a pair of sterile gloves, and use antiseptic solution to wash the skin of the patient's forearm 摆动病人手腕使之前臂平展。戴上手套，用消毒液来清洁病人的前臂。

- from the wrist to the antecubital fossa. Discard the gloves, wash your hands again, and put on the gown and a new pair of sterile gloves. 下至手腕，上至肘前窝。丢弃手套，再次洗手，穿上手术衣并戴上新的无菌手套。

- Drape the patient, exposing only the cleaned forearm from the wrist to the antecubital fossa.铺单，仅暴露操作视野，从手腕部到肘前窝。

5 STERILE TECHNIQUE WITH ULTRASONOGRAPHY超声技术的无菌原则

- Have an assistant clean the ultrasound transducer with an antiseptic wipe. 请助手用消毒液清洁超声换能器

- Apply sterile gel to the inside of the sterile sheath and cover the ultrasound probe without contaminating the sterile gloves or the sheath. 

- Remove any air pockets from around the probe, which, if present, will cause poor-quality ultrasound images. 将无菌凝胶涂在无菌护套的内侧，并覆盖在超声探头上，不要污染无菌手套或护套

- 6 CHOOSING AN INSERTION SITE选择穿刺点

- Vascular assessment is typically performed with a linear array transducer operating at frequencies between 5 and 13 MHz.使用一个频率范围为5至13兆赫的线性阵列换能器超声探头来评估血管情况。

- Make sure that the left side of the ultrasound probe corresponds to the left side of the screen.确保超声探头的左侧匹配左侧的显示屏。

- Starting at the patient's wrist, scan the lateral aspect of the forearm in the transverse orientation and identify the radial artery and the associated veins, 从病人腕部开始，横向扫描前臂外侧来确定桡动脉及其相关静脉。

- which will be located between the styloid portion of the radius and the flexor carpi radialis tendon. 定位应该在桡骨茎突和桡侧腕屈肌肌腱处。

- If necessary, Apply light pressure to help differentiate the artery from the veins; veins will collapse, whereas the artery will not如有必要，可轻微施加压力来帮助将动脉与静脉区分出来；静脉会被压塌而动脉不会。

- have the assistant adjust the gain  and  depth so that the artery Appears in the center of the screen and is clearly visible. 让助手帮助来调节增益和深度使得桡动脉能够清晰地显示在屏幕中央。

- As you scan the artery from the wrist to the antecubital fossa, look for arterial tortuosity and calcification.当你扫描动脉从腕部到肘前窝时，确定动脉的迂曲和钙化。

- Locate a section of the artery with a large diameter and minimal calcification.确定一个有较宽内径和最少钙化的动脉节段。

- To prevent the development of kinks in the catheter after it has been inserted, choose a site that is proximal to the wrist and distal to the elbow. 为了防止导管置入后扭曲打结，选择穿刺的位点应该靠近腕部，远离肘部。

- Kinking can occur when the patient moves or is repositioned.当病人移动或者重新摆体位后也会发生扭曲打结。

7 CATHETER INSERTION IN THE TRANSVERSE ORIENTATION横向的导管穿刺置入

- After locating an Appropriate site for catheterization, slide the probe so that the artery is centered on the screen.当定位好一个适合的穿刺位点后，滑动探头使得动脉位于屏幕正中。 

- After anesthetizing the skin, insert the angiocatheter-covered needle at the middle of the probe at a 45 to 60 angle.对穿刺部位皮肤局麻后，以45-60°方向在探头中央置入动脉穿刺导管。

- Slide or tilt the probe toward the needle tip until you can visualize the tip on the monitor. Make small bouncing movements with the needle to locate the tip. 将探针向针尖方向滑动或倾斜，直到你能在显示器上看到针尖。用针头做小幅度的移动来确定针尖的位置。

- As you advance the needle toward the artery, tilt the probe in the direction of the needle's trajectory to ensure that you can see the needle tip at all times. 当你将针头向动脉推进时，将探针向针头轨迹的方向倾斜，以确保你能一直看到针尖。

