Contraindications for catheterization of the subclavian vein. Subclavian catheter placement algorithm

Behind the sternocleidomastoid joint, the internal jugular and subclavian veins merge to form the brachiocephalic trunk. subclavian artery and brachial plexus located behind subclavian vein, being separated from the vein by the anterior scalene muscle. phrenic nerve and internal thoracic artery pass behind the medial part of the vein, and the thoracic duct is located on the left.

The puncture is made 1 cm below the point located between the inner and middle third of the clavicle. If possible, place a plastic bag of liquid or another soft object between the patient's shoulder blades in order to straighten the spine.

Treat the skin with a solution of iodine or chlorhexidine.

The skin, subcutaneous tissue and periosteum are infiltrated along the lower surface of the clavicle with an anesthetic solution, introducing a needle with a green pavilion (21G) to the pavilion, being careful not to inject the anesthetic into the vein.

Connect the guide needle to a 10 ml syringe and advance the needle under the collarbone. It is safer to first guide the needle to the collarbone, and then guide it directly under and behind the collarbone. Keeping this direction, advance the needle as high as possible above the dome of the pleura. As soon as the needle has slipped behind the collarbone, it is slowly advanced towards the opposite sternoclavicular joint. When using this technique, the success rate for catheterization of the subclavian vein is high, and the risk of pneumothorax is low.

After aspiration venous blood turn the cut of the needle towards the heart. This will facilitate the introduction of the conductor into the brachiocephalic trunk.

The conductor must move freely into the vein. When resistance is felt, try to advance it during the inhalation or exhalation phase.

After advancing the conductor, the guide needle is removed and the dilator is inserted along the guide. After removing the dilator, pay attention to its shape; it should be slightly curved down. If it is bent upward, this means that the conductor has been brought into the inner jugular vein(hereinafter VYAV). If fluoroscopy is available, the position of the guidewire can be corrected, otherwise it will be safer to remove the guidewire and retry catheterization.

After removing the dilator, a catheter is inserted into the vein along the guidewire, the guidewire is removed and the catheter is fixed to the skin.

After catheterization of the subclavian vein, in order to exclude pneumothorax and confirm the correct position of the needle, an X-ray of the organs is mandatory. chest especially in the absence of fluoroscopy.

Central venous catheterization under ultrasound guidance

Traditionally, when performing central vein catheterization, anatomical landmarks are used to determine the course of the vein. However, even healthy people the location of the vein in relation to these landmarks can vary significantly, which leads to a certain frequency of failures and serious complications during its puncture and catheterization. Implementation in medical practice portable ultrasound equipment has made it possible to perform central venous catheterization under the control of a two-dimensional ultrasound image.

Advantages of this method:

• determination of the real location of the vein in relation to the adjacent anatomical structures;
• identification of anatomical features;
• confirmation of the patency of the vein chosen for puncture. As recommended by the National Institute clinical quality(September 2002) "2D ultrasound imaging is recommended in some situations as the preferred method for IVJ catheterization in both adults and children." However, the requirements for the equipment and the medical experience necessary for its implementation limit the wide use of this technique at present.

Required equipment and personnel:

• Standard set for venous catheterization.
• When performing the technique, the help of an assistant is required.

Ultrasonic equipment

Screen: A display that provides a two-dimensional view of anatomical structures.

Insulating film: sterile, PVC or latex, long enough to cover the sensors and their connection to the cable.

Sensors: A transducer that sends and receives reflected sound wave, converting the received information into an image on the screen; marked with an arrow or notch to indicate the direction.

The device operates on battery or mains power.

Sterile gel: transmits ultrasound and ensures good contact of the transducer with the patient's skin.

Preparation for catheterization

An ultrasound scan is preliminarily performed with a non-sterile sensor in order to determine the location of the vein, its size and patency.

Turn the head away from the site of the proposed catheterization and cover it with a sterile material. In order to increase blood supply, the VJV is raised lower limbs the patient or lower their head slightly if the patient's condition allows it. Cover the treated skin with sterile linen.

Excessive rotation or extension in cervical region can lead to a decrease in the diameter of the vein. Ultrasound Equipment « Make sure the display is clearly visible. « The assistant opens the package of insulating film and squeezes contact gel onto it.

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

The film is put on the sensor and the connecting cable.

Fix the film on the sensor and smooth it out, as wrinkles can distort the image.

Squeeze some gel onto the transducer again to ensure have a good time ultrasound and reduction discomfort in the patient when the probe is moved.

Scanning

The most popular scanning direction for VJV catheterization is transverse scanning.

Apply the tip of the transducer to the neck outside of the pulsation site. carotid artery at the level of the cricoid cartilage or in the triangle formed by the heads of the sternocleidomastoid muscle.

