Wire catheterization - central and perfiric: readings, rules and algorithm for the installation of the catheter. Machinery catheterization of a subclavian vein on the Seld Salineer Plug catheter for what

This is a medical manipulation. But the Feldsher should know well how it is performed, in order to help a qualified doctor. The FAP should have a ready-made sterile set for puncture and catheterization. connected Vienna.

Materials and tools. The set for the puncture of the connector vein consists of a thick needle with a slice at an angle of 45 ° 10-15 cm long and a sterile, long-term storage period for the catheterization of a connector vein consisting of a polyethylene catheter (with a diameter of 0.8; 1; 1.4 mm), Lerkest conductor and two or three rubber caps-plugs. The set is produced by the medical industry. Then the syringe 20 ml is needed, a leather anesthesia needle, a novocaine solution 0.25%, alcohol, iodonate, sterile lining for the separation of the operating field. It is advisable to have sterile gloves.

Powder manipulation. The patient is stacked on the back. Under the blades, a roller or a pillow with a thickness of about 10-15 cm in order for the head to be trapped. The head turn to the side opposite catheterization. Operational field is processed: side surface of the neck, over- and plug-in area and region shoulder Sustav. Surgeon washes and handles hands or puts on sterile gloves. Anesthesia of the skin is performed above or under the clavicle depending on the method of puncture. Then a thick needle, sending forward a novocaine solution, the surgeon punctures Vienna. After making sure that the needle was in Vienna in the appearance of blood in a blood syringe, the syringe disconnects and through the needle to the vein injected the conductor. The needle is removed. Then, on the conductor screwing the movements, the catheter is introduced to a depth of about 5-10 cm. The conductor is removed and, making sure that the catheter is in Vienna, proceed to the infusion of medicines. The catheter is fixed with a sticky plaster or laid to the skin.

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For connect access Several points can be used in the plug-in area: Aubaniak, Wilson and Dzhles. Aubaniak point is located 1 cm below the clavicle along the line separating the inner and average third of the clavicle; Wilson's point is 1 cm below the clavicle on the mid-croilent line; Dipper Dzhila is 1 cm below the clavicle and 2 cm in the sternum. In adults for puncture, the point of Aubaniak is most often used.

The needle is directed to the upper edge of the sternosal articulation in such a way that the injection between the needle and the collar is 45 °, and to the plane chest - 25 °. Tightening constantly the piston of the syringe filled with novocaine or saline, slowly promoted the needle in the selected direction (without changing it!). The appearance of blood in the syringe indicates a needle tip in the clearance of the vessel. If blood does not appear in the syringe, but the needle entered the tissue deep enough, then it is necessary to start slowly to take it in the opposite direction (on itself), continuing to create a vacuum in the syringe.

It happens that the needle passes both walls and blood enters the needle clearance only when removing in the opposite direction. After that, the syringe is disconnected and the conductor is introduced through the needle clearance. If the conductor does not pass, then it is advisable to turn the needle around my axis. In our opinion, the change in the position of the needle in Vienna, as V. D. Malyshev (1985) recommends, is unacceptable, for the danger of the division of veins bears. It is impossible to allow an enforced progress of the conductor and the reverse extract. The latter is associated with the danger of cutting the conductor and getting it into the vessel. After removing the needle on the conductor, the polyethylene catheter is introduced with neat rotational movements to the desired depth. By connecting the syringe to the catheter, determined the correctness of the situation: the blood should freely enter the syringe. The catheter is filled with a solution of heparin - 1000 units per 5 ml of isotonic NaCl solution.

The cannula of the catheter is closed by a plug, which is covered with a sterile napkin. Some doctors fix the catheter to the skin of the seam. The place of puncture must be treated with diamond green, and it is better to cover the "Lifusol" aerosol, the catheter is fixed with bactericidal adhesive plane to the skin.

For included access The inclination point is located in the corner formed by the lateral leg of the breast-curable-cottage muscle and the clavicle. The needle is directed to the lower edge of the stern-gluable articulation, the slope of it in relation to the skin is 15 °. The remaining manipulations are performed in the same sequence as under connected access.

Inner jugular vein Powdle only on the right, since the puncture of the left jugular vein carries the risk of damage to the breast lymphatic duct. The patient is stacked as well as for the puncture of the connective vein. Valka needles produce between the legs of the sternum-key-preceding muscle by 1-1.5 cm above the breast-gluable articulation. The needle should be an angle with a sagittal plane of 60 °, and with the skin surface - 30-45 °.

