Patient position: horizontal, under the shoulder girdle (“under the shoulder blades”), the roller can not be placed. The head end of the table is lowered by 25-30 degrees (Trendelenburg position). The upper limb on the side of the puncture is brought to the body, the shoulder girdle is lowered, with the assistant pulling the upper limb down, the head is turned 90 degrees in the opposite direction. In the case of a serious condition of the patient, it is possible to perform a puncture in a semi-sitting position.

Physician position- standing on the side of the puncture.

Preferred Side: right (justification - see above).

The needle is injected at the point Yoffe, which is located in the corner between the lateral edge of the clavicular pedicle of the sternocleidomastoid muscle and the upper edge of the clavicle. The needle is directed at an angle of 40-45 degrees with respect to the collarbone and 15-20 degrees with respect to the anterior surface of the neck. During the passage of the needle in the syringe, a slight vacuum is created. Usually it is possible to get into a vein at a distance of 1-1.5 cm from the skin. A line conductor is inserted through the lumen of the needle to a depth of 10-12 cm, after which the needle is removed, while the conductor adheres and remains in the vein. Then the catheter is advanced along the conductor with screwing movements to the previously indicated depth. If the catheter does not pass freely into the vein, its rotation around its axis can help advance (carefully). After that, the conductor is removed, and a plug cannula is inserted into the catheter.

The technique of percutaneous puncture and catheterization of the subclavian vein according to the principle of "catheter through catheter"

Puncture and catheterization of the subclavian vein can be carried out not only according to the Seldinger principle (“catheter along the conductor”), but also according to the principle "catheter through catheter" . The latest technique has become possible thanks to new technologies in medicine. The puncture of the subclavian vein is carried out using a special plastic cannula (external catheter), put on a needle for catheterization of the central veins, which serves as a puncturing stylet. In this technique, the atraumatic transition from the needle to the cannula is extremely important, and, as a result, there is little resistance to passing the catheter through the tissues and, in particular, through the wall of the subclavian vein. After the cannula with the stylet needle has entered the vein, the syringe is removed from the needle pavilion, the cannula (outer catheter) is held, and the needle is removed. A special internal catheter with a mandrel is passed through the external catheter to the desired depth. The thickness of the inner catheter corresponds to the diameter of the lumen of the outer catheter. The pavilion of the external catheter is connected with the help of a special clamp to the pavilion of the internal catheter. The mandrin is extracted from the latter. A sealed lid is put on the pavilion. The catheter is fixed to the skin.

Requirements for catheter care

Before each introduction of a medicinal substance into the catheter, it is necessary to obtain free blood flow from it with a syringe. If this fails, and fluid is freely introduced into the catheter, this may be due to:

with the exit of the catheter from the vein;

with the presence of a hanging thrombus, which, when trying to get blood from the catheter, acts as a valve (rarely observed);

so that the cut of the catheter rests against the wall of the vein.

It is impossible to infuse into such a catheter. It is necessary first to slightly tighten it and again try to get blood from it. If this fails, then the catheter must be unconditionally removed (danger of paravenous insertion or thromboembolism). Remove the catheter from the vein very slowly, creating negative pressure in the catheter with a syringe. In this way, it is sometimes possible to extract a hanging thrombus from a vein. In this situation, it is strictly unacceptable to remove the catheter from the vein with quick movements, as this can cause thromboembolism.

To avoid thrombosis of the catheter after diagnostic blood sampling and after each infusion, immediately rinse it with any infused solution and be sure to inject an anticoagulant (0.2-0.4 ml) into it. Thrombus formation may occur strong cough patient due to reflux of blood into the catheter. More often it is noted against the background of slow infusion. In such cases, heparin must be added to the transfused solution. If the liquid was administered in a limited amount and there was no constant infusion of the solution, the so-called heparin lock ("heparin plug") can be used: after the end of the infusion, 2000 - 3000 IU (0.2 - 0.3 ml) of heparin in 2 ml are injected into the catheter physiological saline and it is closed with a special stopper or plug. Thus, it is possible to keep the vascular fistula for a long time. The stay of the catheter in the central vein provides for careful skin care at the puncture site (daily antiseptic treatment of the puncture site and daily change of aseptic dressing). The duration of the catheter stay in the subclavian vein, according to different authors, ranges from 5 to 60 days and should be determined medical indications rather than preventive measures (V.N. Rodionov, 1996).

percutaneous catheterization femoral artery on Seldinger performed using a special set of tools, consisting of puncture needle, dilator, introducer, metallic conductor soft end and catheter, size 4-5 F ( in French).