- Reposition the tip periodically to confirm that it is directly above the artery.不间断地重新定位针尖位置，以确保其一直位于动脉上方。

- Insert the needle tip into the arterial lumen and examine the angiocatheter for flashback, or blood return, in order to confirm its position. 将针尖刺入动脉管腔，再检查动脉穿刺针的回退或是回血，以确定它的位置。

- Flatten the angle of the angiocatheter, and then reexamine the area on the ultrasound monitor to make sure that the needle tip is still in the artery.放平导管，再重新检查超声监视器，确保针尖仍在动脉内。

- Slide the catheter over the needle into the arterial lumen. Apply pressure proximal to the catheter, remove the needle, and attach the catheter to the transducer.将导管完全置入动脉管腔内。并对导管施加适当压力，退出针芯，再将导管与换能器连接。

8 CATHETER INSERTION IN THE LONGITUDINAL ORIENTATION纵向的导管穿刺置入

- The catheter can also be inserted in the longitudinal orientation .To  do so begin the procedure with the ultrasound probe in the transverse orientation to locate the artery. 导管同样可从纵向探头置入。进行这项操作之前，需要先将探头置于横向方向上来定位动脉走形。

- Center the artery on the ultrasound screen and then rotate the probe 90 degrees. 将动脉置于屏幕中央再将探头旋转90°。

- You should see the artery in the center of the screen, with a view along its long axis, at its maximum diameter. 你应该看到屏幕中央的动脉，沿其长轴看去，其直径最大。

- Insert the angiocatheter at an angle of 15 to 30 degrees at the exact midline of the long axis of the probe. Advance the needle parallel to the long axis of the probe.以15-30°方向在探头长轴的正中线上置入动脉导管。将针头与探针的长轴平行推进。

- If you do not see the needle, it is probably medial or lateral to the vessel. 如果你没有见到针尖，那么有可能在血管的内侧或后侧。

- Pull back on the needle without withdrawing it completely or letting it leave the skin, and readjust the angle so that you can see the needle tip on the ultrasound screen. 稍将针退后些许，不需要完全退出或是离开皮肤，再重新调整进针角度直到你能在屏幕上见到针尖。

- Then advance the needle again, until it is within the lumen of the vessel, and look for flashback in the angiocatheter.再次推进针尖，直到其进入血管管腔，观察到动脉穿刺针的回血。

- Slide the catheter over the needle and into the arterial lumen. Apply pressure proximal to the catheter, remove the needle, and attach the catheter to the transducer.将导管推入动脉管腔内。并对导管施加适当压力，退出针芯，再将导管与换能器连接。

9 COMPLICATIONS难点

- The main challenges when performing ultrasound-guided catheterization is  visualization of the needle tip and differentiation of the needle tip from the needle shaft, 进行超声引导下的穿刺置管的主要挑战就是针尖的可视化和辨别针尖和针轴，

- since each will Appear as a white dot on the screen . Novice operators sometimes believe that they are visualizing the needle tip on the monitor 由于两者在屏幕上显示都是一个白点。新手有时会误认为他们在显示器上看到的是针尖。

- but  they are actually viewing the needle shaft. In such instances, the unseen needle tip has been inserted more deeply than the operator assumes 但其实他们所观察到的是针轴。在这样的情况下，未见到的针尖往往被操作者置入到更深的位置。

- and can cause injury to deeper structures. For this reason, continuous visualization of the needle tip is crucial during angiocatheter insertion.也会导致深层结构的损伤。出于此种原因，持续针尖观察对于动脉穿刺是至关重要的。

10 SUMMARY总结

- It is easy to learn how to use ultrasound guidance when performing radial arterial catheterization in either the transverse or the longitudinal orientation. 无论在进行横向或纵向的桡动脉穿刺置管时，都很容易学会如何使用超声引导。

- Clinicians who regularly insert arterial catheters should master this technique because it can increase the success rate 需要常规进行动脉穿刺置管的临床医师应当掌握此项技术，因其可提高穿刺成功率

- and reduce the number of attempts required for successful catheterization as compared with the palpation technique.对比触及搏动的方法来说，也会减少穿刺次数。