Catheterization of external jugular veins Made after its surgical selection.

For infusion therapy Systems of one-time use are used in which the nozzle size is designed in such a way that the drop volume is 0.05 ml. Consequently, 1 ml will contain 20 drops. In order to determine the rate of administration of solutions in CAP / min, it is necessary to divide the amount of planned infusion in the tripled time during which the infusion is expected.

Puncture and catheterization of the main veins (medical manipulation)

Indications: Intensive infusiono-transfusion therapy, parenteral nutrition, disintellation therapy, intravenous antibi-octic therapy, sounding and contrasting of the heart, the measurement of the CVD, the implantation of the pacemaker, the impossibility of catheterization of peripheral veins, etc. The use of puncture and catheterization of the main veins has become a choice of intensive therapy and resuscitation departments.

Advantages consist in the possibility of a long (up to several days and weeks) of using the only access to the venous bed, the possibility of massive infusions and the introduction of concentrated solutions, unlimited mobility of the patient in bed, the convenience of serving the patient, etc.

Contraindications: Disorders of the coagulation system of blood, inflammatory processes at the point of puncture and catheterization, injury in the region of the clavicle, bilateral pneumothorax, pronounced respiratory failure with emphysens of the lungs, the upper hollow hollow syndrome, the Podgeta Schurtber syndrome.

For venopunction and catheterization of central veins, you can use the upper and lower hollow veins. It is preferable to spend the catheterization of the upper hollow vein, because At the same time, the mobility of the patient is preserved, the FED measurement is ensured, the danger of troom-milkmic complications is reduced.

Mostly for the catheterization of the upper floor of the vein use an approach through a subclavian vein. The widespread use of this access, according to V.A. Gologogorsky (1972), V.A. Zhuravleva (1985), E.A. Vagner (1986), Yu.F.Sakova and Yu.M. Lopukhina (1989), E.L. Bulanova and

P.A. Vorobyva (1996), etc., due to the anatomy-physiological features of the subclavian vein: Vienna is distinguished by a large diameter, constancy of the location and clear topographic anatomical benchmarks; Vienna vagina fascinated with the perception of the clavicle and I edges. Culgious and thoracic fascia, which ensures the immobility of the vein and prevents its decline even with a sharp decrease in blood volume when all others peripheral Vienna fall out; The location of the vein provides a minimal risk of external infection, does not limit the mobility of patients within the beddown; A significant lumeitive of the vein and the rapid flow of blood in it prevented the thrombotion-vanigo, allow to introduce hypertensive solutions, provide the possibility of simultaneous administration of significant amounts of liquid and for a long time.

This also includes the absence of valves in the lumen of the veins, which ensures the adequacy of physical parameters when measuring the CVD. However, such an approval can be questioned if you get acquainted with the works of V.Dachi (1933), V.N. Shevkunenko (1949), A.N. Maxi - Menkova (1955).

Low pressure in the vein and the density of the surrounding tissues prevents the occurrence of post-section hematomas.

The subclavian vein is the immediate continuation of the axillary, the boundary between them serves the outer edge of the ribs. Here it lies on the top surface of the rib behind the clavicle, located in the preliminary interval in front of the front staircase, csy, then deflects it down and is suitable for the rear surface of the breast-key joint, where it merges with the inner jugular vein, forming a shoulder vein. To the left in the venous angle of the depression

it is breast lymphatic duct, and right - right lymphatic doc. Merger right and left shoulder vein Forms upper hollow vein. In front of All lengths connected Vienna separated fromskin the clavicle, reaching its highest point on Level middle.Lateral part Vienna is the Kepenta and Book Ot Connect artery. Medial vein and artery shares the front staircase muscle with Located on it a diaphragmal nerve, leaving for vienna, A.then in the front mediastone.

In newborns I. Children up to 5. i am connective years old Vienna is projected by the middle of the clavicle, in more older - on Border between internal I. Middle thirds clavicle. Diameter vienna U. Newborn 3-5 mm, in children under 5 years old - 3-7 mm, in children older 5 years - 6-11 mm, in adults 11-26 mm in the finite section of the vessel. Vienna length in adults2-3 cm.

For puncture and catheterization of the subclavian veins, under-and-inviogencies are proposed (Fig. 26).

Fig. 26. Puncture scheme Catheterization through connect vein. one - jugular vein; 2- breast-key-deputy muscle; 4 - clavicle; 5 - connectible vein; 6-1th edge; 7. - top hollow vein; eight -

2nd edge.

1. Connect method:

Puncture of Vienna The book from the clavicle is more justified, because Through the upper wall, large venous trunks, chest or jugular

lymphatic ducts, above clavicle Connected Vienna is closer to the dome of the pleura, while from below Separated from the pleura 1 edge, above the veins and the dodder pass through the subclavian artery and shoulder plexus.

The patient is placed on the back with his hands given to the body. The foot end of the bed is advisable to raise 15-25 ° to increase the venous tributary, which makes it easier to enter the blood in a syringe even with minimal aspiration, and reduces the risk of air embolism. It should be remembered that the position of Trendelenburg is not all patients with all patients.

The head of the patient is turned into the opposite direction from the puncture to tension the rear staircase muscle, which contributes to the swelling of the vein.

Catheterization of the subclavian vein is better to do on the right, because On the left there is a risk of damage to the breast lymphatic duct flowing into the left venous angle. In addition, the path through it to the heart is shorter, straight, vertical. The pleura from the right veins is further than the left.

Pupcation needle with a length of 10-12 cm, with an inner lumen of 1.5-2 mm and a slice of the island at an angle of 40-45 ° connected to a syringe filled with a solution of novocaine or isotonic solution of sodium chloride, pierce the skin Pa 1 cm Book from the lower edge of the clavicle Pa border of her inner and middle third (in Abuniac, 1952). The needle is installed at an angle of 45 ° to the clavicle and 30-40 ° to the surface of the chest and slowly spend into the space between the collar and I edge, directing the tip of the needle behind the clavicle to the upper edge of the groom-dino-key joint. The needle usually falls into the end portion of the connector vein at a depth of 1-1.5 cm in newborns, 1.5-2.5 cm in children under 5 years, 3-4 cm in adults. Promotion of the needle in the depth of soft tissues stops from the moment of blood appearance in the syringe. Carefully sipping the piston on ourselves, under the control of blood flow in the syringe, the needle is carried out into the lumen by 1-1.5 cm.

It should be remembered that the lumen of the plug-in vein, contrary to the existing for a long time Opinion changes depending on the respiratory phase: increases on exhalation and decreases to breathe up to its disappearance (R.N. Kalashnikov, E.V. Rezakhkovsky, P.P. Savin, A.V. Sirnov, 1991). The amplitude of oscillations can reach 7-8 mm.

To control the correct position of the needle cut, in Vienna helps applying scourments or attack on the needle pavilion, respectively,

rone of her sharpening. For the prevention of an air embolism at the time of disconnecting the needle or catheter from the syringe or system to inflate the patient, they ask to take a deep breath, delay their breath and close the needle cannula with a finger, and during IVL increase the pressure in the respiratory circuit. It is advisable to avoid conducting puncture with coughing patients or when the patient is in a half-time position. Disconnecting the syringe, the needle pavilion immediately overlap. Through the clearance of the CGL, the conductor is introduced (the line of polyethylene with a diameter of 0.8-1 mm and 40 cm in diameter) to a depth of 12-15 cm, not less than the length of the catheter, after which the needle is carefully removed. Polyethylene catheter has been putting on the conductor, it is promoted to the lumen of veins by 8-12 cm by rotational and translational movements, the conductor is extracted (catheterization by the method of the celebringer) (Fig. 27). The catheter should penetrate into a vein freely, without effort, and the end of it is located in the upper part of the upper hollow vein, over the pericardium, in the maximum zone

Technique catheterization

The room where the CPV should be carried out with the operating sterility mode: dressing, reanimation unit or operating room.

In preparation for the patient's CPV, it is placed on an operating table with an omitted head end 15 ° for the prevention of an air emblem.

The head is turned toward the opposite punctured, the hands are elongated along the body. In sterile conditions, a hundred is covered with the above tools. The doctor washes his hands as before the usual operation, puts on gloves. The operating field is processed twice with 2% iodine mortar, placed with a sterile diaper and is accessed again with 70 ° alcohol.

Connect access .. A thin needle with a thin needle intracudinoly introduces 0.5% r-p procaine to create a "lemon crust" at a point located 1 cm below the clavicle on the line separating the middle and inner third of the clavicle. The needle is promoted by medially towards the upper edge of the breast-clearable articulation, continuously background R-PRAIN. The needle is carried out under the worship and put the residue of the procaine. The needle is removed .. a thick sharp needle, restricting the index finger to the depth of its administration, pierced the skin at a depth of 1-1.5 cm at the location of the lemon crust. The needle is removed .. In a syringe with a capacity of 20 ml to half, 0.9% rr sodium chloride is gaining, it is not very sharp (to avoid the artery puncture) 7-10 cm length with a stupidly bevelined end. The direction of the bevel must be marked on the cannula. When the needle is introduced, its SCOS must be focused in the caudally medial direction. The needle is introduced into the puncture, pre-made acute needle (see above), while the depth of possible administration of the needle must be limited to the index finger (no more than 2 cm). The needle promotes medially towards the upper edge of the breast-cleaned articulation, periodically sipping the piston back, checking blood flow into the syringe. If the needle fails, it is advised back, without removing it completely, and repeat an attempt by changing the direction of promotion for several degrees. As soon as blood appears in the syringe, part of it is introduced back to Vienna and again they suck into the syringe, trying to get a reliable reverse blood flow. In case of receipt positive result They ask the patient to delay her breathing and remove the syringe from the needle, pinning her hole with a finger .. In the needle, the conductor is introduced into the needle, its length is two with a little time exceeds the length of the catheter. Again, they ask the patient to delay their breath, the conductor is removed by covering the opening of the catheter with his 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 associated with the depressurization of the enlightenment of the needle or catheter, located in a subclavian vein, produce during exhalations .. The catheter is connected to the infusion system and fixed to the skin of a single silk suture. Apply a aseptic dressing.

Behind the breast-drawn articulation, the inner jugular and connectible vein merge, forming a shoulder barrel. Subclavian artery I. shoulder plexus Located behind the plug-in vein, being separated from the veins of the front staircase. The diaphragmapy nerve and inner chest artery take place behind the medial part of the veins, and the nearest is located in the left.

Puncture is produced by 1 cm below the point located between the inner and medium third clavicle. If possible, plastic bag with liquid or other soft object between the patient's blades in order to break the spine.

Proceed with a skin with a solution of iodine or chlorhexidine.

Infiltrate the skin, subcutaneous tissue and periosteum along the lower surface of the clavicle with a anesthetic solution, introducing a needle with a green pavilion (21G) to the pavilion, beating the introduction of anesthetic to Vienna.

Connect the needle conductor with a 10-millilitone syringe and promote the needle under the worship. Safer first to send the needle to the clavicle, and then lead it directly under the wist and for it. Keeping such a direction, promote the needle as high as a dome of the pleura. As soon as the needle slipped over the clavicle, slowly promote it towards the opposite sternum-clavical joint. When using this technique, the percentage of success during the catheterization of the connector vein is high, and the risk of pneumothorax is small.

After aspiration of venous blood turn the needle to the heart. This will make it easy to facilitate the establishment of the conductor in the shoulder barrel.

The conductor must move freely into Vienna. With the feeling of resistance, try to promote it during the phase of inhalation or exhalation.

After promoting the conductor, an exemplary needle is retrieved and dilator dilated on the conductor. After removing the dilatode, pay attention to its form; It should be a little bent down. If it is bent up, this means that the conductor was headed into the inner jugular vein (hereinafter rented). With the possibility of x-ray control, the position of the conductor can be corrected, otherwise it will be safer to remove the conductor and repeat the catheterization.

After removing the dilatar, the catheter is started in a vein on the conductor, remove the conductor and fix the catheter to the skin.

After the catheterization of the connectible vein, in order to eliminate the pneumothorax and confirm the correct position of the needle, it is necessary to conduct radiography of the chest organs, especially in the absence of X-ray control.

Catheterization of the central veins under ultrasound control

Traditionally, when conducting catheterization of central veins, anatomical benchmarks use, allowing to determine the course of veins. However, even in healthy people, the location of the veins in relation to these guidelines can change significantly, which causes a certain frequency of failures and serious complications in its puncture and catheterization. The introduction into the medical practice of portable ultrasound equipment made it possible to carry out the catheterization of the central veins under the control of the two-dimensional ultrasound image.

Advantages of this method:

• determination of the real arrangement of veins in relationship with adjacent anatomical structures;
• identifying anatomical features;
• confirmation of the patency chosen for the Vienna puncture. According to the recommendation of the National Institute of Clinical Quality (September 2002), "The method of two-dimensional ultrasound image in some situations is recommended as the preferred method of catheterization in both adults and in children." However, the requirements for the equipment and the medical experience necessary for it restrict the widespread use of this technique at present.

Necessary equipment and staff:

• Standard vehicle catheterization kit.
• When performing the technique, assistance is needed.

Ultrasonic equipment

Screen: Display that allows you to get a two-dimensional image of anatomical structures.

Insulating film: sterile, polyvinyl chloride or latex, sufficient length to close the sensors and the location of their connections to the cable.

Sensors: The converter that sends and perceives the reflected sound wave, converting the information obtained into the image on the screen; marked with arrow or clipping to indicate the direction.

The device works on the battery or from the network.

Sterile gel: misses ultrasound and provides good contact of the sensor with a patient's skin.

Catheterization preparation

Pre-conduct ultrasonic scanning by the non-sterile sensor in order to determine the location of the vein, its size and permeability.

Turn the head to the side of the location of the expected catheterization and are covered with sterile material. In order to increase the blood flow, it raises lower limbs Patient or slightly lower the head if the patient's condition allows it to do. Blide the treated skin sterile linen.

Excessive rotation or extension in cervical department can lead to a decrease in the diameter of the vein. Ultrasonic equipment "You should make sure that the display is clearly visible. "The assistant opens the packaging of the insulating film and squeezes the contact gel on it.

A large amount of gel provides a good airless contact between the sensor and the film. If the gel is not enough, the image quality on the screen will be worse.

The film is worn on the sensor and connecting cable.

Film film on the sensor and smoothed it, as the folds can distort the image.

Again, squeeze some gel on the sensor to ensure good ultrasound and reduce unpleasant sensations in the patient when the sensor is moving.

Scanning

The most popular direction of scanning during catheterization is transverse scanning.

Apply the top of the sensor to the neck outside of the pulsation sleepy artery At the level of the folding cartilage or in the triangle formed by the heads of the breast-curable-luming muscle.

Keep the perpendicular location of the sensor with respect to the skin during the entire study.

Turn the sensor so that its movement to the left or right coincides with the movement on the screen in the same direction. Usually, marks or cuttings are applied to the sensor to facilitate the orientation. During the direction of the label to the right of the patient, the scanning is carried out in a cross-cut, if the label is directed to the head - in the longitudinal slice. The marked side is marked on the bright label screen.

If the vessels are not immediately visualized, the sensor moves to the left and right, while maintaining its perpendicular position with respect to the skin, until the vessels are detected.

When the sensor moves, look at the screen, and not on your hands!

After visualization, this

The sensor is placed so that it has been visible in the central part of the display.

Fix the position of the sensor.

Send the needle (cut to the sensor) in the caudal direction immediately under the marked mark of the middle of the sensor at an angle of 90 ° to the skin.

The needle slice is sent to the sensor so that it is easier to carry out a conductor in the future.

Promote the needle towards the inner jugular vein.

The needle promotion causes a wave-like tissue offset, the absence of this feature indicates an incorrect position of the needle. Immediately before the puncture, the display can be seen as its lumen is slightly squeezed.

The most difficult aspect of this technique initially its development is the need to conduct puncture and catheterization at a large angle to the skin, but at the same time the needle enters Vienna in the ultrasound plane, which facilitates its visualization, as well as the most direct and short path to Vienna.

With puncture back wall Viennes slowly remove the needle from the vein, conducting a constant aspiration, and stop the extraction when obtaining blood in the syringe, which means the needle in the lumen of the vein.

Conduct the conductor through the needle conductor in the usual way.

Change the angle of inclination of the needle to leather from 60 ° 45 °, which can facilitate the establishment of the conductor. Vienna scanning in a longitudinal cut allows you to visualize the catheter in the lumen of the vein, however, after fixing the catheter and putting the place of puncture, it is still necessary to carry out radiographic control.

Observe sterility throughout the procedure and fix the catheter most convenient for the patient. Most often, especially when catheterization, in a catheter in Vienna, there is a situation due to a partial or full blockade of the catheter due to the partial or complete blockade of the catheter. By connecting the pressure gauge, you should make sure of the catheter's passability, exercising compressing the gauge of the pressure gauge, which simultaneously leads to the elimination of the minimum blockade caused by the inflection of the proximal part of the catheter. Conduct a measuring FED with an orientation to a zero point located along the front axillary line. The CCD decreases with a change in body position to vertical or semi-propical. If this does not occur, lift the console with a CVD monitor approximately 10 cm, and then lowered to the floor. If the FED rises at the same level, then the results detected by the device correspond to reality. Thus, you can make sure that the value measured by the device is rising and decreases to the same values.