Modern angiographic devices are designed in such a way that for puncture it is more convenient to use the right femoral artery. The patient is laid on his back on a special table for angiography and brought right leg to the state of maximum pronation.

The pre-shaven right inguinal region is smeared with iodine, and then wiped with alcohol and isolated with disposable sterile sheets to prepare a large sterile area for conductor and catheter.

Given the topographic anatomy of the femoral artery, it is necessary to find the inguinal ligament and mentally divide it into three parts. The projection of the passage of the femoral artery is often located on the border of the middle and medial third of the inguinal ligament. Find her palpation, as a rule, is not difficult for its pulsation. It is important to remember that medially located from the femoral artery femoral vein, a laterally- femoral nerve.

With the left hand, the femoral artery is palpated on the inner surface of the lower limb 2 cm below the inguinal ligament and fixed between the index and middle fingers.

The painfulness of the manipulation requires the patient, who is conscious, to undergo infiltration anesthesia with a solution of novocaine or lidocaine.

After performing local anesthesia of the skin and subcutaneous tissue 1% lidocaine solution or 2% novocaine solution, produce puncture femoral artery. Puncture needle entered in the direction ripple, at an angle not exceeding 45 degrees, which reduces the subsequent likelihood of excessive kink catheter.

Tilting the outer end needles to the skin, pierce the anterior wall of the vessel. But more often needle passes both walls at once, and then the tip needles enters the lumen of the vessel only when moving it in the opposite direction.

igloo tilt even more to the thigh, remove from it mandrin and insert a metal conductor, the tip of which is advanced into the lumen of the artery by 10-15 cm in the central direction under pupart ligament. Carefully advancing the tool, it is necessary to assess the presence of resistance. In the correct position needles in the vessel, there should be no resistance.

Further promotion conductor, especially in persons over 50 years of age, it is necessary to carry out only under X-ray control to the level of the twelfth thoracic vertebra (Th-12).

Through the skin with the index finger of the left hand is fixed conductor in the lumen of the artery, and needle are pulled out. Finger pressure prevents removal from the artery conductor and leakage past it under the skin of arterial blood.

To the outer end conductor put on dilator, corresponding in diameter to the input catheter. dilator enter by moving along conductor 2-3 cm into the lumen of the femoral artery.

After removal dilator put on the conductor introducer, which is entered by conductor into the femoral artery.

At the next stage catheterization required at the outer end conductor put on catheter and promoting it distally, enter into introducer and then into the femoral artery.

From the femoral artery catheter (from the Greek kathet?r - a surgical instrument for emptying the cavity) - a tube-shaped instrument intended for insertion medicines and radiopaque substances into the natural channels and cavities of the body, blood and lymphatic vessels, as well as to extract their contents for diagnostic or therapeutic purposes. carried out along the vascular bed under X-ray control until aorta, then conductor removed and further advancement of the catheter up to target vessel carried out without it.

It should be remembered that after the end of the procedure, the place puncture must be firmly pressed against the bone base to avoid hematoma.

External iliac artery (arteria iliaca external, femoral artery (arteria temoralis) and their branches. Front view.

1-common iliac artery;

2-internal iliac artery;

3-external iliac artery;

4-lower epigastric artery;

5-femoral vein;

6-external genital arteries;

7-medial artery, envelope of the femur;

8-femoral artery;

9-subcutaneous nerve;

10-lateral artery, envelope of the femur;

11-deep femoral artery;

12-surface circumflex artery ilium;

13-inguinal ligament;

14-deep artery enveloping the ilium;

15-femoral nerve.

Angiography with means X-ray contrast study blood vessels. This technique is used in computed tomography, fluoroscopy and radiography, the main purpose is to assess the roundabout blood flow, the state of the vessels, as well as the extent of the pathological process.

This study should be carried out only in special X-ray angiographic rooms based on specialized medical institutions that have modern angiographic equipment, as well as appropriate computer equipment that can register and process the obtained images.