Keep the transducer perpendicular to the skin throughout the study.

Rotate the sensor so that its movement to the left or right coincides with the movement on the screen in the same direction. Typically, marks or cutouts are applied to the sensor to facilitate orientation. When the mark is directed to the right of the patient, scanning is carried out in a transverse section, if the mark is directed towards the head - in a longitudinal section. The marked side is marked on the screen with a bright mark.

If vessels are not immediately visualized, move the transducer left and right, keeping it perpendicular to the skin, until vessels are detected.

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

After VJV visualization:

The sensor is placed so that the VNV is visible in the central part of the display.

Fix the position of the sensor.

Guide the needle (bevel toward the transducer) caudally just below the marked middle of the transducer tip at a 90° angle to the skin.

The cut of the needle is directed to the sensor, so that in the future it will be easier to pass the conductor into the VYaV.

The needle is advanced towards the internal jugular vein.

The advancement of the needle causes a wave-like displacement of tissues, the absence of this sign indicates an incorrect position of the needle. Immediately before the puncture of the VJV on the display, you can see how its lumen is slightly compressed.

The most difficult aspect of this technique at the beginning of its development is the need to puncture and catheterize at a large angle to the skin, but at the same time the needle enters the vein in the ultrasound plane, which facilitates its visualization, and this is the most direct and shortest path to the vein.

When punctured rear wall the veins slowly withdraw the needle from the vein by continuously aspirating, and stop the withdrawal when blood is received in the syringe, which means the needle enters the lumen of the vein.

The conductor is passed through the conductor needle in the usual way.

Change the angle of the needle to the skin from 60° to 45°, which can facilitate the insertion of the guidewire. Scanning a vein in a longitudinal section allows visualization of the catheter in the lumen of the vein, however, after fixing the catheter and sealing the puncture site, radiographic control is still necessary.

Maintain sterility throughout the procedure and fix the catheter in the most convenient way for the patient. Most often, especially when catheterization of VJV and the catheter being in the vein for some time, there is a situation when, due to partial or complete blockade catheter, there are difficulties in determining the CVP. Having connected the manometer, one should make sure that the catheter is patency by compressing the rubber balloon of the manometer, which at the same time leads to the elimination of minimal blockades caused by the kink of the proximal part of the catheter. The CVP is measured with an orientation to the zero point located along the anterior axillary line. CVP decreases when the body position changes to vertical or semi-vertical. If this does not happen, raise the console with the CVP monitor by about 10 cm, and then lower it to the floor. If the CVP rises to the same level, then the results detected by the device correspond to reality. Thus, it can be verified that the CVP value measured by the device rises and falls by the same values.

Catheterization technique

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

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

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

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

Indications:

The need for intravenous infusions during transportation of a sick or wounded person;

Prolonged infusion of drugs;

Measurement and monitoring of CVP;

Difficulties in puncturing peripheral veins.

Contraindications:

Thrombosis of the subclavian vein;

Increased bleeding (prothrombin index below 50%, platelets less than 20x109/l;

untreated sepsis;

Purulent infection in the subclavian region.

1. The patient lies on his back in the Trendelenburg position, a roller is placed between the shoulder blades. The patient's shoulders are turned back, the head is turned in the direction opposite to the puncture, and is slightly thrown back. The hand on the side of catheterization lies along the body and is slightly pulled down.

2. The skin of the subclavian region is treated with an antiseptic solution and delimited with a sterile material.

3. At the border of the inner and middle third of the clavicle, below it by 0.5-1.0 cm, anesthesia of the skin, subcutaneous tissue and periosteum of the clavicle is performed.

4. On a syringe (5 ml) with a 1% solution of novocaine (lidocaine), put on a needle 5-7 cm long with an outer diameter of 1-2 mm and a short cut, which should be directed downwards.

5. The skin is punctured at the border of the inner and middle third of the clavicle, 0.5-1.0 cm below the latter, and, holding the needle horizontally (to avoid pneumothorax), direct it under the clavicle to the upper edge of the sternoclavicular joint.

6. Before each injection of novocaine, a vacuum is created in the syringe to prevent intravascular ingestion of the drug.

7. Constantly pulling the syringe plunger towards you, slowly advance the needle towards the upper edge of the sternoclavicular joint to a depth of 5 cm until venous blood appears in the syringe.

8. If venous blood does not appear in the syringe, the needle is slightly removed, creating a vacuum in the syringe (both walls of the vein could be pierced). If blood is not aspirated, the needle is withdrawn completely and reinserted 1 cm above the jugular notch.

9. If the result is negative, the skin is anesthetized 1 cm lateral to the first puncture and the attempt is repeated from a new point or they switch to the other side.

10. When venous blood appears in the syringe, it is disconnected by closing the needle cannula with a finger to prevent air embolism.

