A selection of base: SOP) Cathetterization veins .docx, anatomy of the lower hollow vein goth.docx, №34-rts is the catheterization of peripheral veins .doc.

Voronezh state

medical Academy. N.N. Burdenko

Blacks A.V., Isaev A.V., Vitchinkin V.G., Kotuich V.A.,

Yakusheva N.V., Levteev E.V., Maleev Yu.V.

Puncture and catheterization

Connected Vienna

Voronezh - 2001

UDC 611.145.4 - 089.82

Blacks A.V., Isaev A.V., Vitchinkin V.G., Kotuich V.A., Yakusheva N.V., Levteev E.V., Maleev Yu.V. Puncture and catheterization of the subclavian vein.: Educational and methodical manual for students and doctors. - Voronezh, 2001. - 30 s.

The educational and methodological manual was compiled by the staff of the Department of Operational Surgery and Topographic Anatomy of the Voronezh State medical Academy them. N.N. Burdenko. Designed for students and physicians of the surgical profile. The manual discusses issues of the topographic and anatomical and physiological substantiation of the choice of access, methods of anesthesia, methods of catheterization of the subclavian vein, testimony and contraindications to this manipulation, its complications, the care of the catheter, as well as in children.

Fig. 4. Bibliography: 14 Names.
Reviewers:

Doctor of Medical Sciences, Professor,

head of the Department of Anesthesiology and Resuscitation Fow

Shapovalova Nina Vladimirovna
Doctor of Medical Sciences, Professor

departments of anesthesiology and resuscitation

Mikhail Alexandrovich Stroks

© Black A.V., Isaev A.V., Vitchinkin V.G.,

Kotuukh V.A., Yakusheva N.V.,

Levteev E.V., Maleev Yu.V.

The puncture and catheterization of veins, in particular the central, relate to widespread manipulations in practical medicine. Currently, very broad indications are sometimes put to the catheterization of the subclavian vein. Experience shows that this manipulation is not safe enough. Extremely important knowledge of the topographic anatomy of the connectible vein, the technique of performing this manipulation. In this teaching and methodological manual, much attention is paid to the topographic anatomical and physiological substantiation of both the selection of access and the technique of veins catheterization. Clearly formulated indications and contraindications, as well as possible complications. The proposed allowance is intended to facilitate the study of this important material due to a clear logical structure. When writing benefits, both domestic and foreign data were used. The manual, undoubtedly, will help students and doctors to explore this section, and also improves teaching efficiency.
Head Department of Anesthesiology and Resuscitation Fow

Wgm them. N.N. Burdenko, Doctor of Medical Sciences,

professor Shapovova Nina Vladimirovna

In one year, more than 15 million central venous catheters are installed in the world. Among the venous tributaries available for puncture are most often cathetterized by a subclavian vein. In this case, various methods apply. The clinical anatomy of the subclavian vein, accesses, as well as the technique of puncture and catheterization of this vein are set out in various textbooks and manuals, is not fully fully, which is associated with the use of various methods for carrying out this manipulation. All this creates difficulties to students and doctors when studying this issue. The proposed allowance will facilitate the assimilation of the material being studied at the expense of a consistent system approach and should contribute to the formation of strong professional knowledge and practical skills. The manual is written on a high methodical level, meets a typical curriculum and can be recommended as a guide for students and doctors when studying puncture and catheterization of a subclavian vein.

Professor of the Department of Anesthesiology and Resuscitation

Wgm them. N.N. Burdenko, Doctor of Medical Sciences

Mikhail Alexandrovich Stroks

Mente Prius Chirurgus Agat Quam Manu Armata 1

For the first time, puncture of the subclavian vein was carried out in 1952 Aubaniac. They described the puncture method from subclavian access. Wilson.et.al. In 1962, connected access to the catheterization of the subclavian vein was used, and through it - and the upper vein hollow. From this time, the percutaneous catheterization of the subclavian vein began to be widely used for diagnostic studies and treatment. YOFFA.in 1965, he introduced in clinical practice for inspected access to the introduction of a catheter into central veins through a subclavian vein. In the future, various modifications of the on-shifted and connectural access were proposed in order to increase the likelihood of successful catheterization and reducing the risk of complications. Thus, at present, the subclavian vein is considered a convenient vessel for central venous catheterization.

Clinical Anatomy of Plug Vienna

Connected Vienna (Fig.1.2) is the immediate continuation of the axillary veins, moving to the last at the level of the lower edge of the first edge. Here it goes on top of the first edge and lies between the rear surface of the clavicle and the front edge of the front staircase, located in the preliminary interval. The latter is located the front-end triangular slot, which limits the back - the front staircase muscle, in front and sump - sternum-ply and sternum-thyroid muscles, front and outside - the breast-casculously lummy muscle. Connected vein is located in the lower range of the gap. Here it comes to the rear surface of the breast-clearable articulation, merges with the inner jugular vein and forms a shoulder vein with her. The merger's place is denoted as the venous angle of pyrogov, which is projected between the lateral edge of the lower depth of the breast-curable-bed-like muscle and the top edge of the clavicle. Some authors (I.F. Matyushin, 1982) When describing the topographic anatomy of the connector vein, a clavical area is distinguished. The latter is limited: on top and bottom - lines that are 3 cm above and below the clavicle and parallel to it; Outside - the front edge of the trapezoidal muscle, a acryal-clavical articulation, the inner edge of the deltoid muscle; Cancer - the indoor edge of the breast-curable-bed-like muscle to the intersection at the top - with the upper boundary, down - from the bottom. Behind the clavicle, the subclavian vein first is located on the first edge, which separates it from the dome of the pleura. Here Vienna lies the stop from the clavicle, in front of the front staircase muscle (on the front surface of the muscle there is a diaphragmal nerve), which separates the connective vein from the artery of the same name. The latter, in turn, separates the Vienna from the cereals of the shoulder plexus, underlying the arteries' jackadiot. In the newborn, the plug-in veins will be from the same name at a distance of 3 mm, in children under 5 years old - 7 mm, in children over 5 years old - 12 mm, and so on Its diameter.

The subclavian Vienna is projected through a line spent in two points: the upper point is 3 cm on the top edge of the sternum end of the clavicle, the lower - by 2.5-3 cm knutrice from the beak handproof. In newborns and children under 5 years old, the subclavian vein is projected into the middle of the clavicle, and at an older age, the projection shifts to the border between the internal and average third clavicle.

The magnitude of the corner formed by the connector vein with the lower edge of the clavicle, the newborn is 125-127 degrees, in children under 5 years old - 140 degrees, and at an older age - 145-146 degrees. The diameter of the connector 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 - 11-26 mm in the final vessel department.

The subclavian vein goes in the oblique direction: from the bottom up, from the outside. It does not change with the movements of the upper limb, as the walls of the veins are connected to the deep leaflet of the neck of the neck (the third fascia on the classification of V.N. Shevkunenko, the blade and clarifying aponeurosis of rice) and are closely connected with the perception of the clavicle and the first rib, as well as Fascia of subclavian muscles and clarity-chest fascia.

R
isooka 1. Neck veins; Right (according to V.P. Vorobyev)

1 - right plug-in vein; 2 - right inner jugular vein; 3 - right shoulder vein; 4 - left shoulder vein; 5 - upper hollow vein; 6 - front metering vein; 7 - jugular venous arc; 8 - outer jugular vein; 9 - transverse vein neck; 10 - right plug-in artery; 11 - front staircase muscle; 12 - rear staircase muscle; 13 - breast-curable-cottage muscle; 14 - clavicle; 15 - the first edge; 16 - sternum handle.

Figure 2. Clinical anatomy of the upper vein system; Front view (according to V.P. Vorobyev)

1 - right plug-in vein; 2 - left connectible vein; 3 - right inner jugular vein; 4 - right shoulder shoulder vein; 5 - left shoulder shoulder vein; 6 - upper hollow vein; 7 - front metering vein; 8 - jugular venous arc; 9 - outer jugular vein; 10 - unpaired thyroid venous plexus; 11 - internal breast vein; 12 - the lowest thyroid veins; 13 - right plug-in artery; 14 - aortic arc; 15 - front staircase muscle; 16 - shoulder plexus; 17 - clavicle; 18 - the first edge; 19 - Borders of the sternum handle.

The length of the connected vein from the top edge of the corresponding small pectoral muscle to the outer edge of the venous angle at the allotted upper limb ranges from 3 to 6 cm. In the course of the plug-in veins in its upper semi-frequency, the following veins fall into its upper seaside: the neck, the neck, the outdoor, deep, cervical, vertebral. In addition, the finite department of the subclavian vein can be chest (left) or jugular (right) lymphatic ducts.

Topographic anatomical and physiological substantiation of the selection of a connectible vein for catheterization

1. 
   Anatomical accessibility. The subclavian vein is located in a premium gap, separated from the artery of the same name and the braceless plexus stems by the front staircase.
2. 
   Stability of the position and diameter of the lumen. As a result of the battle of the vagina of the subclavian vein with a deep leaflet of the neck of the neck, the perception of the first edge and the clavicle, the clarity-breast fascia, the lumen of the vein remains constant and it does not fall down even with the most severe hemorrhagic shock.

3. Significant (sufficient) Vienna diameter.

4. High blood flow rate (compared to limb veins).

Based on the foregoing, the catheter supplied to Vienna almost does not concern its walls, and the fluid injected on it quickly reaches the right atrium and the right ventricle, which contributes to the active influence of hemodynamics and, in some cases (during resuscitation measures), it makes not even applied intraarterial Digging medicinal preparations. Hypertensive solutions entered into a subclavian vein are quickly mixed with blood, not irritating the intima veins, which allows you to increase the volume and duration of the infusion with the proper formulation of the catheter and the corresponding departure for it. Patients can be transported without danger of damage to the catheter endothelium veins, they can begin early motor activity.

Indications for catheterization of a subclavian vein

1. 
   The inefficiency and impossibility of conducting infusion into peripheral veins (including during the venesection):

(a) due to severe hemorrhagic shock leading to a sharp drop in both arterial and venous pressure (peripheral veins, at the same time, the infusion in them is inefficient);

b) with a network-shaped structure, inexpressiveness and a deep lounge of surface veins.

1. 
   The need for long and intensive infusion therapy:

a) in order to replenish the blood loss and restoring the liquid balance;

b) due to the danger of thrombing of peripheral venous stems at:

Long stay in the needle and catheters vessel (damage to the endothelium veins);

The need to administer hypertensive solutions (irritation of intima veins).

1. 
   The need for diagnostic and control studies:

a) definition and subsequent observation in dynamics for central venous pressure, which allows you to set:

• 
  temp and volume of infusion;
• 
  to diagnose heart failure in a timely manner;

b) sensing and contrasting of the cavities of the heart and trunk vessels;

c) multiple blood takes for laboratory research.