Hagiography is one of the most accurate medical examinations.

This diagnostic method can be used in the diagnosis coronary disease hearts, kidney failure, and to detect various kinds of cerebrovascular accidents.

Types of aortography

In order to contrast the aorta and its branches in the case of preservation of the pulsation of the femoral artery, the method of percutaneous aortic catheterization (Seldinger angiography) is most often used, in order to visually differentiate the abdominal aorta, translumbar puncture of the aorta is used.

It is important! The technique involves the introduction of an iodine-containing water-soluble contrast agent by direct puncture of the vessel, most often through a catheter that is inserted into the femoral artery.

Seldinger catheterization technique

Percutaneous catheterization of the femoral artery according to Seldinger is performed using a special set of instruments, which includes:

• puncture needle;
• dilator;
• introducer;
• metal conductor with a soft end;
• catheter (French size 4-5 F).

A needle is used to puncture the femoral artery to pass a metal conductor in the form of a string. Then the needle is removed, and a special catheter is inserted through the conductor in the lumen of the artery - this is called aortography.

Due to the pain of manipulation, a conscious patient needs infiltration anesthesia with a solution of lidocaine and novocaine.

It is important! Percutaneous catheterization of the aorta according to Seldinger can also be performed through the axillary and brachial arteries. Passing a catheter through these arteries is more often performed in cases where there is obstruction of the femoral arteries.

Seldinger angiography is considered universal in many ways, which is why it is used most often.

Translumbar puncture of the aorta

For the purpose of visual differentiation of the abdominal aorta or arteries lower extremities, for example, when they are affected by aorto-arteritis or atherosclerosis, preference is given to such a method as direct translumbar puncture of the aorta. The aorta is punctured with a special needle from the back.

If it is necessary to obtain contrasting branches of the abdominal aorta, then high translumbar aortography with aortic puncture is performed at the level of the 12th thoracic vertebra. If the task includes the process of contrasting the bifurcation of the artery of the lower extremities or the abdominal aorta, then the translumbar puncture of the aorta is performed at the level of the lower edge of the 2nd lumbar vertebra.

During this translumbar puncture, it is very important to pay special attention to the research methodology, in particular, a two-stage removal of the needle is carried out: first it must be removed from the aorta and only after a few minutes - from the para-aortic space. Thanks to this, it is possible to avoid and prevent the formation of large para-aortic hematomas.

It is important! Techniques such as translumbar puncture of the aorta and Seldinger angiography are the most widely used procedures for contrasting the arteries, the aorta and its branches, which makes it possible to obtain an image of almost any part of the arterial bed.

The use of these techniques in special conditions medical institutions allows to achieve a minimal risk of complications and at the same time is an affordable and highly informative diagnostic method.

INDICATIONS for catheterization may include:

Inaccessibility of peripheral veins for infusion therapy;

Long-term operations with large blood loss;

The need for infusion therapy in a large volume;

The need for parenteral nutrition, including the transfusion of concentrated, hypertonic solutions;

The need for diagnostic and control studies measurement of CVP (central venous pressure).

CONTRAINDICATIONS to PV catheterization are:

Syndrome of the superior vena cava:

Paget-Schroeter syndrome (acute thrombosis of the subclavian vein);

Sharp violations of the blood coagulation system in the direction of hypocoagulation;

Local inflammatory processes in the places of vein catheterization;

Severe respiratory failure with emphysema;

Bilateral pneumothorax;

Collarbone injury.

With unsuccessful CPV or its impossibility, the internal and external jugular or femoral veins are used for catheterization.

The subclavian vein starts from the lower border of the 1st rib, goes around it from above, deviates inwards, down and slightly forward at the point of attachment to the 1st rib of the anterior scalene muscle and enters the chest cavity. Behind the sternoclavicular joint, they connect with the internal jugular vein and form the brachiocephalic vein, which in the mediastinum with the same left side forms the superior vena cava. In front of the PV is the clavicle. The highest point of the PV is anatomically determined at the level of the middle of the clavicle in its upper border.

Laterally from the middle of the clavicle, the vein is located anterior and downward from subclavian artery. Medially behind the vein there are bundles of the anterior scalene muscle, the subclavian artery and, then, the dome of the pleura, which rises above the sternal end of the clavicle. The PV passes anterior to the phrenic nerve. On the left, the thoracic lymphatic duct flows into the brachiocephalic vein.