11. While holding the needle in the same position, a conductor (line) is inserted through it, which should freely pass towards the heart.

12. After insertion of the conductor, the needle is removed, constantly holding the conductor, the puncture hole is expanded with a scalpel, and the subcutaneous tissues to a depth of 3-4 cm - with a dilator inserted through the conductor.

13. The dilator is removed, and a central venous catheter is inserted through the conductor for a length of 15 cm on the right and 18 cm on the left.

14. Remove the conductor, aspirate blood from the catheter, inject sterile saline through it, and attach the transfusion system. The catheter is fixed to the skin with interrupted sutures, a sterile bandage is applied to the puncture site.

15. To exclude pneumo- and hemothorax, percussion and auscultation of the chest are performed, and in a hospital, chest x-ray.

Actions for possible complications:

Artery puncture: finger pressure within 5 min, control of hemothorax;

Pneumothorax: with tension pneumothorax - puncture pleural cavity in the II intercostal space along the midclavicular line, with the middle and large - drainage of the pleural cavity;

Heart rhythm disturbances: occur most often when the catheter is located in the right heart and disappear after moving it into the superior vena cava;

Air embolism: aspiration of air through the catheter, turning the patient on the left side and in the Trendelenburg position (the air is “locked” in the right ventricle and gradually resolves), X-ray control in the position given to the patient.

Realizing that it is impossible to learn any manipulations solely from journals, the authors express the hope that this lecture will help those readers who already have the skills to perform operations to create venous access, and will also be of interest to those who are just starting to acquire them.

Oncological disease, even in a common form, is an absolute indication for central vein catheterization. In oncology, among all methods, priority is currently given to implantable venous port systems (IVPS).

Subclavian catheters (SC) in developed countries in the treatment oncological diseases are not used, but in our country they are the most widely used, yielding in some clinics of the country only to peripheral catheters. So, let's consider the technique of catheterization of the central veins using subclavian catheters.

Catheterization technique

Note that only the superior and inferior vena cava belong to the central veins. All others (subclavian, internal jugular, femoral) are peripheral main veins. For this reason, the expression "catheterization of the subclavian (internal jugular) vein" is not entirely correct, since it is the superior vena cava (SVC) that is catheterized through the subclavian (internal jugular) access.

We do not consider catheterization of the inferior vena cava with access through the femoral vein, since this is accompanied by large quantity infectious and thrombotic complications that develop in a short time.

Placement of a central venous catheter

Since the insertion of a central venous catheter is an invasive and painful procedure, in pediatrics it requires adequate anesthesia. In all cases, 40 minutes before the installation of the PC, premedication (preliminary drug preparation) is performed in dosages corresponding to the age and weight of the patients) in order to eliminate fear and anxiety, and reduce vagal reflexes.

• Droperidol 0.25%, 0.1 ml / year of the patient's life intramuscularly;
• Dormicum 0.5% at 0.3-0.5 mg/kg of the patient's body weight intramuscularly;
• Diphenhydramine 1%, 0.1-0.15 ml / year of the patient's life intramuscularly;
• Atropine 0.1%, 0.1 ml / year of the patient's life intramuscularly.

The installation of the PC is carried out using mask anesthesia with nitrous oxide and oxygen (in a ratio of 3:1 or 4:1).

Recall that at present, almost all manufacturers supply PCs as part of sterile installation kits, including a thin-walled needle (Seldinger cannula), a conductor (guiding probe) with length marks and a flexible J-tip in an unwinding device, a dilator, a scalpel, a tip with Luer lock, 5 cm3 syringe, insert clamp, adjustable winged fixator to secure the suture at the exit site of the catheter (if necessary).

Subclavian vein catheterization

Let us describe the correct technique for catheterization of the subclavian vein (PV). Before installing the PC, the patient is placed on his back in the Trendelenburg position to increase blood flow to the neck veins and, as a result, increase their diameter, with a roller placed under the shoulder blades.

The head is slightly rotated in the direction opposite to the puncture. The upper limbs are placed along the body, while the hands are placed under the buttocks, palms up. The hand on the side of the puncture is rotated by the assistant outward and extended as much as possible along the body.

Before puncture, the neck and subclavian regions are carefully examined and palpated. The choice of the side and place of the puncture is carried out taking into account the clinical situation and the condition of the skin, inflammatory phenomena, metastatic and cicatricial changes are excluded.

All aseptic and antiseptic rules must be observed: sterile gloves, gowns, dressings, surgical masks and caps are used.

Currently, more than 10 infraclavicular PV puncture points and 5 supraclavicular puncture points have been described, which indicates a large variability in the location of the PV. This determines the technical difficulties in its puncture.