1. 
   Electrocardilation by transgeneous path.

5. Conducting extracorporeal detoxification by blood surgery methods - hemosorption, hemodialysis, plasmapheresis, etc.

Contraindications to catheterization of a subclavian vein

1. 
   Syndrome of the upper hollow vein.
2. 
   Syndrome of Pedge Schurtter.
3. 
   Pronounced violations of the coagulation system of blood.
4. 
   Wounds, glasses, infected burns in the field of puncture and catheterization (danger of generalization of infection and the development of sepsis).
5. 
   Brushes injuries.
6. 
   Bilateral pneumothorax.
7. 
   Pronounced breathing failure with emphysema lungs.

Fixed assets and organization

puncture and catheterization of the subclavian vein

Medicines and preparations:

1. 
   a solution of novocaine is 0.25% - 100 ml;
2. 
   heparin solution (5000 units per 1 ml) - 5 ml (1 bottle) or 4% sodium citrate solution - 50 ml;
3. 
   antiseptic for processing the operating field (for example, 2% solution of iodine tincture, 70% alcohol, etc.);
4. 
   cleol.

Laying of sterile tools and materials:

1. 
   syringe 10-20 ml - 2;
2. 
   injection needles (subcutaneous, intramuscular);
3. 
   needle for puncture catheterization of veins;
4. 
   intravenous catheter with cannula and plug;
5. 
   lesk-conductor 50 cm long and thickness corresponding to the diameter of the internal lumen of the catheter;
6. 
   community tools;
7. 
   suture material.

Sterile material in the bikca:

1. 
   sheet - 1;
2. 
   diaper-cutting 80 x 45 cm with a round-neck diameter of 15 cm in the center - 1 or large napkins - 2;
3. 
   surgical mask - 1;
4. 
   surgical gloves - 1 pair;
5. 
   dressing material (gauze balls, napkins).

Puncture catheterization of the subclavian vein should be performed in the procedural room or in a clean (ungounted) dressing. If necessary, it is produced before or during surgery on the operating table, on the sick bed, at the scene, etc.

The manipulation table is placed on the right of the operator in a convenient place and cover the sterile sheets folded twice. Sterile tools, suture material, sterile material from Bix, anesthetic are put on the sheet. The operator puts on sterile gloves and processes them with an antiseptic. Then twice is processed by an antiseptic operating field and is limited to a sterile diaper-cutting.

After these preparatory activities, the puncture catheterization of the subclavian vein proceeds.

Anesthesia

1. 
   Local infiltration anesthesia 0.25% novocaine solution - in adults.
2. 
   General anesthesia:

a) Inhalation anesthesia - usually in children;

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

Select access

Different points for percutaneous puncture of the subclavian vein are proposed (Aubaniac, 1952; Wilson, 1962; YOFFA, 1965 et al.). However, the topographic-anatomical studies carried out to allocate not separate points, but entire zones, within which it is possible to punish Vienna. This expands the punctual access to the connector vein, since in each zone you can outset multiple points for puncture. Usually two such zones are distinguished: 1) included and 2) connectible.

Length included zone It is 2-3 cm. Its boundaries: medial - by 2-3 cm in front of the breast-clavical joint, laterally - by 1-2 cm knutrice from the border of the medial and middle third of the clavicle. Valka needles are produced by 0.5-0.8 cm up from the top edge of the clavicle. When puncture, the needle is directed at an angle of 40-45 degrees relative to the clavicle and at an angle of 15-25 degrees relative to the front surface of the neck (to the frontal plane). Most often, the spacing of the needle is a point Yoffewhich is located in the corner between the lateral edge of the clavary leg of the breast-curable-bed-like muscle and the top edge of the clavicle (Fig. 4).

Included access has certain positive sides.

1) The distance from the skin surface to the veins is shorter than with subclavian access: to achieve veins, the needle must pass through the skin with subcutaneous tissue, surface fascia and subcutaneous muscle of the neck, the surface sheet of the neck of the neck, a deep leaflet of the neck of the neck, loose fiber , Environmental Vienna, as well as pre-convertible fascia, participating in the formation of a fascial vienna vagina. This distance is 0.5-4.0 cm (on average, 1-1.5 cm).

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

1. 
   There is no need to put the roller under the patient's shoulder belt.

However, due to the fact that a person has a screwdriver's shape constantly changes, certain difficulties can represent a reliable fixation of the catheter and protecting the bandage. In addition, the sweat and, therefore, infectious complications are often accumulated in the prescription jam.

Connect zone (Fig. 3) is limited: from above - the lower edge of the clavicle from its middle (point number 1) and not reaching 2 cm to its sort of sorted end (point number 2); lateral - vertical descending by 2 cm down from point number 1; medial - vertical descending by 1 cm down from point number 2; The bottom is the line connecting the lower ends of the vertical. Consequently, when puncture of veins from subclavian access, the spacing of the needle can be put in the boundaries of the wrong quadrangle.

Figure 3. Connected zone:

1 - point number 1; 2 - point number 2.

The angle of inclination of the needle in relation to the clavicle - 30-45 degrees, relative to the surface of the body (to the frontal plane - 20-30 degrees). A general landmark during puncture is the rear-top point of the breast-clearable articulation. When entering the veins, the following points are most often used by connectible access (Fig. 4):

• 
  point Obanka , located 1 cm below the clavicle on the border of the medial and middle third;
• 
  point Wilson located 1 cm below the middle of the clavicle;
• 
  point Jilsa Located 1 cm below the clavicle and 2 cm in front of the sternum.

Figure 4. Points used for puncture of the connector vein.

1 - point Joffe; 2 - Point of Owaniac;

3 - Wilson's point; 4 - Point of Jils.

With subclavian access, the distance from the skin to veins is larger than during the percussion, and the needle must go through the skin with subcutaneous tissue and surface fascia, breast fascia, greater breast muscle, loose fiber, clarity-breasts (rude), gap between the first edge and the clavicle, the connective muscle with its fascial case. This distance is 3.8-8.0 cm (an average of 5.0-6.0 cm).

In general, the topographic-anatomically more substantiated puncture of the connector vein from the connector access, as:

1. 
   in the upper semicircle of the connector vein, large venous branches, chest (left) or jugular (right) lymphatic ducts fall into the upper limit;
2. 
   above the clavicle of Vienna is closer to the dome of the pleura, below the clavicle it is separated from the pleura by the first edge;
3. 
   Fasten the catheter and aseptic bandage in the plug-in area is much easier than in the percussion, conditions for the development of an infection here less.

All this led to the fact that in clinical practice, a subclavian vein from subclavian access is often made. At the same time, obese patients should be preferred to those access at which the most clearly determination of anatomical benchmarks is possible.

vienna according to the Merdinger Method from Plug Access

The success of puncture and catheterization of the subclavian vein is largely due to the observance all Requirements for this manipulation. Of particular importance proper laying of the patient.

Patient position Horizontal with a roller-plated under the shoulder belt ("under the blades") roller, a height of 10-15 cm. The head end of the table is lowered by 25-30 degrees (the position of Trendelenburg). The upper limb on the puncture side is given to the body, the adapter is omitted (with the assistant of the upper limb down), the head is rotated in the opposite direction by 90 degrees. In the event of a severe condition of the patient, it is possible to produce a puncture in a semi-dying position and without lining a roller.

Position of the doctor - Standing on the side of puncture.

Preferred side: Right, since in the final department of the left connector vein can be chest or jugular lymphatic ducts. In addition, when carrying out electrocardialism, sensing and contrasting the cavities of the heart, when the need to advance the catheter in the upper hollow vein, it is easier to right, since the right shoulder shoulder vein is shorter than the left and the direction of it approaches the vertical, while the direction of the left shoulder shoulder vein closer to horizontal.

After handling the hands and corresponding half of the front area of \u200b\u200bthe neck and the plug-in antiseptic area and restrictions on the operating field with a diaper-cutting or napkins (see the "Fixed assets and the organization of the puncture catheterization of the central veins"), an anesthesia is carried out (see the "Anesthetic" section).

The principle of conducting catheterization of the central veins is laid Gerdinger (1953). The puncture is carried out by a special needle from a set for catheterization of central veins, placed on a syringe with a 0.25% solution of novocaine. Patients in consciousness, needle for puncture of a subclavian vein show extremely undesirable Since this is a powerful stress factor (a needle of 15 cm long and more with sufficient thickness). When a skin needle proceeds, significant resistance is observed. This moment is the most painful. Therefore, it must be carried out as quickly as possible. This is achieved by receiving the restriction of the depth of the needle. The doctor who performs manipulation limits the needle's finger at a distance of 0.5-1 cm from its island. This prevents deeply uncontrolled administration of the needle in the fabric when applying considerable effort during the skin puncture. The lumen of the puncture needle is often clogged with tissues when skin crossing. Therefore, immediately after passing the needle of the skin, it is necessary to restore its permeability, the release of a small amount of novocaine solution. Fombing needles produced by 1 cm below the clavicle on the boundary of the medial and middle third (point of the Obanka). The needle should be given the direction to the rear-top edge of the breast-clavical joint or, according to V.N. Rodionova (1996), in the middle of the width of the clavical leg of the breast-curable-bed-like muscle, that is, a few lancer. This direction remains profitable and with different positions of the clavicle. As a result, the vessel is punctured in the region of the venous corner of Pirogov. The needle promotion follows the premium of novocaine. After a puncture of the piston, the piston should be sipped on himself, promoting the needle in a given direction (creating a discharge in the syringe only after the release of a small amount of novocaine solution for the prevention of scoring scabs to the needle of the needle with tissues). After entering the vein in the syringe, a trickle of dark blood appears in the syringe and further to the needle to promote a vessel due to the possibility of damage to the opposite wall of the vessel with the subsequent output of the conductor there. If the patient is in consciousness, it must be asked to delay the breath on the breath (the prevention of the air embolism) and through the surveillance of the needle, removed from the syringe, enter the lastic conductor to a depth of 10-12 cm, after which the needle is removed, and the conductor adheres to and remains in Vienna . Then the catheter is moving clockwise by rotational motions clockwise to the depth previously specified. In each particular case, the principle of choosing the catheter of the maximum possible diameter (for adult inner diameter is 1.4 mm). After that, the conductor is removed, and the heparin solution is introduced into the catheter (see the "Care Care" section) and a cannula-plug is inserted. In order to avoid an air embolism, the lumen of the catheter during all manipulations should be covered with a finger. If the puncture failed, it is necessary to bring the needle to the subcutaneous tissue and move forward in another direction (changes in the direction of the needle in the process of puncture lead to additional damage to the tissues). The catheter is fixed to the skin one of the listed methods:

1. 
   a strip of a bactericidal plaster with two longitudinal slots is pasted around the catheter on the skin with two longitudinal slots, after which a thorough fixation of the catheter of the middle strip of the leukoplower is carried out;
2. 
   to ensure reliable fixation of the catheter, some authors recommend to sow it to the skin. To do this, in the immediate vicinity of the way out of the catheter, the skin is flashed with ligature. The first double knot of the ligature is tied on the skin, the second catheter is fixed to the skin seam, the third knot is tied over the ligature at the level of the cannula and the fourth - around the cannula, which prevents the displacement of the catheter along the axis.

vienna according to the method of an applying access

Patient position: Horizontal, under the shoulder belt ("under the blades") roller can not be laid. The head end of the table is lowered by 25-30 degrees (the position of Trendelenburg). The upper limb on the puncture side is given to the body, the adapter is omitted, with pulling the upper limb to the assistant down, the head is rotated in the opposite direction by 90 degrees. In the case of severe patient's condition, it is possible to make a puncture in a semi-time position.