For CPV, preparations are necessary: ​​novocaine solution 0.25% - 100 ml; heparin solution (5000 IU in 1 ml) - 5 ml; 2% iodine solution; 70° alcohol; antiseptic for the treatment of the hands of the doctor performing the operation; cleol. sterile instruments: scalpel-pointed; syringe 10 ml; injection needles (subcutaneous, intravenous) - 4 pieces; needle for puncture vein catheterization; surgical needle; needle holder; scissors; surgical clamps and tweezers, 2 pieces; an intravenous catheter with a cannula, a plug and a conductor, respectively in thickness to the diameter of the inner lumen of the catheter and twice as long as it; container for anesthetic, bix with a sheet, diaper, gauze mask, surgical gloves, dressing material (balls, napkins).

Catheterization technique

The room where the CPV is performed should be with a sterile operating room: a dressing room, an intensive care unit or an operating room.

In preparation for CPV, the patient is placed on the operating table with the head end lowered by 15° to prevent air embolism.

The head is turned in the direction opposite to the punctured one, the arms are extended along the body. Under sterile conditions, a hundred is covered with the above tools. The doctor washes his hands as before a normal operation, puts on gloves. The operating field is treated twice with a 2% iodine solution, covered with a sterile diaper and once again treated with 70 ° alcohol.

Subclavian access With a syringe with a thin needle, 0.5% solution of procaine is injected intradermally to create a "lemon peel" at a point located 1 cm below the collarbone on the line separating the middle and inner third of the clavicle. The needle is advanced medially towards the upper edge of the sternoclavicular joint, continuously prescribing a solution of procaine. The needle is passed under the collarbone and the rest of the procaine is injected there. The needle is removed with a thick sharp needle, limiting the depth of its insertion with the index finger, the skin is pierced to a depth of 1-1.5 cm at the location of the "lemon peel". The needle is removed In a syringe with a capacity of 20 ml, up to half gain 0.9% chloride solution sodium, put on a not very sharp (to avoid puncture of the artery) needle 7–10 cm long with a bluntly beveled end. The direction of the bevel should be marked on the cannula. When inserting the needle, its bevel should be oriented in the caudal-medial direction. The needle is inserted into a puncture previously made with a sharp needle (see above), while the depth of the possible insertion of the needle should be limited by the index finger (no more than 2 cm). The needle is advanced medially towards the upper edge of the sternoclavicular joint, periodically pulling the piston back, checking the flow of blood into the syringe. If unsuccessful, the needle is moved back without removing it completely, and the attempt is repeated, changing the direction of advance by several degrees. As soon as blood appears in the syringe, some of it is injected back into the vein and sucked back into the syringe, trying to get a reliable backflow of blood. If a positive result is obtained, the patient is asked to hold his breath and remove the syringe from the needle, pinching its hole with a finger. A guidewire is inserted into the needle with light screwing movements up to half, its length is two and a half times the length of the catheter. The patient is again asked to hold his breath, the conductor is removed, closing the catheter hole with a finger, then a rubber stopper is put on the latter. After that, the patient is allowed to breathe. If the patient is unconscious, all manipulations related to the depressurization of the lumen of the needle or catheter located in the subclavian vein are performed during exhalation. The catheter is connected to the infusion system and fixed to the skin with a single silk suture. Apply an aseptic bandage.

Complications

Incorrect position of the guidewire and catheter.

It leads to:

Violation of the heart rhythm;

Perforation of the wall of the vein, heart;

Migration through the veins;

Paravasal administration of fluid (hydrothorax, infusion into the fiber);

Twisting of the catheter and the formation of a knot on it.

In these cases, correction of the position of the catheter, the help of consultants and, possibly, its removal is required to avoid deterioration of the patient's condition.

A puncture of the subclavian artery usually does not lead to serious consequences if it is determined in a timely manner by pulsating bright red blood.

To avoid air embolism, it is necessary to maintain the tightness of the system. After catheterization, a chest x-ray is usually prescribed to rule out possible pneumothorax.

With a long stay of the catheter in the PV, the following complications may occur:

thrombosis of a vein.

Thrombosed catheter,

Thrombo- and air embolism, infectious complications (5 - 40%), such as suppuration, sepsis, etc.

To prevent these complications, it is necessary to properly care for the catheter. Before all manipulations, hands should be washed with soap and water, dried and treated with 70 ° alcohol. For the prevention of AIDS and serum hepatitis, sterile rubber gloves are worn. The sticker changes daily, the skin around the catheter is treated with 2% iodine solution, 1% brilliant green solution or methylene blue. The infusion system is changed daily. After each use, the catheter is flushed with heparin solution to create a "heparin lock". Care must be taken to ensure that the catheter is not filled with blood. The catheter is changed along the conductor after 5-10 days with the whole prevention of complications. If this occurs, the catheter is removed immediately.

Thus, the CPV is quite complex operation, which has its own indications, contraindications. At individual features patient, violation of the technique of catheterization, omissions in the care of the catheter, complications may arise with damage to the patient, therefore, instructions have been created for all levels of medical staff related to this (the attending physician, the team conducting the CPV, nurse manipulation room). All complications must be recorded and analyzed in detail in the department.

Access to the PV can be either subclavian or supraclavicular. The first one is the most common (probably due to its earlier introduction). There are many points for puncture and catheterization of the subclavian vein, some of them (named after the authors) are shown in the figure.

The Abaniak point is widely used, which is located 1 cm below the clavicle along the line separating the inner and middle third of the clavicle (in the subclavian fossa). By own experience the point can be found (this is especially important in obese patients) if the second finger of the left hand (with CVV on the left) is placed on the jugular notch of the sternum, and the first and third slide along the lower and upper edges of the clavicle until the first finger enters the subclavian fossa. The needle for PV puncture should be directed at an angle of 45 to the clavicle in the projection of the sternoclavicular junction between the clavicle and 1 rib (along the line connecting the first and second fingers), it should not be punctured deeper.

RECOGNITION OF ARTERIAL PUNCTION AND PREVENTION OF AIR EMBOLISM.

All patients with normal blood pressure and normal tension of oxygen in the blood, the puncture of the artery is easy to recognize by the pulsating jet and the bright red color of the blood. However, in patients with profound hypotension or significant arterial desaturation, these signs may be absent. If there is any doubt as to whether the guide needle is in a vein or artery, a single-lumen number 18 catheter, which is available in most sets, should be inserted through the metal guide into the vessel. This step does not require the use of an expander. The catheter can be connected to a pressure transducer to identify the venous pulse wave and venous pressure. It is possible to take two identical blood samples at the same time to determine blood gases from the catheter and from any other artery. If the content of gases is significantly different - a catheter in a vein.

Patients with spontaneous breathing have negative venous pressure in the chest at the time of inspiration. If the catheter communicates freely with outside air, this negative pressure can draw air into the vein, resulting in an air embolism. Even a small amount of air can be fatal, especially if it is carried into the systemic circulation through an atrial or ventricular septal defect. To prevent such a complication, the mouth of the catheter must be closed all the time, and at the time of catheterization, the patient must be in the Trendelenburg position. If an air embolism does occur, in order to prevent air from entering the outflow tract of the right ventricle, the patient should be placed in the Trendelenburg position with the body tilted to the left. To speed up air resorption, 100% oxygen should be administered. If the catheter is in the cavity of the heart, air aspiration should be applied.

PREVENTIVE ANTIBIOTICS.

Most studies of prophylactic antibiotic use have shown that this strategy was accompanied by a reduction in infectious complications involving the bloodstream. However, the use of antibiotics is not encouraged, since it contributes to the activation of microorganisms sensitive to antibiotics.

Manipulation site care

OINTMENTS, SUBCUTANEOUS CUFFS AND BANDAGES

Applying an antibiotic ointment (eg, basitramycin, mupirocin, neomycin, or polymyxin) to the site of the catheter increases the incidence of fungal colonization of the catheter, promotes the activation of antibiotic-resistant bacteria, and does not reduce the number of catheter infections involving the bloodstream. These ointments should not be used. Similarly, the use of silver-impregnated hypodermic cuffs does not reduce catheter infections involving the bloodstream and is therefore not recommended. Because data on the optimal dressing type (gauze vs. transparent materials) and optimal dressing frequency are conflicting, evidence-based recommendations cannot be made.