Having chosen one of the access points as the injection site, the puncture needle is advanced towards the notch of the sternum, and the cut of the needle point should be directed away from the head in order to reduce the likelihood of the catheter entering the neck veins. At the same time, the operator simultaneously makes aspiration movements with the syringe plunger and periodically flushes the needle lumen.

Needle movements are made only longitudinally in one direction. Changes in the direction of movement of the needle to radial ones are not allowed, since they can lead to longitudinal cuts in the vein, artery, lung and other severe injuries, as well as to the formation of a tortuous channel, which makes subsequent installation of the catheter difficult.

Successful puncture of the central vein is confirmed by the unhindered flow of venous blood into the syringe. Next, the syringe is disconnected from the needle and a conductor is inserted into the vein through its internal channel with a soft J-shaped end forward.

If it is impossible to insert the conductor, it is removed, a syringe is attached to the needle, the position of the needle cut in the lumen of the vein is re-controlled by aspiration of blood, the angle of inclination of the needle is changed, and the conductor is reintroduced with slight rotational movements. If necessary, the steps are repeated by changing the puncture point of the vein.

When removing the conductor, it is necessary to avoid excessive efforts due to the likelihood of damage, since in the process of moving into the venous bed, it can form a knot. This is fraught with the separation of a part of the conductor with its migration into the vascular bed. If it is impossible to remove the conductor, it should be removed along with the needle.

After the successful insertion of the guidewire into the venous bed, the puncture hole is bougienage with a dilator, which is included in the delivery set of the central catheter. The movements of the dilator are rotational-translational, and to prevent bending and damage to the conductor, it must move freely in the lumen of the dilator, which must be constantly monitored. After bougienage, the dilator is replaced with a catheter using the same technique.

The depth of the catheter is determined by external anatomical landmarks and, if necessary, is corrected after a control radiography of the chest cavity.

In some cases, depending on individual characteristics topographic anatomy patients are required to deviate from the described technique: remove the roller, try to start the guidewire not with a J-shaped, but with a straight end forward or use a guidewire of a thinner diameter, turn the patient's head in the opposite direction.

It is especially important to prevent catheter migration into the internal jugular vein (IJV). This complication makes the use of a central venous catheter unacceptable and will require its subsequent correction. To prevent complications, you should ask the assistant to place the fingers in the area of ​​the VJV projection. Then the assistant will be able to tactilely feel the introduction of the guidewire into the vein and pinch it as low as possible to the PV at the time of reintroduction of the guidewire. For more accurate diagnosis a high-resolution ultrasound device should be used that allows you to see the catheter guide in the lumen of the VJV.

PC removal is carried out in dressing rooms and does not require anesthesia. After careful treatment of the skin around the exit site of the catheter from the patient's body, the catheter is removed with the fingers of one hand at the moment the patient exhales to prevent air embolism. Immediately after that, with the other hand, finger pressing of the puncture wound is performed for 5-7 minutes with sterile gauze wipes moistened with an antiseptic to prevent bleeding. Cold is prescribed for 20 minutes and bed rest for 30-40 minutes.

All IVPS models are supplied in sterile (disposable) insertion kits, including port chamber, 60 cm port catheter with length markings, thin wall needle, 10 cm3 syringe, soft J-tip guidewire in unwinder, 2 locking latches, 2 Huber needles without catheter, 1 Huber needle with fixing wings and an attached catheter, vein lifter, tunneler, bougie dilator, split introducer.

Implantation of venous port systems

Implantation of venous port systems is possible in the operating room using an image intensifier tube (EOP, or C-arm) or in X-ray operating rooms.

40 minutes before the implantation of the port system, premedication is performed in dosages corresponding to the age and weight of patients (Promedol 2%, 0.1 ml / year of the patient's life, or 0.15-0.2 mg / kg / m; Dormicum 0, 5% at 0.3-0.5 mg / kg of the patient's body weight / m; Diphenhydramine 1% at 0.1-0.15 ml / year of the patient's life / m; atropine 0.1%, 0.1 ml / year of life of the patient in / m), in order to eliminate fear and anxiety, provide a sedative and anxiolytic effect, reduce vagal reflexes, facilitate the induction of anesthesia and reduce airway secretion.

The standard set of surgical instruments used in the implantation of port systems consists of a scalpel, a Hegar needle holder, anatomical and surgical tweezers, two mosquito clamps, and Cooper scissors.

When performing implants, only absorbable atraumatic suture material 3-0 or 4-0 (diameter 0.15 to 0.249) mm should be used. This greatly simplifies the procedure for removing IVTS, if necessary, and avoids the removal of skin sutures in the event that the patient drops out of observation after discharge for one reason or another.

In the operating room, before the intervention, an ultrasound marking of the internal jugular vein is performed from the side of the puncture to prevent injury to adjacent anatomical structures and reduce the intervention time.