Position of the doctor - Standing on the side of puncture.

Preferred side: Right (justification - see above).

Fucks needles produced at point Yoffewhich is located in the corner between the lateral edge of the clavical leg of the breast-curable-bed-like muscle and the top edge of the clavicle. The needle is directed at an angle of 40-45 degrees relative to the clavicle and 15-20 degrees relative to the front surface of the neck. During the needle in the syringe creates a small discharge. Usually in Vienna can be reached at a distance of 1-1.5 cm from the skin. Through the surveillance of the needle, the lastic conductor is introduced to a depth of 10-12 cm, after which the needle is removed, and the conductor is adhered to and remains in Vienna. Then the catheter is moving on the conductor to the insertion movements to the depth previously. If the catheter is free to Vienna, it can promote its turns around its axis (carefully). After that, the conductor is removed, and a cannula-plug is inserted into the catheter.

Technique of percutaneous puncture and catheterization of the subclavian vein on the principle of "catheter through a catheter"

Puncture and catheterization of the subclavian vein can be carried out not only on the principle of the Selfger ("Catheter by conductor"), but also on the principle "Catheter through a catheter" . The latter technique was possible thanks to new technologies in medicine. The puncture of the subclavian vein is carried out using a special plastic cannula (outer catheter), bowed to the needle for the catheterization of central veins, which serves as a puncturing stilette. In this technique, the onravitivity of the transition from the needle on the cannula, A, as a result, is extremely important, as a result, a small resistance to the catheter through fabrics and, in particular, through the wall of the subclavian vein. After the cannula with needle-stilette fell into Vienna, the syringe with the needle pavilion takes off the syringe, the cannula (outer catheter) is held, and the needle is removed. Through the outer catheter, a special internal catheter with Mandren on the desired depth is carried out. The thickness of the inner catheter corresponds to the diameter of the enlightenment of the outer catheter. The exterior catheter pavilion is connected using a special retainer with an internal catheter pavilion. Mandren is extracted from the latter. The pavilion is put on hermetic cap. The catheter is fixed to the skin.

Catheter Care Requirements

Before each introduction to the catheter of the medicinal substance, it is necessary to obtain a syringe with a free blood flow. If it fails, the liquid is fluid free into the catheter, it may be connected:

• 
  with the yield of catheter from 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 cutter slice rests on the wall of the vein.

It is impossible to carry out infusion in such a catheter. It is necessary first to slightly pull it out and again try to get blood out of it. If it fails, the catheter is subject to unconditional removal (the danger of paravenous administration or thromboembolism). Extract the catheter from veins need very slow, creating a negative pressure in the catheter With the help of a syringe. This technique is sometimes possible to remove a suspension thrombus from veins. In this situation, it is categorically unacceptable to extract the catheter with rapid movements from the vein, as it can cause thromboembolism.

To avoid thrombing of the catheter after diagnostic blood fences and after each infusion, it should be immediately rinsed with any infusable solution and be sure to introduce an anticoagulant to it (0.2-0.4 ml). The formation of thrombos may be observed with a strong cough of the patient due to blood cast in the catheter. It is more often noted against the background of slow infusion. In such cases, heparin must be added to the transfimony solution. If the fluid was introduced in a limited amount and there was no constant infusion of the solution, it is possible to use the so-called heparin castle ("heparin plug"): after the end of the infusion, 2000 - 3000 units (0.2 - 0.3 ml) of heparin in 2 ml is introduced into the catheter. Physiological solution and it is closed by a special cork or plug. Thus, it is possible to preserve the vascular fistula for a long time. The stay of the catheter in the Central Vienna provides for careful skin care at the point of puncture (daily processing of the antiseptic of puncture and daily change of aseptic dressing). The duration of the stay of the catheter in a subclavian vein according to different authors ranges from 5 to 60 days and should be determined by therapeutic testimony, and not preventive measures (V.N. Rodionov, 1996).

Possible complications

1. 
   Wounding the plug-in artery. This is detected by the pulsating jet of the scarlet blood flowing into the syringe. The needle is extracted, the place of puncture is pressed for 5-8 minutes. Typically, the erroneous puncture of the artery is subsequently accompanied by any complications. However, the formation of hematoma in the anterior mediastinum is possible.
2. 
   Purpose of the dome of the pleura and the tops of the lung with the development of pneumothorax. The unconditional sign is injured of the lung - the emergence of subcutaneous emphysema. The probability of complication by pneumothorax is increased with various deformations chest And when breathing with deep breath. In the same cases, Pneumothorax is most dangerous. At the same time, damage to the subclavian vein with the development of hemopneumothrax is possible. This usually happens with multiple unsuccessful attempts to puncture and coarse manipulation. The cause of the hemotorax may 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 should be prohibited. The development of hemotorax can be associated with damage to the plug-in artery. In such cases, the hemotorax is significant. When puncture of the left connectible vein, in the event of damage to the breast lymphatic duct and the pleura is possible the development of the chylotorax. The latter can manifest itself with abundant outer lymphosterapetion on the wall of the catheter. It is found complicing with a hydrotorax as a result of installing a catheter in pleural cavity With the subsequent transfusion of various solutions. In this situation, after conducting the catheterization of the connector vein, it is necessary to perform a chest control radiography in order to eliminate these complications. It is important to take into account that when the needle is damaged by a light pneumothorax and emphysema, it can develop both in the next few minutes and a few hours after the manipulation. Therefore, with difficult catheterization, and even more so with a random puncture of the lung, it is necessary to purposefully exclude the presence of these complications not only immediately after puncture, but also during the next day (frequent auscultation of the lungs in the dynamics, radiological control, etc.).
3. 
   With an excessively deep administration of the conductor and catheter, damage to the walls of the right atrium, as well as a three-grained valve with severe heart activities, the formation of cloth thrombones, which can serve as an embolism source. Some authors observed a spherical thrombus, which performed the entire cavity of the right ventricle. This is observed more often when using rigid polyethylene conductors and catheters. Their application must be prohibited. Excessively elastic conductors are recommended before use to undergo long-term boiling: it reduces the stiffness of the material. If there is no possibility of choosing a suitable conductor, and the standard conductor is very hard, some authors recommend to perform the following intake - the distal end of the polyethylene conductor is pre-slightly begins to formed a stupid angle. Such a conductor is often much easier to spend in the lumen of the vein, not traumating its walls.
4. 
   Embleya conductor and catheter. The embolism of the conductor arises due to the cutting of the conductor to the edge of the needle is the edge with quick pulling into itself deeply entered in the needle of the conductor. The embolism of the catheter is possible in case of accidental cutting of the catheter and its gradation in Vienna during the intersection with scissors or scalpel of the long ends of the fixing thread or when removing the thread fixing the catheter. It is impossible to extract the conductor from the needle. If necessary, you should remove the needle together with the conductor.
5. 
   Aerial embolism. In the subclavian vein and the upper hollow vein, the pressure may be negative. Causes of embolism: 1) sucking when air breathing in Vienna through open needles or catheter pavilions (this danger is most likely with pride with deep breaths, when puncture and catheterization of veins in the patient's position sitting or with a raised torso); 2) the unreliable compound of the pavilion of the catheter with a nozzle for the needles of overflowing systems (not a tightness or not seen separation of them during breathing, is accompanied by sucking air into the catheter); 3) Random breakdown of the cork with a catheter with a simultaneous breath. To prevent an air embolism during an needle puncture, a syringe must be connected to the syringe, and the introduction of a catheter in Vienna, disconnecting the syringe from the needle, the opening of the pavilion of the catheter should be made during apnea (delay in breathing patient on the breath) or in the Trendenelburg position. Prevents air embolism. Closing an open needle pavilion or catheter with a finger. During the artificial ventilation of the lungs, the prevention of an air embolism is provided by ventilation of the lungs with increased air volumes with the creation of positive pressure at the end of the exhalation. When carrying out infusion to the venous catheter, constant careful tracking of the tightness of the compound of the catheter and the transfusing system is necessary.
6. 
   Watching the shoulder plexus and the neck organs (there is rarely observed). These damage occurs with the deep introduction of the needle with an incorrectly selected deposit direction, with a large number of attempts to puncture Vienna in different directions. This is especially dangerous when the needle direction changes after its deep administration in the tissue. At the same time, the sharp end of the needle injures the fabrics on the principle of the car wiper. To exclude this complication, after an unsuccessful attempt of the Vienna puncture, the needle must be fully removed from the tissues, to change the angle of its introduction to the clavicle by 10-15 degrees and only after that it is puncture. At the same time the needle gain point does not change. If the conductor does not pass through the needle, it is necessary to make sure that the needle is in Vienna, and again, slightly tightening the needle for himself, try without violence to enter the conductor. In Vienna, the conductor must pass absolutely freely.
7. 
   Inflammation of soft tissues in the place of puncture and intracereter infection - a rare complication. It is necessary to remove the catheter and more strictly comply with the requirements of aseptics and antiseptics when performing puncture.
8. 
   Phlebotrombosis and thrombophlebitis of the subclavian vein. It is extremely rare, even with long-term (several months) administration of solutions. The frequency of these complications is reduced if high-quality non-brine catheters are used. Reduces the frequency of phlebotomability Regular flushing of the catheter with an anticoagulant not only after infusion, but also in long interruptions between them. With rare transfuses, the catheter is easily blocked by rolled blood. In such cases, it is necessary to resolve the appropriateness of saving the catheter in a subclavian vein. When signs of thrombophlebitis appear, the catheter must be extracted, appropriate therapy is assigned.
9. 
   Disposition of the catheter. It consists in the exit of the conductor, and then the catheter from the connector vein in the jugular (in the inner or outer). If the catheter is suspected, X-ray control is performed.
10. 
    The obstruction of the catheter. This may be due to blood coagulation in the catheter and its thrombosis. When simply on the formation of a thrombus, the catheter should be removed. A rough mistake is to press the thrombus in Vienna by "washing" a catheter by introducing fluid in pressure into it or by cleaner a catheter conductor. The obstruction may also be associated with the fact that the catheter is driving or rests on the end into the wall of the vein. In these cases, a slight change in the position of the catheter allows you to restore its permeability. Catheters installed in a plug-in vein should have a cross-cut on the end. It is unacceptable to use catheters with slices and with side holes at the distal end. In such cases, the scope of the catheter of the catheter without anticoagulants arises, on which the hanging swarms are formed. It is necessary to strict compliance with the Catheter Care Rules (see the section "Care Care Requirements").
11. 
    Pharalose introduction of infusion-transfusion environments and other drugs. The introduction of irritant liquids (calcium chloride, hyperosmolar solutions, etc.) to the mediastinum is most dangerous. Prevention is obligatory compliance with the rules for working with venous catheter.

in children

1. 
   Puncture and catheterization must be carried out under conditions of perfect anesthesia, ensuring the absence of motor reactions in a child.
2. 
   The body of the child during the puncture and catheterization of the subclavian vein should necessarily be given the position of the Trendelenburg with a high roller under the blades; The head leans back and turns to the side opposite to the punctured.
3. 
   Change of aseptic dressing and skin treatment around the place of the inside should be made daily and after each procedure.
4. 
   In children up to 1 year, a subclavian vein is more advantageous to punish a connector 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 medium thirds of the clavicle (point of the Obanka).
5. 
   The puncture needle should not have a diameter of more than 1-1.5 mm, and the length is more than 4-7 cm.
6. 
   Puncture and catheterization should be performed as atraly as possible. When conducting puncture to prevent an air embolism on the needle, a syringe with a solution must be put on (0.25% novocaine solution).
7. 
   In newborns and children of the first years of life, blood often appears in the syringe during slow removal of the needle (with simultaneous aspiration), as the puncture needle, especially not sharply sharpened, due to the elasticity of the child's tissues easily pierces the front and rear walls of the vein. In this case, in the lumen of the vein, the tip of the needle may be only when it is removed.
8. 
   Conductors for catheters should not be rigid, introduce them to Vienna is very careful.
9. 
   With the deep introduction of the catheter, it can easily get into the right heart departments, into the inner jugular vein, and, both on the side of puncture and on the opposite side. With any suspicion of the improper position of the catheter in Vienna, x-ray control should be carried out (2-3 ml of the X-ray-repeat substance is introduced into the catheter and take a picture in the front-rear projection). It is recommended as the optimal aspect depth of the catheter:

• 
  premature newborn - 1.5-2.0 cm;
• 
  funny newborns - 2.0-2.5 cm;
• 
  breast children - 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

elderly

In the elderly, after the puncture of the subclavian veins and conduct the conductor through it, the introduction of a catheter often meets significant difficulties. This is due to age-related fabric changes: small elasticity, reduced skin turgor and deleting tissue declaration. At the same time, the likelihood of the success of the catheter rises when it wetting (physiological solution, novocaine solution), as a result of which the friction of the catheter decreases. Some authors to eliminate resistance are recommended to cut the distal end of the catheter under an acute angle.

Afterword

Primum Non Nocere 2.

Cracked puncture and catheterization of the subclavian vein is 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 the average medical personnel with the rules for using catheters in a subclavian vein and care.

Sometimes, when performing all the requirements for puncture and catheterization of the connector veins, there may be repeated unsuccessful attempts to the vessel catheterization. At the same time, it is very useful to "change your hand" - to ask another doctor to carry out this manipulation. This does not in any way discredit the doctor who unsuccessfully fulfilled the puncture, but, on the contrary, it will raise it in the eyes of colleagues, since excessive stubbornness and "reference" in this matter can cause significant damage to the patient.

Literature

1. 
   Brown M.P. General Basics of Surgical Technology. - Rostov-on-Don: Publishing House "Phoenix", 1999. - 544 p.
2. 
   Vorobev V.P., Sinelnikov R.D. Atlas of human anatomy. T. IV. Teaching about vessels. - M.-L.: "Medgiz", 1948. - 381 p.
3. 
   Lyrankov Yu.E., Toporov G.N. Anatomy-surgical justification of tactics when terminal states. - M.: Medicine, 1982. - 72 p.
4. 
   Eliseev OM Emergency Reference Guide. - Rostov-on-Don: Publishing House Rostov ON-TA, 1994. - 669 p.
5. 
   Zhuravlev V.A., Svvedieitsa E.P., Sukhorukov V.P. Transfusiological operations. - M.: Medicine, 1985. - 160 p.
6. 
   Loubotsky D.N. Basics of topographic anatomy. - M.: Medgiz, 1953. - 648 p.
7. 
   Matyushin I.F. Guide to operational surgery. - Gorky: Volgogovsky KN. Publishing House, 1982. - 256 p.
8. 
   Rodionov V.N. Water and electrolyte exchange, violations, diagnostics, correction principles. Puncture and catheterization of the subclavian vein / Guidelines For subordinators and interest doctors. - Voronezh, 1996. - 25 s.
9. 
   Rosegen M., Latto Ya.P., NSU. Shening. Expressive catheterization of the central veins. - M.: Medicine, 1986. - 160 s.
10. 
    Silver V.T. Topographic anatomy. - Tomsk: Publishing House of Tomsk University, 1961. - 448 p.
11. 
    Sukhorukov V.P., Berdikyan A.S., Epstein S.L. Puncture and vehicle catheterization / benefit for doctors. - St. Petersburg: St. Petersburg Medical Publishing House, 2001. - 55 p.
12. 
    Hartig V. Modern infusion therapy. Parenteral nutrition. - M.: Medicine, 1982. - 496 p.
13. 
    Tsybulkin E.A., Gorenstein A.I., Matveev Yu.V., Nevolin-Lopatin M.I. Danger of puncture and long-term catheterization of connectible veins in children / pediatrics. - 1976. - № 12. - P. 51-56.
14. 
    Shulutko E.I. et al. Complications of catheterization of central veins. Risk reduction paths / Herald of intensive therapy. - 1999. - № 2. - P. 38-44.

Table of contents

Historical reference ......................................................................4

Clinical anatomy of the subclavian vein .......................................... 4

Topographic anatomical and physiological substantiation

selection of a connectible vein for catheterization .......................................8

Indications for catheterization of a subclavian vein .................................... 9

Contraindications to catheterization of the connector vein ........................ 10

Fixed assets and organization of puncture

and catheterization of a subclavian vein ................................................ 10

Anesthesia ............................................................................................................................... ... 12

Select access ...........................................................................................1.1

Technique of percutaneous puncture and catheterization of the subclavian

vienna according to the Merdinger Method from Plug Access ........................ 16

Technique of percutaneous puncture and catheterization of the subclavian

vienna according to the method of ancient access ....... ................19

Technique of percutaneous puncture and catheterization of the subclavian

vienna on the principle of "catheter through a catheter" .........................................20

Care requirements for catheter ...................................................................20

Possible complications ..............................................................................21

Features of puncture and catheterization of the subclavian vein

in children ....................................................................................................................................

Features of puncture and catheterization of the subclavian vein

elderly people ............................................................... 27

Afterword .................................................................. ............ 28

Literature .............................................................................. .29

2 First of all - do not harm! (Lat.)

Advantages of using a subclavian vein In transfusiology due to its anatomy-physiological features. Vienna has a large diameter (its diameter in an adult -12-14 mm).

Vienna vagina Fucked with the perception of the clavicle and the 1st edge, sternum-clavish fascia, so it is distinguished by a constant location, immobility, does not change its position when changing the position of the body.

Related with surrounding fabrics, Vienna does not fall down even during collapse, that is, when other vessels become inaccessible for venopunction. The location of the vein provides the minimum danger of external infection.

Moreover, considerable speed of blood flow Vienna prevents thrombosis, makes it possible to influence hypertensive solutions, and a large diameter allows the simultaneous administration of significant amounts of liquid.

It is also necessary to note the comparative simplicity puncture and comfortable conditions for the patient (there are no restrictions on the patient's mobility within beddown).
Low pressure in Vienna And the density of the surrounding tissues prevent the formation of post-section hematomas.

The technique of puncture of the subclavian vein followed by catheterization is represented on our video:

Indications:
1. To introduce a catheter to central veins.
2. Measurement and monitoring of the CVD.
3. If necessary and multiple administration of transfusion agents in cases of impossibility of transfusion through peripheral veins (with shock, peripheral vessels).
4. Parenteral nutrition.
5. Introduction of inetropic agents.
6. Hemodialysis.
7. If necessary, fast infusion of liquids.

Contraindications:
1. Venenous thrombosis.
2. Increased bleeding.
3. Untreated sepsis.
4. Clavicle injury.
5. Pronounced respiratory failure.
6. Syndrome of the upper hollow vein.

Anatomy. The subclavian vein is located in the lower part of the subclavian triangle formed by the rear edge of the breast-curable-bed-like muscle, the middle of the clavicle and the front edge of the trapezoid muscle, and is the continuation of the axillary vein. Starting from the lower boundary of the 1st edge and passing over the clavicle to the connection with the inner jugular vein behind the breast-clear articulation, throughout the subclavian vein in the front separates the clavicle from the skin. At the level of the top border of the clavicle, the connectible vein reaches its highest point. Vienna lies on the front staircase, and under the muscle is a subclavian artery. The top of the lung is a deeper artery.
All existing methods of puncture of the connector vein can be divided into 2 groups: with permissible and connectible access.

Included access. It is more convenient access, as the distance from the skin is shorter (0.5-4 cm), Vienna is located right under the skin and the needle when puncture passes only through the skin and fascia. If you need to introduce a catheter to a central vein, the test access has a greater chance of hitting. The needle passes further from the pleura, so less than the risk of pneumothorax. Long-term fixation of the needle or catheter with this access is difficult.

Connect access. In this case, needle has a greater length, as it passes the fascia, the skin, muscular layer. This access is more preferable for long-term catheterization (it is easier to fix the catheter and less conditions for the development of infection). With connected access, pronounced anatomical benchmarks are better used, which contributes to greater security, therefore this method can be recommended for use in obese patients.

To rare complications puncture The subclavian veins include damage to the nerve trunks, trachea and the thyroid gland, the appearance of signs of thrombosis and thrombophlebitis of the subclavian and shoulder veins.

Wound catheterization puncture (Greek, Katheter Probe; Lat. Punctio injection) - the introduction of a special catheter in the lumen of the vein by incoming its puncture with therapeutic and diagnostic objectives. K. in. P. began to be applied since 1953, after Seldinger (Seldinger) proposed the method of percutaneous puncture catheterization of the arteries.

Thanks to the tools and developed technique, the catheter can be carried out in any vein available puncture.

In Wedge, Practice, the most distribution was obtained by puncture catheterization of the subclavian and femoral veins.

Cathetterization of subclavian veins

For the first time, puncture of the subclavian vein was performed in 1952 by Obaniac (R. Aubaniac). The connectible vein has a significant diameter (12-25 mm), the catheterization is less frequently complicated by a phlebitis, thrombophlebitis, wound suppuration, which allows for a long time (up to 4-8 weeks), with testimony, 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 the venopunctions of subcutaneous veins; the need to study central hemodynamics and biochemical, blood paintings in the process of intensive therapy; Conducting heart catheterization (see), angiocardiography (see) and endocardial electrical heart stimulation (see pacemake).

Contraindications: Inflammation of the skin and tissues in the zone of a dashed vein, acute vein thrombosis, subject to puncture (see the Syndrome Podgeta Syndrome), the compression syndrome of the upper hollow vein, coagulopathy.

Technics. For the catheterization of the subclavian vein, it is necessary: \u200b\u200ban needle for puncture of veins with a length of at least 100 mm with an internal lumen of the channel 1.6-1.8 mm and the slice of the needle is at an angle of 40-45 °; A set of catheters from siliconized fluoroplastic with a length of 180-120 mm; a set of conductors, which are a drop-down literal string with a length of 400-600 mm and a thickness that does not exceed the inner diameter of the catheter, but quite tightly complaining its lumen (you can use a set of serviceher); Tools for anesthesia and fixation of the catheter to the skin.

The position of the patient - on the back with his hands given to the body. Vienna puncture is more often carried out under local anesthesia; Children and persons with impaired psyche - under general anesthesia. By connecting the puncture needle with a syringe, half filled with P-r-novocaine, in one of the specified points (the wound point is most often used; Fig. 1) Pierce the skin. The needle is installed at an angle of 30-40 ° to the surface of the chest and are slowly carried out into the space between the collar and I edge towards the upper seat of the surface of the breast-blood joint. When piercing the veins, the feeling of "falling" and blood appears in the syringe. Carefully sipping the piston on itself, under the control of blood flow in the syringe, the needle is introduced into the lumen of the vein by 10-15 mm. Disconnecting the syringe, a catheter to a depth of 120-150 mm is introduced into the surveillance of the needle. Fixing the catheter above the needle, the last to remove it gently. It is necessary to make sure that the catheter is in the lumen of the vein (on the free flow of blood in the syringe) and at a sufficient depth (on the tags on the catheter). Mark "120-150 mm" should be at the level of the skin. The catheter is fixed to the skin of a silk suture. In the distal end of the catheter, the cannula is inserted (needle Duffo), k-room is connected to the system for infusion of p-docks or close with a special plug, after completing the heparin r-rum catheter. The catheterization of veins can be carried out according to the method of the celebringer (see Seldinger Method).

The duration of the functioning of the catheter depends on the proper care of it (the content in the conditions of strict aseptics of the puncture channel wounds, prevent thrombing of the lumen by washing the catheter after each shutdown for a long time).

Complications: Vienna perforation, pneumatic, hemotorax, thrombophlebitis, wound suppuration.

Catheterization of femoral veins

The first on puncture of the femoral vein was told Lac (J. Y. Luck) in 1943

Indications. The catheterization of the femoral vein is mainly used for diagnostic purposes: Ileokavography (see phlebography, pelvis), angiocardiography and catheterization of the heart. Due to the high risk of developing acute thrombosis in the femoral or pelvic veins, the long-term catheterization of the femoral vein is not applicable.

Contraindications: Inflammation of the skin and tissues in the puncture zone, thigh veins thrombosis, coagulopathy.

Technics. The catheterization of the femoral vein is carried out with the help of the toolkit used in the catheterization of the arteries according to the Meringine method.

Patient position - on back with several divorced legs. Under local anesthesia, they pierce the skin for 1-2 cm below the groove (pipeline) bundle in the projection of the femoral artery (Fig. 2). The needle is installed at an angle of 45 ° to the skin surface and carefully carried out to the sensation of the pulsating artery. Then the end of the needle deflects in the medial side and slowly introduce up in the inguinal ligament. About finding the needle in the lumen of the veins are judged by the emergence of dark blood in the syringe. The introduction of the catheter in Vienna is carried out according to the method of the Merdinger.

Complications: Vienna damage, occasional hematomas, acute vein thrombosis.

Bibliography: Gologogorsky V. A. and others. Clinical Evaluation Catheterization of a subclavian vein, Vestn, Hir., Vol. 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; Sel Dierger 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.

Indications
Intensive infusion transfusion therapy, parenteral nutrition, disintellation therapy, intravenous antibiotic 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.
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 place of puncture and catheterization, injury in the region of the clavicle, bilateral pneumothorax, pronounced respiratory failure with emphysema lungs, the upper hollow hollow syndrome, a Spridger Syndrome.
For catheterization of the upper floor of the vein, the approach is preferably used through a subclavian vein. The widespread use of this access is due to the anatomy-physiological features of the connector vein: Vienna is distinguished by a large diameter, constancy of the location and clear topographic and anatomical benchmarks; Vienna vagina is fascinated with a charming of the clavicle and 1 ribs, the curable-breast fascia, which ensures the immobility of the vein and prevents its decline even with a sharp decrease in blood volume, when all other peripheral veins fall down; 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 prevent thrombosis, allow you to introduce hypertensive solutions, provide the possibility of simultaneous administration of significant amounts of liquid and for a long time. Low pressure in the vein and the density of the surrounding tissues prevents the occurrence of post-section hematomas.
The connectible vein is the immediate continuation of the axillary, the boundary between them serves the outer edge of 1 ribs. Here it lies on the top surface of 1 ribs behind the clavicle, located in the preliminary interval in front of the front staircase muscle, then deflects it down and comes up to the rear surface of the breast-clear joint, where it merges with the inner jugular vein, forming a shoulder vein. On the left to the venous angle there is a breast lymphatic duct, and right - right lymphatic duct. The fusion of the right and left shoulder veins forms the upper hollow vein. Front all over the connective vein separated from the skin by the clavicle, reaching its highest point at the level of it. The lateral part of the vein is the Kepenta and a book from the subclavian artery. The medial vein and artery shares the front staircase muscle with a diaphragmal nerve located on it, and then to the front mediastinum.
In newborns and children under 5 years old, the subclavian vein is projected into the middle of the clavicle, at an older age - on the border between the inner and medium thirds of the clavicle. The diameter of the 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 11-26 mm in the final section of the vessel. Vienna length in adults 2-3 cm.
For punctuation and catheterization of the subclavian vein, under-and-invioced access are proposed.
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 are flowing, above the clavicle. The connectible vein is closer to the dome of the pleura, while it is separated from the pleura with 1 edge, above the veins and the duck are a 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 o 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. 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.
A puncture needle of 10-12 cm long, with an inner lumen of 1.5-2 mm and a slice of the island at an angle of 40-45 o, connected to a syringe filled with a solution of novocaine or isotonic sodium chloride solution, pierce the skin to 1 cm Book from the lower edge of the clavicle At the border of its inner and middle third. The needle is installed at an angle of 45 o to the clavicle and 30-40 o to the surface of the chest and slowly spend into the space between the collar and 1 edge, directing the tip of the needle behind the clavicle to the upper edge of the breast-cleaned articulation. The needle usually falls into the final 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 old, 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, changes depending on the respiratory phase: increases in exhalation and decreases to breathe up to its disappearance. The amplitude of oscillations can reach 7-8 mm.
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, an explorer (line of polyethylene with a diameter of 0.8-1 mm and 40 cm in diameter of 0.8-1 mm and 40 cm long) is introduced to a depth of 12-15 cm, not less than the length of the catheter, after which the needle is carefully removed. Polyethylene catheter on the conductor, it is promoted to the lumen of the veins by 8-12 cm by rotational and translational movements, the conductor is extracted (catheterization by the method of the celebringer). 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 zone of maximum blood flow, which warns the appearance of erosion or punching of veins, right atrium and ventricle. This corresponds to the level of articulation of the 2nd rib with the sternum, where the upper hollow vein is formed.
The length of the insertion part of the catheter should be determined by the depth of the needle gains with adding the distance from the breast-clavical joint to the lower edge of the 2nd rib. In the outer end of the catheter insert the needle-cannula, which serves as an adapter to connect with a syringe or an infusion system. Proceed control aspiration. The correct location of the catheter is recognized by synchronous blood movement in it with swings up to 1 cm. If the fluid level in the catheter with each inhalation of the patient leaves the outdoor end of the catheter - the inner is in the right place. If the fluid actively comes back the catheter reached atrium or even ventricle.
Upon completion of each infusion, the catheter is closed with a special plug-plug, pre-filled with a solution of heparin 1000-2500. On 5 ml of isotonic solution of sodium chloride. This can be done and by puncture plugs with a thin needle.
The outer end of the catheter should be reliably fixed to the skin of a silk seam, adhesive meter, etc .. The fixation of the catheter prevents its movement that promotes mechanical and chemical irritation of intima, and reduces infection by migrating bacteria from the surface of the skin into deep-breeding fabrics. During the infusion or temporal blockade of the catheter, the plug must ensure that the catheter is not filled with blood, because This can lead to its rapid thrombing. During daily dressings, the condition of surrounding soft tissues should be estimated, using a bactericidal plaster.

2. The test method: Of several methods, preference is given to access from the point of Ioffa. The inclination point is located in the corner formed by the outer edge of the clavical leg of the breast-curable-luming muscle and the top edge of the clavicle. The game is guided at an angle of 45 o to the sagittal plane and 15 o to the frontal. At a depth of 1-1.5 cm, the vein is recorded. The advantage of this access before the subclavian is that the puncture is more accessible to anesthesiologist during operations when it is from the head of the patient: the course of the needle during puncture corresponds to the direction of the vein. At the same time, the needle is gradually deviated from the subclavian artery and pleura, which reduces the risk of damage; The skeleton area is clearly defined; The distance from the skin to Vienna is shorter, i.e. When puncture and catheterization obstacles are practically no.
Complications of puncture and catheterization of a subclavian veinthey are divided into 3 groups:
1. related to the technique of puncture and catheterization: pneumothorax, damage to the breast lymphatic duct, puncture of the pleura and lung with the development of pneumatic, gem, hydro, or chylotrax (due to the danger of the bilateral pneumothorax attempt attempts to puncture Vienna should be carried out only on the one hand, damage to the brachial nervous plexus, trachea, thyroid gland, air embolism, puncture of a connectible artery.
Punch of the plug-in artery is possible:
a) if the vein puncture is carried out on the breath when its lumen decreases sharply;
b) Artery, as an option location, may not be behind, but ahead of the vein.
Improper promotion of the catheter may depend on the magnitude of the Pyrogov angle (the fusion of the connectible and inner jugular vein), which, especially on the left, can exceed 90 o. The magnitude of the corner on the right averages 77 o (from 48-103 o), on the left - 91 o (from 30 to 122 o). This sometimes contributes to the penetration of the catheter into the inner jugular vein. This complication is accompanied by a violation of the outflow of venous blood from this vein, the edema of the brain corresponding to half of the face and neck. If medicinal substances are introduced against venous current, it is possible to disorder the brain circulation, pain in the neck pain appear, irradiating in an external hearing pass. In the inner jugular vein can migrate a randomly cut-off needle conducting conductor.
2. The position of the catheter: arrhythmia, perforation of the vein or atrium wall, migration of the catheter in the cavity of the heart or the pulmonary artery, extinguishing from the vein outward, paravazal injection of the liquid, cutting the conductor to the edge of the needle islar and embolism of the heart cavity, long bleeding from the puncture hole in Vienna;
3. Condected long finding a catheter in Vienna: phlebotromboosis, thrombophlebitis, pulmonary artery thromboembolism, suppuration of soft tissues along the catheter, "catheter" sepsis, septicemia, septicopemia.

The catheterization of veins (central or peripheral) is a manipulation that allows you to provide full-fledged venous access to the bloodstream in patients requiring long or permanent intravenous infusions, as well as in order to quickly provide emergency care.

Venous catheters are central and peripheral, respectively, the first are used for puncturing the central veins (subclavian, jugular or femoral) and can be installed only by the doctor by a resuscator-anesthesiologist, and the second are installed in the peripheral peripheral lumen. Last manipulation can be performed not only by a doctor, but also nurse or anesthesis.

The central venous catheter is a long flexible tube (Okolosm), which is firmly installed in the lumen of large veins. In this case, special access is carried out because the central veins are located rather deeply, in contrast to the peripheral subcutaneous veins.

The peripheral catheter is represented by a shorter hearing with a thin needle-stilette located insidely, which is performed by puncture of the skin and the venous wall. Subsequently, the needle-stilette is removed, and the thin catheter remains in the lumen of the peripheral vein. Access to subcutaneous vein is usually not complicated, so the procedure can be performed by a nurse.

Advantages and disadvantages of the methodology

The undoubted advantage of catheterization is the implementation of rapid access to the patient's blood circuit. In addition, when setting a catheter, the need for daily puncture of the Vienna is eliminated in order to conduct drip intravenous injections. That is, the patient is quite once to install the catheter instead of every morning again "prick" vein.

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

Of the disadvantages, it is possible to note the impossibility of a long presence of a catheter in a peripheral vein (no more than three days), as well as the risk of complications (although extremely low).

Indications for the formulation of the catheter in Vienna

Often, in emergency conditions, access to the patient's vascular bed cannot be carried out by other methods by virtue of many reasons (shock, collapse, low blood pressure, spruce veins, etc.). In this case, to save the life of a heavy patient, the introduction of medicines so that they come immediately into the bloodstream. And here the catheterization of the central veins comes to the rescue. Thus, the main indication for setting the catheter to the central vein is to provide emergency and emergency care in the conditions of the intensive care unit or the chamber, where intensive therapy is carried out by patients with severe diseases and disorders of vital functions.

Sometimes catheterization of femoral veins can be carried out, for example, if the doctors conduct cardiovascular resuscitation (artificial ventilation of the lungs + indirect heart massage), and another doctor carries out venous access, and at the same time does not prevent his colleagues on the chest. Also, the catheterization of the femoral vein can be tried to perform in an ambulance in the peripheral veins not to find, and the introduction of drugs is required in emergency mode.

central Vienna catheterization

In addition, the following testimony exist for the production of the central venous catheter:

• Conduct operation on the open heart, with the help of an artificial circulation apparatus (AIC).
• The implementation of access to the bloodstream in severe patients in resuscitation and intensive therapy.
• Installing an electrocardiotimulator.
• Introduction of the probe into cardiac cameras.
• Measuring central venous pressure (CVD).
• Conducting X-ray-sensitive studies of the cardiovascular system.

Installation of the peripheral catheter is shown in the following cases:

• Early start of infusion therapy at the stage of ambulance medical care. With hospitalization to the hospital, the patient with the already installed catheter continues to be proceeded, thereby saving time to produce a dropper.
• Installation of catheter with patients who are planned abundant and / or round-the-clock infusion of medicines and medical solutions (Piz. Solution, glucose, ringer solution).
• Intravenous inflation to the patients of the surgical hospital when an operation may be required at any time.
• The use of intravenous anesthesia for small operational interventions.
• Installation of the catheter to the women in labor at the beginning of the generic activity so that there are no problems with venous access in childbirth.
• The need for a multiple fence of venous blood for research.
• Blood transfusion, especially multiple.
• The inability to feed the patient through the mouth, and then with the help of a venous catheter it is possible to conduct parenteral nutrition.
• Intravenous rehydration during dehydration and with electrolyte changes in the patient.

Contraindications for vehicle catheterization

Installation of the central venous catheter is contraindicated in the case of the patient in inflammatory changes on the leather of the connector region, in the case of blood coagulation disorders or the injury of the clavicle. Due to the fact that it can be carried out both on the right and left, then the presence of a one-sided process will not prevent the installation of the catheter on the healthy side.

From contraindications for the peripheral venous catheter, it is possible to note the surmock vein thrombophlebitis patient, but again, if there is a need for catheterization, it is possible to manipulate a healthy hand.

How is the procedure?

Special preparation for catheterization of both central and peripheral veins is not required. The only condition at the beginning of working with the catheter is the full compliance with the rules of asepsifetics and antiseptics, including the processing of the staff of the personnel establishing a catheter, and thorough skin treatment in the area where the Vienna puncture will be carried out. Working with a catheter, of course, it is necessary using a sterile toolkit - a set for catheterization.

Catheterization of central veins

Cathetterization of subclavian veins

When catheterization of the connector vein (with a "plug-in", in the slang anesthesiologists), the following algorithm is performed:

cathetterization of subclavian veins

Put the patient on the back with your head turned into the opposite catheterization of the side and with a hand lying along the body on the side of catheterization,

Conduct local anesthesia of the skin according to the type of infiltration (lidocaine, novocaine) from the depth of the clavicle on the border between its internal and medium-sized thirds,

A long needle, in the lumen of which an explorer (inverter) is inserted to carry out a checkbox between the first edge and the clavicle and to ensure that the method of catheterization of the central veins in the celestial vehicle is founded on this (Introduction of the catheter using the conductor),

Check for venous blood in the syringe,

Bring out the needle from Vienna

On the guide to introduce a catheter in Vienna and fix the outer part of the catheter with several seams to the skin.

Video: Cathetterization of the subclavian vein - training video

catheterization of the inner jugular vein

The catheterization of the inner jugular vein is somewhat different on the technique:

• The patient's position and pain relief is the same as when the catheterization of the connectible vein,
• The doctor, being at the patient's head, determines the place of puncture - a triangle formed by the legs of the breast-curable-preceding muscle, but by 0.5-1 cm of the dust from the sternum edge of the clavicle,
• Valka needles are carried out at an alertowers towards the navel,
• The remaining steps in conducting manipulation are the same as when the catheterization of the subclavian vein.

Catheterization of femoral veins

The catheterization of the femoral vein from the above described is significantly:

1. The patient is placed on the back with the reserved dust of the thigh,
2. Particularly measured the distance between the front iliac row and the LONA joint (pubic symbol),
3. The resulting value is divided by three thirds,
4. Find the border between the inner and medium thirds,
5. Determine the pulsation of the femoral artery in the groin yam in the resulting point,
6. 1-2 cm closer to the genital organs is the femoral vein,
7. The implementation of venous access is carried out using a needle and conductor under the alerts towards the navel.

Video: Catheterization of the central veins - training film

Cathetterization of peripheral veins

From peripheral veins are most preferable in terms of paragraph lancer and medial veins of the forearm, intermediate elbow vein, as well as vein on the rear of the brush.

cathetterization of peripheral veins

The algorithm for the introduction of the catheter in Vienna on the hand is reduced to the following:

• After treatment with antiseptic solutions, the required catheter is selected. Usually catheters are marked depending on the size and have different colors - purple color in the shortest catheters having a small diameter, and orange color in the longest with a large diameter.
• The patient is superimposed harness on the shoulder above the catheterization site.
• The patient is asked to "work" a fist, squeezing and squeezing fingers.
• After palpator definition of veins, skin treatment with antiseptic is carried out.
• The puncture of the skin and veins needle-stiletta is carried out.
• The needle stylet is pulled out from Vienna while the cannula catheter in Vienna is introduced.
• Next, the system for intravenous infusions is connected to the catheter and therapeutic solutions are influenced.

Video: Puncture and catheterization of the elbow vein

Care for catheter

In order to minimize the risks of the development of complications, the catheter should be made correct care.

First, the peripheral catheter must be installed no more than a three-day. That is, the catheter can stand in Vienna no more than 72 hours. If the patient needs an additional infusion of solutions, the first catheter should be removed and put the second, on the other hand or to another vein. Unlike the peripheral, central venous catheter may be in Vienna to two or three months, but under the condition of the weekly replacement of the catheter to the new one.

Secondly, the stub on the catheter should be washed with heparinized solution every 6-8 hours. It is necessary to prevent blood clots in the worst of the catheter.

Thirdly, any manipulations with the catheter should be carried out according to the rules of asepsis and antiseptics - the staff must carefully process the hands and work in gloves, and the place of catheterization should be protected by a sterile bandage.

Fourth, to prevent accidental circumcision of the catheter, it is strictly forbidden to use scissors when working with a catheter, for example, for trimming a leucoplasty, which is fixed to the skin.

The listed rules when working with the catheter make it possible to significantly reduce the frequency of thromboembolic and infectious complications.

Are complications possible during vehicle catheterization?

Due to the fact that veins catheterization is interference in the human body, to predict how the body will react to this intervention, it is impossible. Of course, the overwhelming majority of patients does not arise any complications, but in extremely rare cases it is possible.

So, when installing central catheter Radinary complications are damage to neighboring organs - a plug-in, sleepy or femoral artery, a shoulder nervous plexus, perforation (spinning) of the pleural dome with air penetration into the pleural cavity (pneumothorax), damage to the trachea or esophagus. The air embolism includes such complications - penetration into the bloodstream air bubbles from the environment. The prevention of complications is technically correct conducting the catheterization of the central veins.

When installing both central and peripheral catheters, formidable complications are thromboembolic and infectious. In the first case, thrombophlebitis and thrombosis are possible, in the second - systemic inflammation up to sepsis (blood infection). The prevention of complications is careful observation of the catheterization zone and the timely removal of the catheter at the slightest local or general changes - pain along the catheterized vein, redness and swelling at the point of puncture, an increase in body temperature.

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

Cathetterization of subclavian veins: machinery, methods, complications, sets

The axillary vein goes into a subclavian vein at the intersection area with the lateral edge of the I edge and is directly under the worship.

Behind the breast-drawn articulation, the inner jugular and connectible vein merge, forming a shoulder barrel. Connected artery and shoulder plexus are located behind the subclavian 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 the 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.

The tip of the sensor is applied to the neck outside of the remission of the carotid artery at the level of the hand-shaped cartilage or in the triangle formed by the heads of the breast-curable-bed-like 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.

When the rear wall of the veins, the veins 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.

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2. Puncture and catheterization of the subclavian artery.

The execution of this manipulation is facilitated by the following topographic analytics: - the connectible vein has a significant diameter (especially in a fusion site with an inner jugular vein); - Vienna is firmly fixed to the adjustment to the anatomical elements and therefore does not fall; - The subclavian vein has a relatively surface location and clear benchmarks, which facilitates access to it.

Topography and puncture of connectible veins

The subclavian vein is a continuation of the axillary vein (v. Axillaris) and is sent from the front edge of 1 edges to a merge with the inner jugular vein (the venous angle of pyrogov). Diameter of the connector vein 1-2 cm, length 2-5 cm; The test area v.Subclavia passes along the top surface of 1 edges (medial - rear edge m. SCM, laterally - the boundary of the inner and middle third of the clavicle); Place of puncture: 1.5-2 cm. Above the clavicle in the direction of the corner between the collar and m. SCM.

For punctuation: - 0.25% novocaine solution; - a set of needles for local anesthesia; - a special curved needle for the percutaneous puncture of the vessels -Kateter with the conductor. In addition, sterile balls and napkins are needed for the separation of the puncture zone, the leukoplasty for fixing the catheter to the knife.

The position of the patient (the victim) is on the back, with a roller-ended under the blades (the head is rotated in the opposite direction). In severe patients, it is permissible to conduct puncture in a sessen position. The projection line of the connectible vein in most people corresponds to the boundary between the inner and medium thirds of the length of the clavicle, passing the space outside the inside and bottom. Puncture Vienna either under the collar, or above it - on the neck. The prescription area of \u200b\u200bthe puncture is limited to the medial - the rear edge of the breast-sized muscle; lateral - line conducted on the border of the inner and medium third-party clavicle. When puncture, the needle is directed at an angle of 40-45 ° but the ratio to the clavicle .. the sequence of action: - perform local infiltration anesthesia in a puncture zone of 0.25% novel solution; - Produce point abscess at the point of puncture.

In most cases, this stage is not necessary.

Produce puncture with a needle planted on a syringe with a solution of novocaine.

With the feeling of failure, the piston squeeze "on themselves".

In the absence of a dark blood stream, the needle should be pulled back or promoting further paт. Distance 0.5-1 cm. A similar search puncture should be carried out carefully, changing the direction of the needle movement.

The needle movement must be monitored by the novel solution.

the incision of the needle should be directed up and medial.

The usual impact depth of the needle is 3-5 cm. Promotion is deeper dangerous due to the possibility of injury to the dome of the pleura, subclavian artery, shoulder plexus.

On the end of the needle in the lumen of the veins are judged by the appearance in the syringe of dark venous blood. Exposing the plug-in artery

Access by Janelidze. The incision provides the best path to the plug-in artery when switching it to the axillary artery. The incision starts 1-2 cm in front of the sternum-clarifying joint and spend it over the clavicle to the bevum-like blades. Next, the incision is carried out by a book on a deltoid-thoracic furrow for 5-6 cm. The clavicle is repaired or ledated, the clavical muscle intersect. Access to Petrovsky. The incision provides wider access to the plug-in artery when it exits it due to the sternum, as well as in the area of \u200b\u200bthe inter-jet gap. Produce a T-shaped layer cut of soft tissues. The horizontal part of the cut length passes along the front surface of the clavicle, and the vertical part goes down the book by 5 cm in the middle of the clavicle. Further, the operation of the operation is identical to the above-described method. In both ways, the ligation of the plug-in artery should be made below the place of departure of the shielding barrel, from which the appropriate artery is departed. This artery anastomoses with a subordinate artery, the branch of the axillary, with the result that after the dressing the blade arterial circle is formed, according to which the collateral blood circulation of the upper limb is carried out.

3. Anatomy-surgical justification of the paths of propagation of the purulent-inflammatory process and the hematoma of the retroperitoneal space, drainage.

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Catheterization of the central veins (subclavian, jugs): execution technique, indications, complications

For puncture and catheterization of central veins, the right-hand connective vein or inner jugular is most often used.

The central venous catheter is a long flexible tube that is used for the catheterization of the central veins.

The central veins include the upper and lower hollow veins. It is clear from the name that the bottom hollow vein collects venous blood from the lower parts of the body, the top of the head and the right part. Both veins fall into the right atrium. Preference in the formulation of the central venous catheter is given to the upper hollow vein, because Access is closer and the mobility of the patient is preserved.

The right and left plug-in veins and the right and left internal jugs are falling into the upper hollow vein.

Blue shows the right and left connectible, internal jugular veins and top hollow vein.

Indications and contraindications

Allocate the following testimony for the catheterization of the central veins:

• Complex operations with possible massive blood loss;
• Operations on the open heart with aics and generally on the heart;
• The need for intensive therapy;
• Parenteral nutrition;
• The possibility of measuring the CVD (central venous pressure);
• The possibility of repeated blood sampling for control;
• Introduction of the electrostimulator of the heart;
• X-ray - contrasting study of the heart;
• Sensing of the cavities of the heart.

Contraindications

Contraindications for catheterization of the central veins are:

• Blood coagulation disorders;
• Inflammatory in the place of puncture;
• Injury clavitz;
• Two-way penotoraxes and some others.

However, it is necessary to understand that contraindications are relative, because If the catheter needs to be put on life indications, it will be done under any circumstance, because To save a person's life in an emergency, venous access is needed)

For the catheterization of central (trunk) veins, one of the following methods can be selected:

1. Through the peripheral veins of the upper limb, more often the elbow bend. The advantage in this case is the simplicity of execution, the catheter is carried out to the mouth of the upper hollow vein. The disadvantage that the catheter can stand no more than two to three days.

2. Through a subclavian vein on the right or left.

3. Through the inner jugular vein as to the right or on the left.

The complications of the catheterization of the central veins include the occurrence of phlebitis, thrombophlebitis.

For the puncture catheterization of the central veins: jugular, connectible (and, by the way, the arteries) use the method of the Seldger (with a conductor), the essence of which is as follows:

1. The needle is punctured vein, the conductor is carried out to a depth of 10 - 12 cm.

3. After that, the conductor is cleaned, the catheter is fixed to the leather with a plaster.

Cathetterization of subclavian veins

Puncture and catheterization of the connectible vein can be performed above and connectible access, on the right or left - no values. The subclavian vein has a diameter in an adult., Fixed with a muscular - a ligalar apparatus between the collar and the first edge, almost does not fall. Vienna has good blood flow, which reduces the risk of thrombosis.

The technique of performing the catheterization of the connector vein (connectible catheterization) implies the introduction of the patient of local anesthesia. The operation is carried out under full sterility. A multiple access points for the catheterization of the subclavian vein are described, but I prefer the Abaniaka point. It is located on the border of the inner and middle third of the clavicle. The percentage of successful catheterization reaches%.

After processing the operating field, we cover the operational field with a sterile diaper, we leave open only the place of operation. The patient lies on the table, the head turns as much as possible in the opposite direction from the operation, the hand is on the side of the puncture along the body.

Consider in detail the stages of the subcipable catheterization:

1. Local leather pain relief and subcutaneous fiber in the puncture zone.

2. A syringe on 10 ml from a special former with a novocaine and a needle needle a length of 8-10 cm. Purchase the skin, constantly introducing novocaine for the anesthesia and washing the needle's lumen, promote the needle ahead. At a depth of 2 - 3 - 4 cm. Depending on the patient's constitution and the point of the instead, the feeling is punishing the bundle between the first edge and the clavicle, we continue carefully, simultaneously sneeze the piston of the syringe on yourself and forward in order to wash the needle lumen.

3. Then the feeling of piercing the walls of the vein will affect, while simultaneously exploring the piston of the syringe, we obtain dark venous blood.

4. The most dangerous moment is the prevention of an air embolism: We ask the patient if he is in consciousness, do not breathe deeply, disconnect the syringe, close the needle pavilion and quickly enter the conductor through the needle, now it's a metal string, (before just a fishing line) looks like a guitar, On the necessary depth, see 10-12.

5. We remove the needle, on the conductor by rotational movements we carry out the catheter to the desired depth, we remove the conductor.

6. We attach a syringe with saline, check the free receipt of venous blood on the catheter, rinse the catheter, there should be no blood in it.

7. Fix the catheter with silk seam to the skin, i.e. We flash the skin, tie the nodes, then around the catheter tie the nodes, and even for reliability, we tie the nodes around the catheter's pavilion. All the same thread.

8. Ready. We attach a dropper. It is important that the tip of the catheter should not stand in the right of atrium, the danger of arrhythmia. Good and enough at the mouth of the upper hollow vein.

With the catheterization of the subclavian veins, complications are possible, they are minimal in the hands of an experienced specialist, but consider them:

• Puncture of the plug-in artery;
• Trauma shoulder nervous plexus;
• Dome damage pleural followed by pneumothorax;

Damage to trachea, esophagus and thyroid gland;

Air embolism;

Left damage to the breast lymphatic duct.

Complications, can also be associated with the position of the catheter:

• Perforation of the walls of veins, or atrium or ventricle;
• Paravazal injection of fluid;
• Arrhythmia;
• Vein thrombing;
• Thromboembolia.

There is also a possibility of complication caused by infection (suppuration, sepsis)

By the way, the catheter in Vienna may be up to two to three months. It is better to change more often, once in one - two weeks, a change is simple: a guide is conducted in the catheter, a catheter is removed and a new conductor is installed on the conductor. The patient can even walk with a drip in his hands.

Catheterization of the inner jugular vein

Indications for catheterization of internal jugular veins are similar as for the catheterization of the subclavian vein.

The advantage of catheterization of the inner jugular vein is that in this case the risk of damage to the pleura and lungs is significantly less.

The disadvantage - Vienna is mobile, so the puncture is more difficult, while nearby is a carnal artery.

The technique of puncture and catheterization of the inner jugular vein: the doctor stands at the head of the patient, the needle is enhanced in the center of the triangle, which is caused by the legs of the breast-curable-bed-like muscle (in the native) and 0.5 - 1 cm. Lateral than. The duck from the sifted end of the clavicle. The direction caudally i.e. Approximately on the tailbone, under the alerts to the skin. Also, local anesthesia is needed: syringe with Novocaine, the technique is similar to a subcipter puncture. The doctor feels two "failures" puncture of the cervical fascia and the walls of the vein. Interest in Vienna at a depth of 2 - 4 cm. Further as well as with the catheterization of the connector vein.

It is interesting to know: there is a science topographic anatomy, so that the point of imposition of the upper hollow vein into the right atrium in the projection on the body surface corresponds to the place of articulation of the second edge to the right with the sternum.

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Infusion therapy is a treatment method based on the introduction of intravenously or under the skin of various medicinal solutions and preparations, with the purpose of ...

Cathetterization of a subclavian artery

Vein catheterization puncture (Greek, Katheter probe; Lat. Punctio injection) - the introduction of a special catheter in the lumen of the vein by incoming its puncture with therapeutic and diagnostic objectives. K. in. P. began to be applied since 1953, after Seldinger (Seldinger) proposed the method of percutaneous puncture catheterization of the arteries.

Thanks to the tools and developed technique, the catheter can be carried out in any vein available puncture.

In Wedge, Practice, the most distribution was obtained by puncture catheterization of the subclavian and femoral veins.

Cathetterization of subclavian veins

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

Indications: the need for long-term infusion therapy (see), including patients in terminal states, and parenteral nutrition (see); great difficulties in performing the venopunctions of subcutaneous veins; the need to study central hemodynamics and biochemical, blood paintings in the process of intensive therapy; Conducting heart catheterization (see), angiocardiography (see) and endocardial electrical heart stimulation (see pacemake).

Contraindications: inflammation of the skin and tissues in the zone of a dashed vein, acute vein thrombosis, subject to puncture (see Pedinger Syndrome), the syndrome of the superior hollow vein, coagulopathy.

Technics. For the catheterization of the subclavian vein, it is necessary: \u200b\u200ban needle for puncture of veins with a length of at least 100 mm with an internal lumen of the channel 1.6-1.8 mm and the slice of the needle is at an angle of 40-45 °; A set of catheters from siliconized fluoroplastic with a length of 180-120 mm; a set of conductors, which are a drop-down literal string with a length of 400-600 mm and a thickness that does not exceed the inner diameter of the catheter, but quite tightly complaining its lumen (you can use a set of serviceher); Tools for anesthesia and fixation of the catheter to the skin.

The position of the patient - on the back with his hands given to the body. Vienna puncture is more often carried out under local anesthesia; Children and persons with impaired psyche - under general anesthesia. By connecting the puncture needle with a syringe, half filled with P-r-novocaine, in one of the specified points (the wound point is most often used; Fig. 1) Pierce the skin. The needle is installed at an angle of 30-40 ° to the surface of the chest and are slowly carried out into the space between the collar and I edge towards the upper seat of the surface of the breast-blood joint. When piercing the veins, the feeling of "falling" and blood appears in the syringe. Carefully sipping the piston on itself, under the control of blood flow in the syringe, the needle is introduced into the lumen of the vein by 10-15 mm. Disconnecting the syringe, a catheter to a depth of 120-150 mm is introduced into the surveillance of the needle. Fixing the catheter above the needle, the last to remove it gently. It is necessary to make sure that the catheter is in the lumen of the vein (on the free flow of blood in the syringe) and at a sufficient depth (on the tags on the catheter). The "120-150 mm" mark should be at the skin level. The catheter is fixed to the skin of a silk suture. In the distal end of the catheter, the cannula is inserted (needle Duffo), k-room is connected to the system for infusion of p-docks or close with a special plug, after completing the heparin r-rum catheter. The catheterization of veins can be carried out according to the method of the celebringer (see Seldinger Method).

The duration of the functioning of the catheter depends on the proper care of it (the content in the conditions of strict aseptics of the puncture channel wounds, prevent thrombing of the lumen by washing the catheter after each shutdown for a long time).

Complications: Perforation of veins, pneumatic, hemotorax, thrombophlebitis, wound suppuration.

Catheterization of femoral veins

The first on puncture of the femoral vein was told Lac (J. Y. Luck) in 1943

Indications. The catheterization of the femoral vein is mainly used for diagnostic purposes: Ileokavography (see phlebography, pelvis), angiocardiography and catheterization of the heart. Due to the high risk of developing acute thrombosis in the femoral or pelvic veins, the long-term catheterization of the femoral vein is not applicable.

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

Technics. The catheterization of the femoral vein is carried out with the help of the toolkit used in the catheterization of the arteries according to the Meringine method.

Patient position - on back with several divorced legs. Under local anesthesia, they pierce the skin for 1-2 cm below the groove (pipeline) bundle in the projection of the femoral artery (Fig. 2). The needle is installed at an angle of 45 ° to the skin surface and carefully carried out to the sensation of the pulsating artery. Then the end of the needle deflects in the medial side and slowly introduce up in the inguinal ligament. About finding the needle in the lumen of the veins are judged by the emergence of dark blood in the syringe. The introduction of the catheter in Vienna is carried out according to the method of the Merdinger.

Complications: Vienna damage, occasional hematomas, acute vein thrombosis.

Bibliography: Gologogorsky V. A. and others. Clinical assessment of the catheterization of the subclavian vein, Vestn, Hir., Vol. 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; Sel Dierger 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.

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Cathetterization of subclavian veins

The puncture and catheterization of veins, in particular the central, relate to widespread manipulations in practical medicine. Currently, very broad indications are sometimes put to the catheterization of the subclavian vein. Experience shows that this manipulation is not safe enough. Extremely important knowledge of the topographic anatomy of the connectible vein, the technique of performing this manipulation. In this teaching and methodological manual, much attention is paid to the topographic anatomical and physiological substantiation of both the selection of access and the technique of veins catheterization. Clearly formulated indications and contraindications, as well as possible complications. The proposed allowance is intended to facilitate the study of this important material due to a clear logical structure. When writing benefits, both domestic and foreign data were used. The manual, undoubtedly, will help students and doctors to explore this section, and also improves teaching efficiency.

In one year, more than 15 million central venous catheters are installed in the world. Among the venous tributaries available for puncture are most often cathetterized by a subclavian vein. In this case, various methods apply. The clinical anatomy of the subclavian vein, accesses, as well as the technique of puncture and catheterization of this vein are set out in various textbooks and manuals, is not fully fully, which is associated with the use of various methods for carrying out this manipulation. All this creates difficulties to students and doctors when studying this issue. The proposed allowance will facilitate the assimilation of the material being studied at the expense of a consistent system approach and should contribute to the formation of strong professional knowledge and practical skills. The manual is written on a high methodical level, meets a typical curriculum and can be recommended as a guide for students and doctors when studying puncture and catheterization of a subclavian vein.

Cracked puncture and catheterization of the subclavian vein is 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 the average medical personnel with the rules for using catheters in a subclavian vein and care.

Sometimes, when performing all the requirements for puncture and catheterization of the connector veins, there may be repeated unsuccessful attempts to the vessel catheterization. At the same time, it is very useful to "change your hand" - to ask another doctor to carry out this manipulation. This does not in any way discredit the doctor who unsuccessfully fulfilled the puncture, but, on the contrary, it will raise it in the eyes of colleagues, since excessive stubbornness and "reference" in this matter can cause significant damage to the patient.

For the first time, the puncture of the subclavian vein was carried out in 1952 by Aubaniac. They described the puncture method from subclavian access. Wilson et al. In 1962, connected access to the catheterization of the subclavian vein was used, and through it - and the upper vein hollow. From this time, the percutaneous catheterization of the subclavian vein began to be widely used for diagnostic studies and treatment. YOFFA in 1965 introduced on clinical practice for inspected access to the introduction of a catheter into central veins through a subclavian vein. In the future, various modifications of the on-shifted and connectural access were proposed in order to increase the likelihood of successful catheterization and reducing the risk of complications. Thus, at present, the subclavian vein is considered a convenient vessel for central venous catheterization.

Clinical Anatomy of Plug Vienna

Connected Vienna (Fig.1.2) is the immediate continuation of the axillary veins, moving to the last at the level of the lower edge of the first edge. Here it goes on top of the first edge and lies between the rear surface of the clavicle and the front edge of the front staircase, located in the preliminary interval. The latter is located the front-end triangular slot, which limits the back - the front staircase muscle, in front and sump - sternum-ply and sternum-thyroid muscles, front and outside - the breast-casculously lummy muscle. Connected vein is located in the lower range of the gap. Here it comes to the rear surface of the breast-clearable articulation, merges with the inner jugular vein and forms a shoulder vein with her. The merger's place is denoted as the venous angle of pyrogov, which is projected between the lateral edge of the lower depth of the breast-curable-bed-like muscle and the top edge of the clavicle. Some authors (I.F. Matyushin, 1982) When describing the topographic anatomy of the connector vein, a clavical area is distinguished. The latter is limited: on top and bottom - lines that are 3 cm above and below the clavicle and parallel to it; Outside - the front edge of the trapezoidal muscle, a acryal-clavical articulation, the inner edge of the deltoid muscle; Cancer - the indoor edge of the breast-curable-bed-like muscle to the intersection at the top - with the upper boundary, down - from the bottom. Behind the clavicle, the subclavian vein first is located on the first edge, which separates it from the dome of the pleura. Here Vienna lies the stop from the clavicle, in front of the front staircase muscle (on the front surface of the muscle there is a diaphragmal nerve), which separates the connective vein from the artery of the same name. The latter, in turn, separates Vienna from the braceral plexus trunks underlying and the stop from the artery. In the newborn, the plug-in veins fall from the same name at a distance of 3 mm, in children under 5 years old - 7 mm, in children over 5 years old - 12 mm, etc. located over the dome of the pleura, the connectible vein sometimes covers its edge to half the artery at half Its diameter.

The subclavian Vienna is projected through a line spent in two points: the upper point is 3 cm on the top edge of the sternum end of the clavicle, the lower - by 2.5-3 cm knutrice from the beak handproof. In newborns and children under 5 years old, the subclavian vein is projected into the middle of the clavicle, and at an older age, the projection shifts to the border between the internal and average third clavicle.

The magnitude of the corner formed by the subclavian vein with the lower edge of the clavicle, in newborns equalsigrass, in children under 5 years old - 140 degrees, and at an older age-degree. The diameter of the connector vein in newborns is 3-5 mm, in children up to 5 years - 3-7 mm, in children older than 5 years - 6-11 mm, in adults -mm in the final vessel department.

The subclavian vein goes in the oblique direction: from the bottom up, from the outside. It does not change with the movements of the upper limb, as the walls of the veins are connected to the deep leaflet of the neck of the neck (the third fascia on the classification of V.N. Shevkunenko, the blade and clarifying aponeurosis of rice) and are closely connected with the perception of the clavicle and the first rib, as well as Fascia of subclavian muscles and clarity-chest fascia.

Figure 1. Neck veins; Right (according to V.P. Vorobyev)

1 - right plug-in vein; 2 - right inner jugular vein; 3 - right shoulder vein; 4 - left shoulder vein; 5 - upper hollow vein; 6 - front metering vein; 7 - jugular venous arc; 8 - outer jugular vein; 9 - transverse vein neck; 10 - right plug-in artery; 11 - front staircase muscle; 12 - rear staircase muscle; 13 - breast-curable-cottage muscle; 14 - clavicle; 15 - the first edge; 16 - sternum handle.

Figure 2. Clinical anatomy of the system of the upper hollow vein; Front view (according to V.P. Vorobyev)

1 - right plug-in vein; 2 - left connectible vein; 3 - right inner jugular vein; 4 - right shoulder shoulder vein; 5 - left shoulder shoulder vein; 6 - upper hollow vein; 7 - front metering vein; 8 - jugular venous arc; 9 - outer jugular vein; 10 - unpaired thyroid venous plexus; 11 - internal breast vein; 12 - the lowest thyroid veins; 13 - right plug-in artery; 14 - aortic arc; 15 - front staircase muscle; 16 - shoulder plexus; 17 - clavicle; 18 - the first edge; 19 - