Puncture of the femoral artery along the Seldinger. Catheterization of veins - central and peripheral: indications, rules and algorithm for installing a catheter

Venous catheterization (central or peripheral) is a manipulation that allows to provide full venous access to the bloodstream in patients requiring long-term or continuous intravenous infusions, as well as to provide faster emergency care.

Venous catheters are central and peripheral, accordingly, the first ones are used for puncturing the central veins (subclavian, jugular or femoral) and can only be installed by a resuscitator-anaesthetist, and the second ones are installed in the lumen of the peripheral (ulnar) vein. The last manipulation can be performed not only by a doctor, but also by a nurse or anesthetist.

Central venous catheter is a long flexible tube (about 10-15 cm), which is firmly installed in the lumen of a large vein. In this case, a special access is made, because the central veins are located quite deep, in contrast to the peripheral saphenous veins.

peripheral catheter It is represented by a shorter hollow needle with a thin stylet needle located inside, which is used to puncture the skin and venous wall. Subsequently, the stylet needle is removed and the thin catheter remains in the lumen of the peripheral vein. Access to the saphenous vein is usually not difficult, so the procedure can be performed by a nurse.

Advantages and disadvantages of the technique

The undoubted advantage of catheterization is the implementation of quick access to the patient's bloodstream. In addition, when placing a catheter, the need for daily vein puncture for the purpose of intravenous drip is eliminated. That is, it is enough for the patient to install a catheter once instead of “pricking” a vein again every morning.

Also, the advantages include sufficient activity and mobility of the patient with the catheter, since the patient can move after the infusion, and there are no restrictions on hand movements with the catheter installed.

Among the shortcomings, one can note the impossibility of a long-term presence of a catheter in a peripheral vein (no more than three days), as well as the risk of complications (albeit extremely low).

Indications for placing a catheter in a vein

Often in emergency conditions access to the patient's vascular bed cannot be achieved by other methods due to many reasons (shock, collapse, low blood pressure, collapsed veins, etc.). In this case, to save the life of a severe patient, the administration of medicines is required so that they immediately enter the bloodstream. This is where central venous catheterization comes in. In this way, The main indication for placing a catheter into a central vein is the provision of emergency and emergency care in the conditions of an intensive care unit or ward where intensive care is provided to patients with serious illnesses and disorders of vital functions.

Sometimes catheterization may be performed femoral vein, for example, if doctors perform (artificial lung ventilation + chest compressions), and another doctor provides venous access, and at the same time does not interfere with his colleagues with manipulations on the chest. Also, femoral vein catheterization can be attempted in an ambulance when peripheral veins cannot be found and drugs are required on an emergency basis.

central venous catheterization

In addition, for the placement of a central venous catheter, there are the following indications:

Open heart surgery using a heart-lung machine (AIC).
Providing access to the bloodstream in critically ill patients in intensive care and intensive care.
Installing a pacemaker.
Introduction of the probe into the cardiac chambers.
Measurement of central venous pressure (CVP).
Carrying out radiopaque studies of the cardiovascular system.

Installation of a peripheral catheter is indicated in the following cases:

early start infusion therapy at the ambulance stage medical care. When a patient is admitted to a hospital with an already installed catheter, the treatment started continues, thereby saving time for setting up a dropper.
Placement of a catheter in patients who are scheduled for abundant and / or round-the-clock infusions of medications and medical solutions (saline, glucose, Ringer's solution).
Intravenous infusions for patients in a surgical hospital, when surgery may be required at any time.
The use of intravenous anesthesia for minor surgical interventions.
Installation of a catheter for women in labor at the beginning of labor to ensure that there are no problems with venous access during childbirth.
The need for multiple venous blood sampling for research.
Blood transfusions, especially multiple ones.
The impossibility of feeding the patient through the mouth, and then using a venous catheter, parenteral nutrition is possible.
Intravenous rehydration for dehydration and electrolyte changes in a patient.

Contraindications for venous catheterization

The installation of a central venous catheter is contraindicated if the patient has inflammatory changes in the skin of the subclavian region, in case of blood clotting disorders or trauma to the collarbone. Due to the fact that the catheterization of the subclavian vein can be performed both on the right and on the left, the presence of a unilateral process will not interfere with the installation of the catheter on the healthy side.

Of the contraindications for a peripheral venous catheter, it can be noted that the patient has an ulnar vein, but again, if there is a need for catheterization, then manipulation can be performed on a healthy arm.

How is the procedure carried out?

Special preparation for catheterization of both central and peripheral veins is not required. The only condition when starting to work with the catheter is the full observance of the rules of asepsis and antisepsis, including the treatment of the hands of the personnel installing the catheter, and careful treatment of the skin in the area where the vein will be punctured. Of course, it is necessary to work with the catheter using sterile instruments - a catheterization kit.

Central venous catheterization

Subclavian vein catheterization

When catheterizing the subclavian vein (with the “subclavian”, in the slang of anesthesiologists), the following algorithm is performed:

Video: Subclavian Vein Catheterization - Instructional Video

Catheterization of the internal jugular vein

catheterization of the internal jugular vein

Catheterization of the internal jugular vein differs somewhat in technique:

The position of the patient and anesthesia is the same as for the catheterization of the subclavian vein,
The doctor, being at the patient's head, determines the puncture site - a triangle formed by the legs of the sternocleidomastoid muscle, but 0.5-1 cm outward from the sternal edge of the clavicle,
The needle is inserted at an angle of 30-40 degrees towards the navel,
The remaining steps in the manipulation are the same as for catheterization of the subclavian vein.

Femoral vein catheterization

Femoral vein catheterization differs significantly from those described above:

The patient is placed on his back with the thigh abducted outward,
Visually measure the distance between the anterior iliac spine and the pubic symphysis (pubic symphysis),
The resulting value is divided by three thirds,
Find the border between the inner and middle thirds,
Determine the pulsation of the femoral artery in the inguinal fossa at the obtained point,
1-2 cm closer to the genitals is the femoral vein,
The implementation of venous access is carried out with the help of a needle and a conductor at an angle of 30-45 degrees towards the navel.

Video: Central venous catheterization - educational film

Peripheral vein catheterization

Of the peripheral veins, the lateral and medial veins of the forearm, the intermediate cubital vein, and the vein on the back of the hand are most preferred in terms of puncture.

peripheral venous catheterization

The algorithm for inserting a catheter into a vein in the arm is as follows:

After treating the hands with antiseptic solutions, a catheter of the required size is selected. Typically, catheters are marked according to size and have different colors - purple for the shortest catheters with a small diameter, and orange for the longest with a large diameter.
A tourniquet is applied to the patient's shoulder above the catheterization site.
The patient is asked to "work" with his fist, clenching and unclenching his fingers.
After palpation of the vein, the skin is treated with an antiseptic.
The skin and vein are punctured with a stylet needle.
The stylet needle is pulled out of the vein while the catheter cannula is inserted into the vein.
Further, a system for intravenous infusions is connected to the catheter and an infusion of therapeutic solutions is carried out.

Video: puncture and catheterization of the ulnar vein

Catheter Care

In order to minimize the risk of complications, the catheter must be properly cared for.

First, the peripheral catheter should be installed for no more than three days. That is, the catheter can stand in the vein for no more than 72 hours. If the patient requires an additional infusion of solutions, the first catheter should be removed and a second one placed on the other arm or in another vein. Unlike the peripheral the central venous catheter can be in the vein for up to two to three months, but subject to weekly replacement of the catheter with a new one.

Second, the plug on the catheter should be flushed every 6-8 hours with heparinized saline. This is necessary to prevent blood clots in the lumen of the catheter.