The marking is applied after the patient is placed in the Trendelenburg position in order to increase the diameter of the neck veins and prevent air embolism immediately before the start of the operation, after the completion of anesthetic manipulations (induction anesthesia) and placing the patient's head on the side opposite to the puncture. Changing the position of the patient's body after the marking of the vessel is applied to the skin is unacceptable.

The implantation of the venous port system is a complete operation that must be performed under anesthesia. In older children (> 16 years), with their consent, implantation under local anesthesia with premedication, however, it should be remembered that it does not allow immobility from the patient, often causes active resistance on his part, accompanied by inadequate, after premedication, behavior, difficult contact, which may require an emergency transition to general anesthesia.

Used to provide general anesthesia endotracheal anesthesia sevoran (without the use of muscle relaxants) with a single bolus intravenous administration fentanyl 0.005%, 1.0 ml / year of the patient's life before tracheal intubation.

In some cases, instead of an endotracheal tube, a laryngeal mask can be used - a rigid respiratory tube with a wide lumen, at the end of which there is an elliptical-shaped mask with a sealing cuff, the inflation of which isolates the entrance to the larynx.

Although its use is less traumatic and has known advantages (laryngoscopy is not required, the possibility of unintentional one-lung ventilation is excluded), it is advisable to resort to tracheal intubation when implanting port systems, since the laryngeal mask significantly shifts the anatomical structures of the neck when the patient's head is turned to the side opposite to that chosen for implantation, which can create difficulties during puncture and catheterization of VJV, and also make it difficult for the gas mixture to enter the Airways. In addition, the latter, when using a laryngeal mask, are less protected from aspiration.

All patients should have a nasogastric tube inserted to prevent gastric regurgitation, which can occur after the patient is placed in Trendelenburg position. In some cases, we noted abundant liquid and semi-solid discharge through nasogastric tubes. This is due to the violation of the ban on eating and drinking on the eve of the operation. After conversations with the parents of the patients, it was found that the children violated the regime without permission. This clearly illustrates the need for a nasogastric tube.

After finishing induction anesthesia and reaching the surgical stage of general anesthesia, the operation begins.

The operating field is treated three times with antiseptic solutions and lined with sterile sheets. The VJV is punctured and catheterized according to the Seldinger method: a port catheter guide (string) is inserted into the needle lumen, the needle is removed, and a bougie dilator is inserted through the guide. In cases where attempts to catheterize through the VJV are unsuccessful, it is allowed to puncture the subclavian vein with inferior or supraclavicular accesses from the Abaniak or Yoffe points.

In children under the age of 1 year, due to the small diameter of the central veins, about 0.3 cm, to facilitate the insertion of the port catheter guide into the SVC, it is convenient to puncture the PV from the Yoffe point. Although such an approach carries, according to the literature, an increased risk of damage to the organs of the chest cavity due to the features of the topographic anatomy, it makes it possible to avoid twisting the conductor into a knot or its erroneous entry into the tributaries of the SVC.

Note that the injection of the needle during puncture of the EJV is performed perpendicular to the surface of the patient's skin to exclude injury to adjacent anatomical structures. After puncture of the VJV, the syringe is tilted to an angle of 45° to the skin surface to facilitate the insertion of the conductor. During and after giving the needle with the syringe the desired angle of inclination, the location of the needle cut in the lumen of the vein is constantly monitored by aspiration and obtaining venous blood.

Considering that the thin-walled needle intended for catheterization according to the Seldinger method has a large diameter and often slides along the outer venous wall or crushes it, we consider it expedient in some cases (deep location of the vein of a small diameter, less than 0.5 cm) to perform a primary diagnostic puncture veins with a thin (search) needle of a syringe of 5 or 10 cm3. This helps to make sure that the site chosen for the puncture is correct, while failures in puncture with a thin-walled needle can lead to an unreasonable change in the punctured point.

After the introduction of the conductor, its position is necessarily controlled by intraoperative fluoroscopy. The patient is then placed in an anti-Trendelenburg position (head above leg level) to reduce bleeding from the puncture wound and subsequent incision.

When passing the bougie-dilator along the conductor into the lumen of the vein, to facilitate its passage through the thickness of the skin, the following technique is used: the skin is slightly stretched with the tip of the bougie, then the bougie is removed, and the hole in the skin at the entry point of the conductor is moved apart by the jaws of the mosquito-type clamp, which facilitates the introduction dilator through skin and further formation of the subcutaneous tunnel.

In our opinion, this tactic is less traumatic than incising the skin with a scalpel, and contributes to the speedy healing of the puncture wound. Special attention is paid to the introduction of the bougie along the conductor into the vessel. During this procedure, the free movement of the conductor in the lumen of the bougie is constantly monitored to prevent it from breaking or tearing.

After that, the conductor and internal bougie are removed, and a port catheter is inserted into the lumen of the dilator bougie, pre-filled with saline to prevent air embolism. Blood is immediately aspirated with a syringe attached to the inserted catheter to control its standing in the lumen of the vein, and it is washed with 10-20 ml of saline to prevent thrombosis.

After installing the catheter below the puncture site in the corresponding subclavian region along the anterior axillary line in the place where the subcutaneous fat is most developed, a horizontal skin incision is made 2-4 cm long, depending on the size of the port chamber.

With the help of scissors, the subcutaneous fat is mobilized above and below the incision. Below the incision, a subcutaneous cavity - a "pocket" is formed in a blunt way with the help of the operator's fingers. Careful hemostasis of the surgical field is performed. The formed "pocket" is tamponed with gauze napkins moistened with hydrogen peroxide.

With the help of a special tool - a tunneler, included in the port implantation kit supplied by all manufacturers, a subcutaneous tunnel for the catheter is created between the subcutaneous "pocket" and the vein puncture site, passing over the clavicle. The tunneler is passed under the skin through the subcutaneous fat, above the collarbone from the "pocket" towards the exit site of the catheter from the skin, and is brought to its surface in the same puncture hole as the catheter.

When performing this manipulation, the position of the tunneler is always controlled by the fingers to prevent injury by the sharp end of the tunnel to the organs and vessels of the chest cavity, head and neck. Further, the outer end of the catheter is fixed to the tunneler, passed through the formed tunnel and brought out into the subcutaneous "pocket". After that, a control aspiration of blood is performed with a syringe attached to the catheter and it is washed with saline.

Further, inside the “pocket”, two ligatures are applied to the fascia of the pectoralis major muscle, which are taken on the “handles”. The port camera is hung on them, which ensures its reliable fixation. In order to remove air, the chamber is flushed with saline by puncturing the membrane with a syringe with a straight Huber needle (without a catheter).

Since successful operation of the port system is possible only when the distal end of the catheter is located in the SVC lumen above its confluence with the right atrium, and after the operation is completed, there is no non-invasive possibility of correcting the position of the system in the venous bed, the level of installation of the distal tip of the catheter is determined using visual control.

For this, intraoperative fluoroscopy of the chest cavity is performed using an image intensifier tube. The port catheter is positioned at the required depth, cut, and connected to the port chamber. The connection point is fixed with a special lock supplied with the IVPS. Then the formed structure is immersed in the "pocket"; the ligatures on which the port chamber hung are tied.

With the help of anatomical tweezers, the position of the port catheter in the subcutaneous tunnel is carefully controlled to avoid its kinks and twists, which happens at the stage of system immersion. The use of anatomical tweezers in this case is important, since the teeth of surgical tweezers can easily damage the catheter without the operator noticing, which will lead to leakage of drugs injected through the system into the surrounding tissues.

For reliable fixation of the junction of the port chamber and the catheter, it is fixed with an additional ligature, which excludes the kink of the system in this place.

The incision is sutured in layers. A rubber graduate is left for a day. The IVTS is fitted with an infusion set consisting of a Huber needle with a small catheter fitted with a clamp, which is also supplied with a venous port. After receiving a retrograde blood flow and thoroughly flushing the system with saline, it is ready for use. An aseptic bandage is applied. Cold is locally prescribed for 20 minutes 2 times with an interval of 15 minutes.

Prophylactic postoperative antibiotic therapy is prescribed for 5-7 days. The choice of drugs is carried out depending on the clinical situation. Skin sutures removed no earlier than 10 days later.

If necessary (difficult, multiple puncture of the central veins), the next day, a control radiography of the patient's chest cavity is performed in order to exclude pneumothorax.

In some cases, it is possible to use the external jugular vein to access the SVC. To do this, a venesection of the external jugular vein is performed: it is isolated, taken on two "handles", longitudinally incised between them and tied with a non-absorbable suture material above the cut. A catheter is inserted into the vein through a guidewire. To do this, use the vein lift supplied with the IVPS. Further, the operation is carried out according to the method described above.

Conclusion

Such a first invasive manipulation as venous access can significantly delay and worsen the prognosis in the treatment of oncological diseases in children. Therefore, it is extremely important to increase the literacy of doctors and strictly follow the technique aimed at preventing complications that can be avoided.

However, much depends on the material and technical base: the presence of an image intensifier tube, an operating table with an electric drive that allows you to change the position of the patient, ultrasound equipment, Huber needles. Reducing complications associated with long-term intravenous infusions is a long-term and priority task for Russian medicine, the solution of which will not only improve the quality of medical care, but will also save budgetary funds. At present, Russia lags behind developed countries in terms of venous access for more than 30 years.