Thirdly, any manipulations with the catheter must be carried out in accordance with the rules of asepsis and antisepsis - the personnel must carefully clean their hands and work with gloves, and the catheterization site must be protected with a sterile dressing.

Fourth, in order to prevent accidental cutting of the catheter, it is strictly forbidden to use scissors when working with the catheter, for example, to cut the adhesive plaster with which the bandage is fixed to the skin.

These rules when working with a catheter can significantly reduce the incidence of thromboembolic and infectious complications.

Are there complications during vein catheterization?

Due to the fact that venous catheterization is an intervention in the human body, it is impossible to predict how the body will react to this intervention. Of course, the vast majority of patients do not experience any complications, but in extremely rare cases this is possible.

So, when installing a central catheter, rare complications are damage to neighboring organs - the subclavian, carotid or femoral artery, brachial nerve plexus, perforation (perforation) of the pleural dome with the penetration of air into pleural cavity(pneumothorax), damage to the trachea or esophagus. Air embolism is one of these complications - penetration of air bubbles into the bloodstream from environment. Prevention of complications is technically correct central venous catheterization.

When installing both the central and peripheral catheters, formidable complications are thromboembolic and infectious. In the first case, the development of thrombosis is also possible, in the second - systemic inflammation up to (blood poisoning). Prevention of complications is careful monitoring of the catheterization area and timely removal of the catheter at the slightest local or general changes - pain along the catheterized vein, redness and swelling at the puncture site, fever.

In conclusion, it should be noted that in most cases, catheterization of veins, especially peripheral ones, passes without a trace for the patient, without any complications. But the therapeutic value of catheterization is difficult to overestimate, because the venous catheter allows you to carry out the amount of treatment that is necessary for the patient in each individual case.

The success of puncture and catheterization of the subclavian vein is largely due to compliance with all requirements for this operation. Of particular importance is correct positioning of the patient.

The position of the patient horizontal with a roller placed under the shoulder girdle (“under the shoulder blades”), 10-15 cm high. 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 pulling by an assistant upper limb down), the head is turned in the opposite direction by 90 degrees. In the case of a serious condition of the patient, it is possible to perform a puncture in a semi-sitting position and without placing a roller.

Physician position- standing on the side of the puncture.

Preferred Side: right, since the thoracic or jugular lymphatic ducts can flow into the final section of the left subclavian vein. In addition, when performing pacing, probing and contrasting the heart cavities, when it becomes necessary to advance the catheter into the superior vena cava, this is easier to do on the right, since the right brachiocephalic vein is shorter than the left one and its direction approaches vertical, while the direction of the left brachiocephalic vein is closer to horizontal.

After treating the hands and the corresponding half of the anterior neck and subclavian region with an antiseptic and limiting the surgical field with a cutting diaper or napkins (see the section “Basic equipment and organization of puncture catheterization of the central veins”), anesthesia is performed (see the section “Pain control”).

The principle of central venous catheterization is based on Seldinger (1953). The puncture is carried out with a special needle from the central vein catheterization kit, attached to a syringe with a 0.25% novocaine solution. For conscious patients, show the subclavian vein puncture needle highly undesirable , as this is a powerful stress factor (needle 15 cm long or more with sufficient thickness). When a needle is punctured into the skin, there is significant resistance. This moment is the most painful. Therefore, it must be carried out as quickly as possible. This is achieved by limiting the depth of needle insertion. The doctor performing the manipulation limits the needle with a finger at a distance of 0.5-1 cm from its tip. This prevents the needle from penetrating the tissue deeply and uncontrollably when a significant amount of force is applied during the puncture of the skin. The lumen of the puncture needle is often clogged with tissues when the skin is punctured. Therefore, immediately after the needle passes through the skin, it is necessary to restore its patency by releasing a small amount of novocaine solution. The needle is injected 1 cm below the clavicle at the border of its medial and middle thirds (Aubanyac's point). The needle should be directed to the posterior superior edge of the sternoclavicular joint or, according to V.N. Rodionov (1996), in the middle of the width of the clavicular pedicle of the sternocleidomastoid muscle, that is, somewhat lateral. This direction remains beneficial even with a different position of the clavicle. As a result, the vessel is punctured in the region of Pirogov's venous angle. The advance of the needle should be preceded by a stream of novocaine. After the needle pierces the subclavian muscle (feeling of failure), the piston should be pulled towards itself, moving the needle in a given direction (you can create a vacuum in the syringe only after releasing a small amount of novocaine solution to prevent clogging of the needle lumen with tissues). After entering the vein, a trickle of dark blood appears in the syringe, and further the needle should not be advanced into the vessel because of the possibility of damage to the opposite wall of the vessel with the subsequent exit of the conductor there. If the patient is conscious, he should be asked to hold his breath while inhaling (prevention of air embolism) and through the lumen of the needle removed from the syringe, insert the line conductor 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 rotational movements clockwise to the previously indicated depth. In each case, the principle of choosing a catheter of the largest possible diameter (for adults, the inner diameter is 1.4 mm) must be observed. After that, the guidewire is removed, and a heparin solution is introduced into the catheter (see the section “care of the catheter”) and a cannula-stub is inserted. To avoid air embolism, the lumen of the catheter during all manipulations should be covered with a finger. If the puncture is not successful, it is necessary to withdraw the needle into the subcutaneous tissue and move it forward in the other direction (changes in the direction of the needle during the puncture lead to additional tissue damage). The catheter is fixed to the skin in one of the following ways:

a strip of a bactericidal patch with two longitudinal slots is glued to the skin around the catheter, after which the catheter is carefully fixed with a middle strip of adhesive tape;

to ensure reliable fixation of the catheter, some authors recommend suturing it to the skin. To do this, in the immediate vicinity of the exit site of the catheter, the skin is stitched with a ligature. The first double ligature knot is tied on the skin, the catheter is fixed to the skin suture with the second, the third knot is tied along the ligature at the level of the cannula, and the fourth knot is around the cannula, which prevents the catheter from moving along the axis.

PUNCTION VEIN CATHETERIZATION (Greek, katheter probe; Latin punctio injection) - the introduction of a special catheter into the lumen of a vein by percutaneous puncture for therapeutic and diagnostic purposes.

K. v. the item began to be applied since 1953 after Seldinger (S. Seldinger) offered a method of percutaneous puncture catheterization of arteries.

Thanks to the created instrumentation and the developed technique, the catheter can be inserted into any vein accessible for puncture.

In a wedge, practice the puncture catheterization of subclavian and femoral veins was most widespread.

For the first time the puncture of a subclavian vein is executed in 1952 by R. Aubaniac. The subclavian vein has a significant diameter (12-25 mm), its catheterization is less often complicated by phlebitis, thrombophlebitis, suppuration of the wound, which allows for a long time (up to 4-8 weeks), if indicated, to leave the catheter in its lumen.

Indications: the need for long-term infusion therapy (see), including in patients in terminal states, and parenteral nutrition (see); great difficulties in performing venipuncture of the saphenous veins; the need to study central hemodynamics and biochemical, blood pictures during intensive care; conducting catheterization of the heart (see), angiocardiography (see) and endocardial electrical stimulation of the heart (see Cardiostimulation).

Contraindications: inflammation of the skin and tissues in the area of the punctured vein, acute thrombosis of the vein to be punctured (see Paget-Schretter syndrome), compression syndrome of the superior vena cava, coagulopathy.

Technique. For catheterization of the subclavian vein, the following are required: a needle for vein puncture at least 100 mm long with an internal lumen of the canal of 1.6-1.8 mm and a cut of the needle point at an angle of 40-45°; a set of catheters made of siliconized fluoroplast, 180-220 mm long; a set of conductors, which are a nylon cast string 400-600 mm long and with a thickness not exceeding the inner diameter of the catheter, but densely obturating its lumen (you can use the Seldinger set); instruments for anesthesia and fixation of the catheter to the skin.

The position of the patient is on the back with the hands brought to the body. Vein puncture is often performed under local anesthesia; children and persons with mental disorders - under general anesthesia. Having connected the puncture needle with a syringe half-filled with a solution of novocaine, at one of the indicated points (the Aubanyac point is most often used; Fig. 1), the skin is pierced. The needle is set at an angle of 30-40° to the surface of the chest and slowly passed into the space between the clavicle and the 1st rib towards the upper back surface of the sternoclavicular joint. When the vein is pierced, there is a feeling of "falling through" and blood appears in the syringe. Carefully pulling the piston towards you, under the control of blood flow into the syringe, insert the needle into the lumen of the vein by 10-15 mm. Having disconnected the syringe, a catheter is inserted into the lumen of the needle to a depth of 120-150 mm. Having fixed the catheter above the needle, the latter is carefully removed from it. It is necessary to make sure that the catheter is in the lumen of the vein (according to the free flow of blood into the syringe) and at a sufficient depth (according to the marks on the catheter). The mark "120-150 mm" should be at the level of the skin. The catheter is fixed to the skin with a silk suture. A cannula (Dufo's needle) is inserted into the distal end of the catheter, which is connected to the system for infusion of solutions or closed with a special plug, having previously filled the catheter with heparin solution. Vein catheterization can also be carried out using the Seldinger method (see Seldinger method).

The duration of the catheter depends on proper care behind it (maintaining the wound of the puncture channel under conditions of strict asepsis, preventing thrombosis of the lumen by washing the catheter after each disconnection of it for long time) .

Complications: vein perforation, pneumo-, hemothorax, thrombophlebitis, wound suppuration.

Femoral vein catheterization

The first to report on the femoral vein puncture was Luck (J. Y. Luck) in 1943.

Indications. Femoral vein catheterization is mainly used for diagnostic purposes: ileocavography (see Phlebography, pelvic), angiocardiography and cardiac catheterization. Due to the high risk of developing acute thrombosis in the femoral or pelvic veins, long-term catheterization of the femoral vein is not used.

Contraindications: inflammation of the skin and tissues in the puncture zone, femoral vein thrombosis, coagulopathy.

Technique. The catheterization of the femoral vein is carried out using the instruments used in arterial catheterization according to the Seldinger method.

The position of the patient is on the back with legs slightly apart. Under local anesthesia, the skin is pierced 1-2 cm below the inguinal (pupart) ligament in the projection of the femoral artery (Fig. 2). The needle is set at an angle of 45° to the surface of the skin and gently pushed inward until a pulsating artery is felt. Then the end of the needle is deflected to the medial side and slowly inserted upward under the inguinal ligament. The presence of the needle in the lumen of the vein is judged by the appearance of dark blood in the syringe. The introduction of a catheter into a vein is carried out according to the Seldinger method.

Complications: damage to the vein, perivascular hematomas, acute vein thrombosis.

Bibliography: Gologorsky V. A., etc. Clinical assessment of catheterization of the subclavian vein, Vestn, hir., t. 108, No. 1, p. 20, 1972; Aubaniac R. L'injection intraveneuse sous-claviculaire, d'aivantages et technique, Presse m6d., t. 60, p. 1456, 1952; J of f a D. Supraclavicular subclavion venepuncture and catheteri-sation, Lancet, v. 2, p. 614, 1965; L u-k e J. C. Retrograde venography of the deep leg veins, Ganad. med. Ass. J., v. 49, p. 86, 1943; Seldinger S. I. Catheter replacement of needle in percutaneous arteriography, Acta radiol. (Stockh.), v. 39, p. 368, 1953; Verret J.e. a. La voie jugulaire externe, Cah. Anesth., t. 24, p. 795, 1976.

Subclavian vein catheterization technique. subclavian method according to the Seldinger method:

subclavian method according to the Seldinger method:

7) the patient is laid on his back with his hands brought to the body, a roller 10 cm high is placed under the shoulder blades, the head is turned to the side opposite to the side of the puncture, the foot end of the bed or operating table is raised to prevent the occurrence of air embolism with negative venous pressure;

8) the skin in the supraclavicular and subclavian areas is treated with an antiseptic;

9) under the clavicle in the area of the proposed puncture of the vein, the skin and underlying tissues are anesthetized. More often they use the Aubanyac point - on the border between the inner and middle thirds of the body of the clavicle (Fig. 19.24a);

10) with a puncture needle connected to a syringe half-filled with novocaine solution or saline, pierce the skin under the clavicle at the border of its inner and middle third;

11), the needle is placed at an angle of 45 degrees to the clavicle and degrees to the surface of the chest and is slowly drawn up and inward towards the upper posterior surface of the sternoclavicular joint (between the clavicle and 1 rib), and the tip of the needle should slide along the posterior surface of the clavicle (Fig. 19.24b);

12) when carrying out the needle, they constantly pull the piston of the syringe - the appearance of a feeling of “falling through” and blood in the syringe indicates that the needle has entered the lumen of the vein;

13) pulling the piston towards itself, under the control of the flow of blood into the syringe, the needle is carefully advanced into the lumen of the vein namm;

14) disconnect the syringe from the needle and quickly close the cannula of the needle with your finger (to prevent air embolism);

15) through the lumen of the needle, a conductor is inserted into the vein for 1/3 of its length (Fig. 19.24c);

16) having fixed the conductor above the needle, it is carefully removed, a catheter is put on the conductor and rotated into the lumen of the vein to a depth cm (Fig. 19.24 d, e);

17) the conductor is removed, using a syringe attached to the catheter, the presence of a reverse blood flow is checked (Fig. 19.24e);

18) a system for transfusion is connected to the catheter or closed with a special plug, previously filled with a solution of heparin (2.5-5 thousand units in isotonic sodium chloride solution);

19) the outer end of the catheter is fixed to the skin with adhesive tape and a skin suture;

20) the length of the outer end of the catheter is measured and these data are recorded in the medical history to monitor the position of the catheter in the vein in order to exclude its displacement into the lumen of the vein.

Rice. 19.24. Subclavian vein catheterization technique according to Seldinger

The position of the patient is horizontal with a roller placed under the shoulder girdle (“under the shoulder blades”), height cm. The head end of the table is lowered with awards (Trendelenburg position).

Preferred side: right, since the thoracic or jugular lymphatic ducts can flow into the final section of the left subclavian vein.

The principle of central venous catheterization is based on Seldinger (1953).

The puncture is carried out with a special needle from the central vein catheterization kit, attached to a syringe with a 0.25% novocaine solution. (needle length of 15 cm or more with sufficient thickness

The doctor performing the manipulation limits the needle with a finger at a distance of 0.5-1 cm from its tip. This prevents the needle from penetrating the tissue deeply and uncontrollably when a significant amount of force is applied during the puncture of the skin.

The needle is injected 1 cm below the clavicle at the border of its medial and middle thirds (Aubanyac's point). The needle should be directed to the posterior superior edge of the sternoclavicular joint or, according to V.N. Rodionov (1996), in the middle of the width of the clavicular pedicle of the sternocleidomastoid muscle, that is, somewhat lateral. As a result, the vessel is punctured in the region of Pirogov's venous angle. The advance of the needle should be preceded by a stream of novocaine.

After the needle pierces the subclavian muscle (feeling of failure), the piston should be pulled towards itself, moving the needle in a given direction (you can create a vacuum in the syringe only after releasing a small solution of novocaine to prevent clogging of the needle lumen with tissues). After entering the vein, a trickle of dark blood appears in the syringe, and further the needle should not be advanced into the vessel because of the possibility of damage to the opposite wall of the vessel with the subsequent exit of the conductor there. If the patient is conscious, he should be asked to hold his breath while inhaling (prevention of air embolism) and through the lumen of the needle removed from the syringe, insert the line conductor to a depth of 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 rotational movements clockwise to the previously indicated depth.

After that, the conductor is removed, and a heparin solution is injected into the catheter and a plug cannula is inserted. To avoid air embolism, the lumen of the catheter during all manipulations should be covered with a finger. If the puncture is not successful, it is necessary to withdraw the needle into the subcutaneous tissue and move it forward in the other direction (changes in the direction of the needle during the puncture lead to additional tissue damage). The catheter is fixed to the skin

The position of the patient: horizontal, under the shoulder girdle ("under the shoulder blades"), the roller can not be placed. The head end of the table is lowered with awards (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.

The position of the doctor is standing on the side of the puncture.

Preferred side: right

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 degrees relative to the collarbone and degrees relative 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. Through the lumen of the needle, a guidewire is inserted to a depth of cm, after which the needle is removed, while the guidewire 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 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.

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Subclavian vein catheterization

Punctures and catheterizations of veins, in particular central veins, are widely used manipulations in practical medicine. Currently, very broad indications are sometimes given for catheterization of the subclavian vein. Experience shows that this manipulation is not safe enough. Knowledge is extremely important topographic anatomy subclavian vein, techniques for performing this manipulation. In this teaching aid, much attention is paid to the topographic-anatomical and physiological substantiation of both the choice of access and the technique of vein catheterization. Indications and contraindications are clearly stated, as well as possible complications. The proposed manual is designed to facilitate the study of this important material through a clear logical structure. When writing the manual, both domestic and foreign data were used. The manual, no doubt, will help students and doctors to study this section, and also increases the effectiveness of teaching.

In one year, more than 15 million central venous catheters are installed in the world. Among the venous tributaries available for puncture, the subclavian vein is most often catheterized. In this case, various methods are used. Clinical Anatomy subclavian vein, accesses, as well as the technique of puncture and catheterization of this vein are not fully described in various textbooks and manuals, which is associated with the use of various techniques for this manipulation. All this creates difficulties for students and doctors in studying this issue. The proposed manual will facilitate the assimilation of the studied material through a consistent systematic approach and should contribute to the formation of strong professional knowledge and practical skills. The manual is written at a high methodological level, corresponds to a typical curriculum and can be recommended as a guide for students and doctors in the study of puncture and catheterization of the subclavian vein.

Percutaneous puncture and catheterization of the subclavian vein is an effective, but not safe manipulation, and therefore only a specially trained doctor with certain practical skills can be allowed to perform it. In addition, it is necessary to familiarize nursing staff with the rules for using and caring for catheters in the subclavian vein.

Sometimes, when all the requirements for puncture and catheterization of the subclavian vein are met, there may be repeated unsuccessful attempts to catheterize the vessel. At the same time, it is very useful to “change hands” - to ask another doctor to perform this manipulation. This in no way discredits the doctor who performed the puncture unsuccessfully, but, on the contrary, will exalt him in the eyes of his colleagues, since excessive perseverance and "stubbornness" in this matter can cause significant harm to the patient.

The first puncture of the subclavian vein was performed in 1952 by Aubaniac. He described the technique of puncture from the subclavian access. Wilson et al. in 1962, a subclavian access was used to catheterize the subclavian vein, and through it, the superior vena cava. Since that time, percutaneous catheterization of the subclavian vein has been widely used for diagnostic studies and treatment. Yoffa in 1965 introduced into clinical practice supraclavicular access for the introduction of a catheter into the central veins through the subclavian vein. Subsequently, various modifications of the supraclavicular and subclavian approaches were proposed in order to increase the likelihood of successful catheterization and reduce the risk of complications. Thus, at present, the subclavian vein is considered a convenient vessel for central venous catheterization.

Clinical anatomy of the subclavian vein

subclavian vein(Fig.1,2) is a direct continuation of the axillary vein, passing into the latter at the level of the lower edge of the first rib. Here it goes around the top of the first rib and lies between the posterior surface of the clavicle and the anterior edge of the anterior scalene muscle, located in the prescalene gap. The latter is a frontally located triangular gap, which is limited behind - by the anterior scalene muscle, in front and inside - by the sternohyoid and sternothyroid muscles, in front and outside - by the sternocleidomastoid muscle. The subclavian vein is located in the lowest part of the gap. Here it approaches the posterior surface of the sternoclavicular joint, merges with the internal jugular vein and forms with it the brachiocephalic vein. The fusion site is designated as Pirogov's venous angle, which is projected between the lateral edge lower section sternocleidomastoid muscle and the upper edge of the clavicle. Some authors (I.F. Matyushin, 1982) distinguish the clavicular region when describing the topographic anatomy of the subclavian vein. The latter is limited: above and below - by lines running 3 cm above and below the clavicle and parallel to it; outside - the front edge of the trapezius muscle, the acromioclavicular joint, the inner edge of the deltoid muscle; from the inside - by the inner edge of the sternocleidomastoid muscle until it intersects at the top - with the upper border, at the bottom - with the lower one. Behind the clavicle, the subclavian vein is first located on the first rib, which separates it from the dome of the pleura. Here the vein lies posterior to the clavicle, in front of the anterior scalene muscle (the phrenic nerve passes along the anterior surface of the muscle), which separates the subclavian vein from the artery of the same name. The latter, in turn, separates the vein from the trunks of the brachial plexus, which lie above and behind the artery. In newborns, the subclavian vein is 3 mm away from the artery of the same name, in children under 5 years of age - 7 mm, in children over 5 years of age - 12 mm, etc. Located above the dome of the pleura, the subclavian vein sometimes covers with its edge the artery of the same name by half its diameter.

The subclavian vein is projected along a line drawn through two points: the upper point is 3 cm downward from the upper edge of the sternal end of the clavicle, the lower one is 2.5-3 cm medially from the coracoid process of the scapula. In newborns and children under 5 years of age, the subclavian vein is projected to the middle of the clavicle, and at an older age, the projection shifts to the border between the inner and middle thirds of the clavicle.

The angle formed by the subclavian vein with the lower edge of the clavicle in newborns is equal to degrees, in children under 5 years old - 140 degrees, and at an older age - degrees. The diameter of the subclavian vein in newborns is 3-5 mm, in children under 5 years old - 3-7 mm, in children over 5 years old - 6-11 mm, in adults - mm in the final section of the vessel.

The subclavian vein runs in an oblique direction: from bottom to top, from the outside inwards. It does not change with the movements of the upper limb, since the walls of the vein are connected to the deep sheet of the own fascia of the neck (the third fascia according to the classification of V.N. Shevkunenko, the scapular-clavicular aponeurosis of Richet) and are closely connected with the periosteum of the clavicle and the first rib, as well as with fascia of the subclavian muscles and the clavicular-thoracic fascia.

Figure 1 Veins of the neck; on the right (according to V.P. Vorobyov)

1 - right subclavian vein; 2 - right internal jugular vein; 3 - right brachiocephalic vein; 4 - left brachiocephalic vein; 5 - superior vena cava; 6 - anterior jugular vein; 7 - jugular venous arch; 8 - external jugular vein; 9 - transverse vein of the neck; 10 - right subclavian artery; 11 - anterior scalene muscle; 12 - posterior scalene muscle; 13 - sternocleidomastoid muscle; 14 - clavicle; 15 - the first rib; 16 - handle of the sternum.

Figure 2. Clinical anatomy of the superior vena cava system; front view (according to V.P. Vorobyov)

1 - right subclavian vein; 2 - left subclavian vein; 3 - right internal jugular vein; 4 - right brachiocephalic vein; 5 - left brachiocephalic vein; 6 - superior vena cava; 7 - anterior jugular vein; 8 - jugular venous arch; 9 - external jugular vein; 10 - unpaired thyroid venous plexus; 11 - internal thoracic vein; 12 - the lowest thyroid veins; 13 - right subclavian artery; 14 - aortic arch; 15 - anterior scalene muscle; 16 - brachial plexus; 17 - clavicle; 18 - the first rib; 19 - borders of the manubrium of the sternum.

The length of the subclavian vein from the upper edge of the corresponding pectoralis minor muscle to the outer edge of the venous angle with the upper limb retracted is in the range of 3 to 6 cm. cervical, vertebral. In addition, the thoracic (left) or jugular (right) lymphatic ducts can flow into the final section of the subclavian vein.

Topographic-anatomical and physiological substantiation of the choice of the subclavian vein for catheterization

Anatomical accessibility. The subclavian vein is located in the prescalene space, separated from the artery of the same name and the trunks of the brachial plexus by the anterior scalene muscle.
Stability of the position and diameter of the lumen. As a result of fusion of the subclavian vein sheath with a deep leaf of the own fascia of the neck, the periosteum of the first rib and the clavicle, the clavicular-thoracic fascia, the lumen of the vein remains constant and it does not collapse even with the most severe hemorrhagic shock.
Significant(sufficient) vein diameter.
High blood flow rate(compared to limb veins)

Based on the foregoing, the catheter placed in the vein almost does not touch its walls, and the fluids injected through it quickly reach the right atrium and right ventricle, which contributes to an active effect on hemodynamics and, in some cases (during resuscitation), allows you not even to use intra-arterial injection medicines. Hypertonic solutions injected into the subclavian vein quickly mix with blood without irritating the intima of the vein, which makes it possible to increase the volume and duration of infusion with the correct placement of the catheter and appropriate care for it. Patients can be transported without the risk of damage to the endothelium of the vein by the catheter, they can begin early motor activity.

Indications for catheterization of the subclavian vein

1. Inefficiency and impossibility of infusion into peripheral veins (including during venesection):

a) due to severe hemorrhagic shock, leading to a sharp drop in both arterial and venous pressure (peripheral veins collapse and infusion into them is ineffective);

b) with a network-like structure, lack of expression and deep occurrence of superficial veins.

2. The need for long-term and intensive infusion therapy:

a) in order to replenish blood loss and restore fluid balance;

b) due to the risk of thrombosis of peripheral venous trunks with:

Prolonged stay in the vessel of needles and catheters (damage to the endothelium of the veins);

The need for the introduction of hypertonic solutions (irritation of the intima of the veins).

3. The need for diagnostic and control studies:

a) determination and subsequent monitoring in dynamics of the central venous pressure, which allows you to establish:

Rate and volume of infusions;

Early diagnosis of heart failure

b) probing and contrasting the cavities of the heart and great vessels;

c) repeated blood sampling for laboratory research.

4. Electrocardiostimulation by transvenous way.

5. Carrying out extracorporeal detoxification by methods of blood surgery - hemosorption, hemodialysis, plasmapheresis, etc.

Contraindications for catheterization of the subclavian vein

Syndrome of the superior vena cava.
Paget-Schretter Syndrome.
Severe disorders of the blood coagulation system.
Wounds, abscesses, infected burns in the area of puncture and catheterization (danger of generalization of infection and development of sepsis).
Clavicle injury.
Bilateral pneumothorax.
Severe respiratory failure with emphysema.

Fixed assets and organization of puncture and catheterization of the subclavian vein

Medications and preparations:

local anesthetic solution;
heparin solution (5000 IU in 1 ml) - 5 ml (1 bottle) or 4% sodium citrate solution - 50 ml;
antiseptic for processing the surgical field (for example, 2% solution of iodine tincture, 70% alcohol, etc.);

Laying of sterile instruments and materials:

syringeml - 2;
injection needles (subcutaneous, intramuscular);
needle for puncture vein catheterization;
intravenous catheter with cannula and plug;
a guide line 50 cm long and with a thickness corresponding to the diameter of the inner lumen of the catheter;
general surgical instruments;
suture material.

sheet - 1;
cutting diaper 80 X 45 cm with a round neckline 15 cm in diameter in the center - 1 or large napkins - 2;
surgical mask - 1;
surgical gloves - 1 pair;
dressing material (gauze balls, napkins).

Puncture catheterization of the subclavian vein should be performed in a procedure room or in a clean (non-purulent) dressing room. If necessary, it is performed before or during surgery on the operating table, on the patient's bed, at the scene, etc.

The manipulation table is placed to the right of the operator in a place convenient for work and covered with a sterile sheet folded in half. Sterile instruments, suture material, sterile bix material, anesthetic are placed on the sheet. The operator puts on sterile gloves and treats them with an antiseptic. Then the surgical field is treated twice with an antiseptic and is limited to a sterile cutting diaper.

After these preparatory measures, puncture catheterization of the subclavian vein is started.

Local infiltration anesthesia.
General anesthesia:

a) inhalation anesthesia - usually in children;

b) intravenous anesthesia - more often in adults with inappropriate behavior (patients with mental disorders and restless).

Various points for percutaneous puncture of the subclavian vein have been proposed (Aubaniac, 1952; Wilson, 1962; Yoffa, 1965 et al.). However, the conducted topographic and anatomical studies make it possible to single out not individual points, but entire zones within which it is possible to puncture a vein. This expands the puncture access to the subclavian vein, since several points for puncture can be marked in each zone. Usually there are two such zones: 1) supraclavicular and 2) subclavian.

Length supraclavicular zone is 2-3 cm. Its boundaries are: medially - 2-3 cm outward from the sternoclavicular joint, laterally - 1-2 cm medially from the border of the medial and middle third of the clavicle. The needle is injected 0.5-0.8 cm up from the upper edge of the clavicle. When puncturing, the needle is directed at an angle of degrees with respect to the collarbone and at an angle of degrees with respect to the anterior surface of the neck (to the frontal plane). Most often, the needle injection site is the Yoffe point, which is located in the angle between the lateral edge of the clavicular pedicle of the sternocleidomastoid muscle and the upper edge of the clavicle (Fig. 4).

Supraclavicular access has certain positive aspects.

1) The distance from the surface of the skin to the vein is shorter than with the subclavian approach: to reach the vein, the needle must pass through the skin with subcutaneous tissue, the superficial fascia and subcutaneous muscle of the neck, the superficial sheet of the own fascia of the neck, the deep sheet of the own fascia of the neck, the loose fiber layer surrounding the vein, as well as the prevertebral fascia involved in the formation of the fascial sheath of the vein. This distance is 0.5-4.0 cm (average 1-1.5 cm).

2) During most operations, the puncture site is more accessible to the anesthesiologist.

There is no need to put a roller under the patient's shoulder girdle.

However, due to the fact that the shape of the supraclavicular fossa is constantly changing in humans, reliable fixation of the catheter and protection with a bandage can present certain difficulties. In addition, sweat often accumulates in the supraclavicular fossa and, therefore, infectious complications can occur more often.

Subclavian zone(Fig. 3) limited: from above - the lower edge of the clavicle from its middle (point No. 1) and not reaching 2 cm to its sternal end (point No. 2); laterally - a vertical descending 2 cm down from point No. 1; medially - a vertical descending 1 cm down from point No. 2; bottom - a line connecting the lower ends of the verticals. Therefore, when puncturing a vein from the subclavian access, the needle injection site can be placed within the borders of an irregular quadrangle.

Figure 3. Subclavian zone:

The angle of inclination of the needle in relation to the clavicle - degrees, in relation to the surface of the body (to the frontal plane - degrees). The general guideline for puncture is the posterior superior point of the sternoclavicular joint. When puncturing a vein with subclavian access, the following points are most often used (Fig. 4):

Figure 4. Points used to puncture the subclavian vein.

1 – Yoffe point; 2 – Aubanyac point;

3 – Wilson point; 4 - Giles point.

With subclavian access, the distance from the skin to the vein is greater than with supraclavicular access, and the needle must pass through the skin with subcutaneous tissue and superficial fascia, pectoral fascia, pectoralis major muscle, loose tissue, clavicular-thoracic fascia (Gruber), a gap between the first rib and the clavicle, the subclavian muscle with its fascial sheath. This distance is 3.8-8.0 cm (average 5.0-6.0 cm).

In general, the puncture of the subclavian vein from the subclavian access is more justified topographically and anatomically, since:

large venous branches, thoracic (left) or jugular (right) lymphatic ducts flow into the upper semicircle of the subclavian vein;
above the clavicle, the vein is closer to the dome of the pleura; below the clavicle, it is separated from the pleura by the first rib;
fixing the catheter and aseptic dressing in the subclavian region is much easier than in the supraclavicular region, there are fewer conditions for the development of infection.

All this has led to the fact that in clinical practice the puncture of the subclavian vein is more often performed from the subclavian access. At the same time, in obese patients, preference should be given to the access that allows the most clear definition of anatomical landmarks.

The technique of percutaneous puncture and catheterization of the subclavian vein according to the Seldinger method from the subclavian access

The position of the patient horizontal with a roller placed under the shoulder girdle (“under the shoulder blades”), height cm. The head end of the table is lowered with awards (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 in the opposite direction by 90 degrees. In the case of a serious condition of the patient, it is possible to perform a puncture in a semi-sitting position and without placing a roller.

Physician position- standing on the side of the puncture.

The principle of central venous catheterization was laid down by Seldinger (1953).

The puncture is carried out with a special needle from the central vein catheterization kit, attached to a syringe with a 0.25% novocaine solution. For conscious patients, show the subclavian vein puncture needle highly undesirable , as this is a powerful stress factor (needle 15 cm long or more with sufficient thickness). When a needle is punctured into the skin, there is significant resistance. This moment is the most painful. Therefore, it must be carried out as quickly as possible. This is achieved by limiting the depth of needle insertion. The doctor performing the manipulation limits the needle with a finger at a distance of 0.5-1 cm from its tip. This prevents the needle from penetrating the tissue deeply and uncontrollably when a significant amount of force is applied during the puncture of the skin. The lumen of the puncture needle is often clogged with tissues when the skin is punctured. Therefore, immediately after the needle passes through the skin, it is necessary to restore its patency by releasing a small amount of novocaine solution. The needle is injected 1 cm below the clavicle at the border of its medial and middle thirds (Aubanyac's point). The needle should be directed to the posterior superior edge of the sternoclavicular joint or, according to V.N. Rodionov (1996), in the middle of the width of the clavicular pedicle of the sternocleidomastoid muscle, that is, somewhat lateral. This direction remains beneficial even with a different position of the clavicle. As a result, the vessel is punctured in the region of Pirogov's venous angle. The advance of the needle should be preceded by a stream of novocaine. After the needle pierces the subclavian muscle (feeling of failure), the piston should be pulled towards itself, moving the needle in a given direction (you can create a vacuum in the syringe only after releasing a small amount of novocaine solution to prevent clogging of the needle lumen with tissues). After entering the vein, a trickle of dark blood appears in the syringe, and further the needle should not be advanced into the vessel because of the possibility of damage to the opposite wall of the vessel with the subsequent exit of the conductor there. If the patient is conscious, he should be asked to hold his breath while inhaling (prevention of air embolism) and through the lumen of the needle removed from the syringe, insert the line conductor to a depth of 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 rotational movements clockwise to the previously indicated depth. In each case, the principle of choosing a catheter of the largest possible diameter (for adults, the inner diameter is 1.4 mm) must be observed. After that, the guidewire is removed, and a heparin solution is introduced into the catheter (see the section “care of the catheter”) and a cannula-stub is inserted. To avoid air embolism, the lumen of the catheter during all manipulations should be covered with a finger. If the puncture is not successful, it is necessary to withdraw the needle into the subcutaneous tissue and move it forward in the other direction (changes in the direction of the needle during the puncture lead to additional tissue damage). The catheter is fixed to the skin in one of the following ways:

a strip of a bactericidal patch with two longitudinal slots is glued to the skin around the catheter, after which the catheter is carefully fixed with a middle strip of adhesive tape;
to ensure reliable fixation of the catheter, some authors recommend suturing it to the skin. To do this, in the immediate vicinity of the exit site of the catheter, the skin is stitched with a ligature. The first double ligature knot is tied on the skin, the catheter is fixed to the skin suture with the second, the third knot is tied along the ligature at the level of the cannula, and the fourth knot is around the cannula, which prevents the catheter from moving along the axis.

The technique of percutaneous puncture and catheterization of the subclavian vein according to the Seldinger method from the supraclavicular approach

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 with awards (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 Yoffe point, which is located in the angle 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 degrees relative to the collarbone and degrees relative 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. Through the lumen of the needle, a guidewire is inserted to a depth of cm, after which the needle is removed, while the guidewire 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 photo shows the main landmarks used to select the puncture point - the sternocleidomastoid muscle, its sternal and clavicular pedicles, external jugular vein, clavicle and jugular notch. The most commonly used puncture point is shown, which is located at the intersection of the lateral edge of the clavicular pedicle of the sternocleidomastoid muscle and the clavicle (red mark). As a rule, alternative puncture points are located in the interval between the intersection of the outer edge of the clavicular head of the sternocleidomastoid muscle with the clavicle and the intersection of the external jugular vein with the clavicle. It is also reported that a puncture is performed from a point 1-2 cm above the edge of the clavicle. The vein runs under the clavicle, around the first rib, descends into the chest, where it joins the ipsilateral internal jugular vein at approximately the level of the sternoclavicular joint.

An exploratory puncture is performed with an intramuscular needle in order to localize the location of the vein with minimal risk of damaging light or massive bleeding if the artery is inadvertently punctured. The needle is placed at the puncture point in a plane parallel to the floor, the direction is caudal. After that, the syringe is deflected laterally with awards, while the needle is directed towards the sternum, then the syringe is tilted downwards at approximately awards, i.e. the needle should go under the collarbone, sliding along its inner surface.

The needle is smoothly guided in the selected direction, while the vacuum is maintained in the syringe. The picture schematically continues the movement of the needle (blue arrow), as you can see, its direction approximately indicates the sternoclavicular joint, which is recommended to be used as a guide for the primary search puncture. As a rule, the vein is located at a distance of 1-3 cm from the skin. If, after passing the search needle along the very pavilion, you did not manage to find a vein, also smoothly withdraw it back, not forgetting to maintain a vacuum in the syringe, because. the needle may have passed through two walls of the vein, in which case you will receive blood in the syringe on reverse traction.

If it is impossible to determine the vein during puncture in the selected direction, you can try other options for puncture from the same point. I recommend decreasing the lateral angle of the needle and pointing it slightly below the sternoclavicular joint. The next step is to reduce the angle of deviation from the horizontal plane. In third place among alternative methods, I put an attempt to puncture from another point located laterally from the angle of intersection of the clavicular head of the sternocleidomastoid muscle with the upper edge of the clavicle. In this case, the needle should also be directed primarily towards the sternoclavicular joint.

The puncture of the vein with a needle from the set is performed in the direction determined during the search puncture. In terms of reducing the risk of pneumothorax, it is recommended to advance the syringe with the needle between breaths, which is true for both spontaneous breathing and mechanical ventilation in mechanically ventilated patients. Needless to mention further the maintenance of vacuum in the syringe and the possibility of being in a vein when the syringe is retracted.

Having received the blood in the syringe, evaluate its color, in case of doubt that the blood is venous, you can try to carefully disconnect the syringe while holding the needle in place to assess the nature of the outflow of blood (a pulsation of scarlet blood, of course, indicates an arterial puncture). Sometimes, with high central venous pressure, blood can flow from the needle with a characteristic pulsation, which can be misleading and force the doctor to repeat punctures with an increased risk of puncture complications. Sufficient specificity in relation to verification of being in a vein has a technique for recording blood pressure in a needle, for the application of which a sterile line is required, the corresponding end of which is extended to an assistant, who will connect it to a pressure sensor and fill it with a solution. No curve blood pressure and characteristic curve for venous pressure indicate entry into the vein.

Once you are sure you have found the vein, remove the syringe while holding the needle in place. Try to rest your hand on some immovable structure (collarbone) to minimize the risk of needle migration from the lumen of the vein due to microtremor of the fingers at the moment when you take the guidewire. The guidewire should be placed in close proximity to you so that you do not have to bend and reach in an attempt to get it, as this most often loses concentration on holding the needle still and it comes out of the lumen of the vein.

The conductor should not encounter significant resistance during insertion, sometimes you can feel the characteristic friction of the corrugated surface of the conductor on the edge of the cut of the needle if it exits at a large angle. If you feel resistance, do not try to pull out the conductor, you can try to rotate it and if it rests against the wall of the vein, it may slip further. When the conductor is pulled back, it can catch on the edge of the cut with a braid and, at best, “get tattered”, in the worst case, the conductor will be cut off and you will get problems incommensurable with the convenience of checking the position of the needle without removing it, but removing the conductor. Thus, with resistance, remove the needle with the conductor and try again, already knowing where the vein passes. The conductor is inserted into the needle no further than the second mark (from the needle pavilion) or cm to prevent it from entering the atrial cavity and flotation there, which can provoke arrhythmias.

A dilator is inserted along the conductor. Try to take the dilator with your fingers closer to the skin in order to avoid bending the conductor and additional tissue injury, and even a vein. There is no need to insert the dilator right up to the pavilion, it is enough to create a tunnel in the skin and subcutaneous tissue without penetration into the lumen of the vein. After removing the dilator, it is necessary to press the puncture site with your finger, because. from there, a copious flow of blood is possible.

The catheter is inserted to a depth cm. After the introduction of the catheter, its position in the vein is traditionally verified by blood aspiration, free outflow of blood indicates that the catheter is in the lumen of the vein.

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 through the conductor”), but also according to the principle “catheter through the 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.

The use of ultrasound guidance has been promoted as a method to reduce the risk of complications during central venous catheterization. According to this technique, an ultrasound test is used to localize the vein and measure the depth of its location under the skin. Then, under the control of ultrasound imaging, the needle is passed through the tissue into the vessel. Ultrasound guidance during internal jugular vein catheterization reduces the number of mechanical complications, the number of failures in catheter placement, and the time required for catheterization. The fixed anatomical connection of the subclavian vein to the clavicle makes ultrasound-guided catheterization more difficult than catheterization based on external landmarks. As with all new techniques, ultrasound-guided catheterization requires practice. If ultrasound equipment is available in the hospital and clinicians are adequately trained, ultrasound guidance should usually be considered.

Requirements for catheter care

Before each catheter insertion medicinal substance from it it is necessary to obtain a free blood flow 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. Catheter stay in 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).

Ointments, subcutaneous cuffs and dressings. Applying an antibiotic ointment (eg, Bazitramycin, 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. Such ointments should not be used. The use of silver-impregnated hypodermic cuffs also does not reduce catheter infections involving the bloodstream and is therefore not recommended. Because data on the optimal type of dressing (gauze vs. transparent materials) and the optimal dressing frequency are conflicting.

Sleeves and systems for needleless injections. Catheter plugs are a common source of contamination, especially during prolonged catheterization. The use of two types of antiseptic-treated plugs has been shown to reduce the risk of catheter infections involving the bloodstream. In some hospitals, the introduction of needle-free systems has been associated with an increase in these infections. This increase was due to non-compliance with the manufacturer's requirement to change the plug after each injection and the entire needle-free injection system every 3 days, due to the fact that more frequent plug changes were required before the rate of catheter infections involving the bloodstream returned to baseline.

Change of catheter. Because the risk of catheter infection increases over time, each catheter should be removed as soon as it is no longer needed. In the first 5–7 days of catheterization, the risk of catheter colonization and catheter infections involving the bloodstream is low, but then begins to increase. Multiple studies have investigated strategies to reduce catheter infections, including catheter repositioning with a guidewire, and planned routine catheter repositioning at a new site. However, none of these strategies has been shown to reduce catheter infections involving the bloodstream. In fact, the planned routine replacement of the catheter over the guidewire was accompanied by a trend towards an increase in the number of catheter infections. In addition, placement of a new catheter in a new site was more frequent if the patient had mechanical complications during catheterization. A meta-analysis of the results of 12 studies of catheter replacement strategies showed that the data do not support either guidewire catheter repositioning or planned routine catheter repositioning at a new site. Accordingly, the central venous catheter should not be repositioned without reason.

Wound of the subclavian artery. This is detected by a pulsating stream of scarlet blood entering the syringe. The needle is removed, the puncture site is pressed for 5-8 minutes. Usually, an erroneous puncture of the artery in the future is not accompanied by any complications. However, the formation of a hematoma in the anterior mediastinum is possible.
Puncture of the dome of the pleura and the apex of the lung with the development of pneumothorax. An unconditional sign of a lung injury is the appearance of subcutaneous emphysema. The likelihood of complications with pneumothorax is increased with various deformities of the chest and with shortness of breath with deep breathing. In these cases, pneumothorax is the most dangerous. At the same time, damage to the subclavian vein with the development of hemopneumothorax is possible. This usually happens with repeated unsuccessful attempts at puncture and gross manipulations. The cause of hemothorax can also be perforation of the wall of the vein and the parietal pleura with a very rigid conductor for the catheter. The use of such conductors shall be prohibited.. The development of hemothorax may also be associated with damage to the subclavian artery. In such cases, hemothorax is significant. When puncturing the left subclavian vein in case of damage to the thoracic lymphatic duct and pleura, chylothorax may develop. The latter can be manifested by abundant external lymphatic leakage along the catheter wall. There is a complication of hydrothorax as a result of the installation of a catheter into the pleural cavity, followed by the transfusion of various solutions. In this situation, after the catheterization of the subclavian vein, it is necessary to perform a control chest x-ray in order to exclude these complications. It is important to consider that if the lung is damaged by a needle, pneumothorax and emphysema can develop both in the next few minutes and several hours after the manipulation. Therefore, with difficult catheterization, and even more so with accidental lung puncture, it is necessary to purposefully exclude the presence of these complications not only immediately after the puncture, but also during the next day (frequent auscultation of the lungs in dynamics, X-ray control, etc.).
Excessively deep insertion of the conductor and catheter may damage the walls of the right atrium, as well as the tricuspid valve with severe cardiac disorders, the formation of parietal thrombi, which can serve as a source of embolism. Some authors observed a spherical thrombus that filled the entire cavity of the right ventricle. This is more common with rigid polyethylene guidewires and catheters. Their application should be prohibited. Excessively elastic conductors are recommended to be boiled for a long time before use: this reduces the rigidity of the material. If it is not possible to select a suitable conductor, and the standard conductor is very rigid, some authors recommend performing the following technique - the distal end of the polyethylene conductor is first slightly bent so that an obtuse angle is formed. Such a conductor is often much easier to pass into the lumen of the vein without injuring its walls.
Embolism with guidewire and catheter. Embolism with a conductor occurs due to the cutting of the conductor by the edge of the needle tip when the conductor deeply inserted into the needle is quickly pulled towards itself. Catheter embolism is possible when the catheter is accidentally cut and slipped into the vein while cutting the long ends of the fixing thread with scissors or a scalpel or when removing the thread fixing the catheter. It is impossible to remove the conductor from the needle. If necessary, remove the needle together with the guidewire.
Air embolism. In the subclavian vein and the superior vena cava, pressure can normally be negative. Causes of embolism: 1) suction during breathing air into the vein through the open pavilions of the needle or catheter (this danger is most likely with severe shortness of breath with deep breaths, with puncture and catheterization of the vein in the patient's sitting position or with the body elevated); 2) unreliable connection of the catheter pavilion with a nozzle for needles of transfusion systems (non-tightness or not noticed their separation during breathing, accompanied by air being sucked into the catheter); 3) accidental tearing of the plug from the catheter with simultaneous inspiration. To prevent air embolism during puncture, the needle should be connected to the syringe, and the introduction of the catheter into the vein, disconnecting the syringe from the needle, opening the catheter pavilion should be done during apnea (holding the patient's breath on inspiration) or in the Trendelenburg position. Prevents air embolism by closing the open pavilion of the needle or catheter with a finger. During mechanical ventilation, prevention of air embolism is provided by ventilation of the lungs with increased volumes of air with the creation of positive pressure at the end of exhalation. When carrying out infusion into a venous catheter, constant careful monitoring of the tightness of the connection between the catheter and the transfusion system is necessary.
Injury to the brachial plexus and organs of the neck(rarely seen). These injuries occur when the needle is deeply inserted with the wrong direction of injection, with a large number of attempts to puncture the vein in different directions. This is especially dangerous when changing the direction of the needle after it is deeply inserted into the tissue. In this case, the sharp end of the needle injures the tissues like a car windshield wiper. To exclude this complication, after an unsuccessful attempt to puncture the vein, the needle must be completely removed from the tissues, the angle of its introduction in relation to the clavicle of the awards should be changed, and only after that the puncture should be performed. In this case, the point of injection of the needle does not change. If the conductor does not pass through the needle, it is necessary to make sure that the needle is in the vein with a syringe, and again, pulling the needle slightly towards you, try to insert the conductor without violence. The conductor must pass completely freely into the vein.
Soft tissue inflammation at the puncture site and intracatheter infection is a rare complication. It is necessary to remove the catheter and more strictly observe the requirements of asepsis and antisepsis when performing a puncture.
Phlebothrombosis and thrombophlebitis of the subclavian vein. It is extremely rare, even with prolonged (several months) administration of solutions. The frequency of these complications is reduced if high-quality non-thrombogenic catheters are used. Reduces the frequency of phlebothrombosis regular flushing of the catheter with an anticoagulant, not only after infusions, but also in long breaks between them. With rare transfusions, the catheter is easily clogged with clotted blood. In such cases, it is necessary to decide whether it is advisable to keep the catheter in the subclavian vein. If signs of thrombophlebitis appear, the catheter should be removed, appropriate therapy is prescribed.
disposition of the catheter. It consists in the exit of the conductor, and then the catheter from the subclavian vein to the jugular (internal or external). If a disposition of the catheter is suspected, X-ray control is performed.
Catheter obstruction. This may be due to blood clotting in the catheter and its thrombosis. If a thrombus is suspected, the catheter should be removed. A gross mistake is to force a thrombus into a vein by “flushing” the catheter by introducing liquid under pressure into it or by cleaning the catheter with a conductor. Obstruction may also be due to the fact that the catheter is bent or rests with its end against the wall of the vein. In these cases, a slight change in the position of the catheter allows you to restore its patency. Catheters installed in the subclavian vein must have a transverse cut at the end. It is unacceptable to use catheters with oblique cuts and with side holes at the distal end. In such cases, there is a zone of the lumen of the catheter without anticoagulants, on which hanging blood clots form. Strict adherence to the rules for caring for the catheter is necessary (see the section "Requirements for caring for the catheter").
Paravenous administration of infusion-transfusion media and other medicinal products. The most dangerous is the introduction of irritating liquids (calcium chloride, hyperosmolar solutions, etc.) into the mediastinum. Prevention consists in the obligatory observance of the rules for working with a venous catheter.

Algorithm for the management of patients with catheter-associated bloodstream infections (CAIC)

AMP - antimicrobials

Algorithm for managing patients with bacteremia or fungemia.

AMP - antimicrobials

"Antibacterial lock" - the introduction of small volumes of a solution of antibiotics in high concentration into the lumen of the CVC of the catterer, followed by exposure for several hours (for example, 8-12 hours at night when the CVC is not used). As a "lock" can be used: Vancomycin at a concentration of 1-5 mg / ml; Gentamimin or Amikocin at a concentration of 1-2 mg / ml; Ciprofoloxacin at a concentration of 1-2 mg / ml. Antibiotics are dissolved in 2-5 ml of isotonic NaCl with the addition of Heparin ED. Before subsequent use, the Antibacterial Castle CVC is removed.

Features of puncture and catheterization of the subclavian vein in children

Puncture and catheterization must be performed under conditions of perfect anesthesia, ensuring the absence of motor reactions in the child.
During the puncture and catheterization of the subclavian vein, the child's body must be given the Trendelenburg position with a high roller under the shoulder blades; the head leans back and turns in the direction opposite to the punctured one.
Change of aseptic dressing and treatment of the skin around the injection site should be done daily and after each procedure.
In children under 1 year old, it is more expedient to puncture the subclavian vein from the subclavian access at the level of the middle third of the clavicle (Wilson's point), and at an older age - closer to the border between the inner and middle thirds of the clavicle (Aubanyac's point).
The puncture needle should not have a diameter of more than 1-1.5 mm, and a length of more than 4-7 cm.
Puncture and catheterization should be performed as atraumatically as possible. When performing a puncture, a syringe with a solution (0.25% novocaine solution) must be put on the needle to prevent air embolism.
In newborns and children of the first years of life, blood often appears in the syringe during the slow removal of the needle (with simultaneous aspiration), since the puncture needle, especially not sharpened, easily pierces the anterior and posterior walls of the vein due to the elasticity of the child's tissues. In this case, the tip of the needle may be in the lumen of the vein only when it is removed.
Conductors for catheters should not be rigid, they must be inserted into the vein very carefully.
With a deep introduction of the catheter, it can easily get into the right parts of the heart, into the internal jugular vein, both on the side of the puncture and on the opposite side. If there is any suspicion of an incorrect position of the catheter in the vein, an X-ray control should be carried out (2-3 ml of a radiopaque substance is injected into the catheter and a picture is taken in the anterior-posterior projection). The following depth of catheter insertion is recommended as optimal:

premature newborns - 1.5-2.0 cm;
full-term newborns - 2.0-2.5 cm;
infants - 2.0-3.0 cm;
children aged 1-7 years - 2.5-4.0 cm;
children aged 7-14 years - 3.5-6.0 cm.

Features of puncture and catheterization of the subclavian vein in the elderly

In elderly people, after puncture of the subclavian vein and passage of a conductor through it, the introduction of a catheter through it often encounters significant difficulties. This is due to age-related changes in tissues: low elasticity, reduced skin turgor and sagging of deeper tissues. At the same time, the probability of success of the catheter is increased when it is wetting(physiological solution, novocaine solution), as a result of which the friction of the catheter decreases. Some authors recommend cutting the distal end of the catheter at an acute angle to eliminate resistance.

Angiography c refers to the X-ray contrast study of 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.