In conclusion, we note that attracting the attention of specialists, the active introduction and popularization of IVPS in pediatric oncological practice had their effect. To date, already in several Russian clinics, not only at the federal level, there is a positive experience of using IVPS in children with various diseases requiring continuous long-term venous access.

M.Yu. Rykov, E.V. Gyokova, V.G. Polyakov

A central venous catheter (CVC) is not required in awake patients with stable circulation and in patients not receiving high osmolarity solutions. Before placing such a catheter, it is necessary to weigh all possible complications and risks. In this article, we will look at how central vein catheterization is performed.

Selecting an installation site

When choosing a place for installing a catheter (puncture), first of all, the experience of a health worker is taken into account. Sometimes the view is taken into account surgical intervention, the nature of the damage and anatomical features. In particular, for male patients, a catheter is placed in the subclavian vein (because they have a beard). If the patient has high intracranial pressure, do not place a catheter in the jugular vein, as this may impede the outflow of blood.

Alternative puncture sites are axillary, medial, and lateral. saphenous veins hands, in which the installation of a central catheter is also possible. PICC catheters are in a special category. They are installed in the vein of the shoulder under the control of ultrasound and may not change for several months, representing, in fact, Alternative option port. Complications of a specific type are thrombosis and thrombophlebitis.

Indications

Catheterization of the central vein is performed according to the following indications:

• The need to administer hyperosmolar solutions to the patient (more than 600 mosm / l).
• Hemodynamic control - measurement of central venous pressure (CVP), PICCO hemodynamic monitoring. Only the measurement of CVP is not an indication for the installation of a catheter, since the measurements do not give an accurate result.
• Measurement of blood saturation level with carbon dioxide (in individual cases).
• The use of catecholamines and other substances that irritate the veins.
• Long-term, more than 10 days, infusion treatment.
• Venous dialysis or venous hemofiltration.
• Purpose infusion therapy at bad condition peripheral veins.

Contraindications

Contraindications to the installation of a catheter are:

• Infectious lesion in the puncture area.
• Thrombosis of the vein into which the catheter is planned to be inserted.
• Impaired coagulation (condition after a systemic failure, anticoagulation). In this case, it is possible to install a catheter in the peripheral veins on the arms or thigh.

Site selection and precautions

Before catheterization of the central vein, some rules must be observed:

• Precautions: use sterile gloves, mask, cap, sterile gown and wipes, special attention should be paid to skin disinfection.
• Patient Position: The head-down position is the best option, as this facilitates insertion of the catheter into the jugular and subclavian veins. It also reduces the risk of developing pulmonary embolism. However, it should be borne in mind that such a position of the body can provoke an increase intracranial pressure. The set for catheterization of the central veins according to Seldinger will be considered below.

Restrictions

The choice of puncture site is milestone procedures and subject to the following restrictions:

Catheter Care

Disconnection and manipulation of the system must be avoided. Kinks and unsanitary condition of the catheter are unacceptable. The system is fixed in such a way that there are no displacements in the puncture area. The development of complications and the risk of their occurrence should be checked daily. The best option- apply a transparent dressing to the catheter insertion site. The catheter is subject to urgent removal in the event of a systemic or local infection during central vein catheterization.

Hygiene standards

In order to avoid urgent removal of the catheter, strict adherence to hygienic standards and asepsis during its installation is necessary. If the CVC was installed at the scene of an accident, then it is removed after the patient is taken to the hospital. It is necessary to exclude any unnecessary manipulations with the catheter and observe the rules of asepsis when taking blood and injections. Disconnection of the catheter from the infusion set requires disinfection of the CVC handpiece with a special solution. It is necessary to use sterile disposable dressings and plugs for the three-way stopcock, to minimize the number of tees and connections, and to strictly control the levels of protein, leukocytes and fibrinogen in the blood to avoid infection.

Following all these rules, you can not change the catheter often. After removal of the CVC, the syringe is sent to special study even if there are no symptoms of infection.

Replacement

The length of stay of the needle for central venous catheterization is not regulated, it depends on the patient's susceptibility to infections and the body's response to the introduction of CVC. If the catheter is installed in a peripheral vein, then replacement is necessary every 2-3 days. If placed in a central vein, the catheter is removed at the first symptoms of sepsis or fever. The syringe, removed under sterile conditions, is sent to microbiological research. If the need to replace the CVC occurs within the first 48 hours, and there is no irritation or signs of infection at the puncture point, a new catheter is placed using the Seldinger method. Observing all the asepsis requirements, the catheter is pulled back a few centimeters so that it, together with the syringe, still remains in the vessel, and only after that the syringe is removed. After the gloves are changed, a guidewire is inserted into the lumen and the catheter is removed. Next, a new catheter is inserted and fixed.

Possible Complications

After the procedure, the following complications are possible:

• Pneumothorax.
• Hematoma, hemomediastinum, hemothorax.
• Arterial puncture with the risk of damage to the integrity of the vessels. Hematomas and bleeding, strokes, arteriovenous fistulas and Horner's syndrome.
• Pulmonary embolism.
• Puncture of lymph vessels with chylomediastinum and chylothorax.
• Incorrect position of the catheter in the vein. Infusothorax, catheter in the pleural cavity or too deep in the ventricle or atrium with right side, or incorrect direction of the CCV.
• Injury to the shoulder or diaphragmatic or vagus nerve, stellate node.
• Sepsis and infection of the catheter.
• vein thrombosis.
• Violation of the heart rhythm during the advancement of the catheter for catheterization of the central veins according to Seldinger.

CVC installation

There are three main areas for placement of a central venous catheter:

A qualified person should be able to place a catheter in at least two of the listed veins. When catheterizing the central veins, ultrasonic guidance is especially important. This will help localize the vein and identify the structures associated with it. Therefore, it is important to be able to use the ultrasound machine whenever possible.

The sterility of the central venous catheterization set is of paramount importance, as the risk of infection must be minimized. The skin must be treated with special antiseptics, the injection site should be covered with sterile wipes. Sterile gowns and gloves are strictly required.

The patient's head goes down, which allows you to fill the central veins, increasing their volume. This position facilitates the process of catheterization, minimizes the risk of pulmonary embolism during the procedure itself.

The internal jugular vein is most often used to place a central venous catheter. With this type of access, the risk of pneumothorax is reduced (compared to subclavian catheterization). In addition, in case of bleeding, it is stopped by clamping the vein by means of compression hemostasis. However, this type of catheter is inconvenient for the patient, it can dislodge the wires of the temporary pacemaker.

Protocol actions

The protocol of central venous catheterization involves the following steps:

Access to the subclavian vein

The installation of a catheter in is used when there is no access to the patient's neck. This is possible with cardiac arrest. The catheter installed in this place is located on the front of the chest, it is convenient to work with it, it does not cause inconvenience to the patient. The disadvantages of this type of access are the high risk of developing pneumothorax and the inability to clamp the vessel if it is damaged. If it was not possible to install a catheter on one side, you should not immediately try to insert it on the other, as this dramatically increases the risk of developing pneumothorax.

Installing a catheter involves the following steps:

• There is a point at the top of the rounded edge of the clavicle between one third of the medial and two thirds of the lateral.
• The injection site is located 2 centimeters below this point.
• Next, anesthesia is introduced, and both the puncture site and the area of ​​\u200b\u200bthe collarbone around the initial point are anesthetized.
• The catheterization needle is inserted in the same way as anesthesia.
• As soon as the end of the needle is under the collarbone, you need to deploy it to the lower point of the jugular notch of the sternum.

Access through is especially often used in emergency cases, as it helps to enter a large vein for further manipulations. In addition, with this type of access, it is easy to stop bleeding by clamping the vein. This access allows you to put a temporary pacemaker. The main complication of this type of catheterization is the high risk of infection and the required immobility of the patient.

How is the catheter placed?

The catheter is installed as follows:

• The patient is in horizontal position. The leg turns and moves to the side.
• The groin area is shaved, the skin is treated with an antiseptic and lined with sterile wipes.
• The femoral artery is palpable at the crease at the base of the leg.
• The area where the catheter is inserted is anesthetized.
• The needle is inserted at an angle of 30-45 degrees.
• The vein is usually located at a depth of about 4 cm.

Central venous catheterization is a complex and dangerous medical procedure. It should only be carried out by experienced and qualified specialist, since an error in this case can cost the patient life and health.

What is included in the dual-channel central venous catheterization kit?

As part of sterile (disposable) installation kits - a port chamber, a port catheter, a thin-walled needle, a 10 cm 3 syringe, two fixing locks, a wire with a soft J-tip in the unwinder, two Huber needles without a catheter, a vein lifter, one Huber needle with fixing wings and attached catheter, bougie-dilator, tunneler, split introducer.

Set for catheterization of the central vein

The kit is designed for catheterization according to the Seldinger method. May require prolonged administration medicines, conducting parenteral nutrition, invasive monitoring blood pressure.

Known set for catheterization of the central veins "Certofix".

In the set you can see:

• Polyurethane radiopaque catheter with extensions equipped with a clip.
• Seldinger needle (introducer).
• The conductor is straight kapron.
• Dilator (expander).
• Additional attachment for fixing to the patient's skin.
• Plug with injection membrane.
• Mobile clamp.

The set for catheterization of the central veins "Certofix" is used most often.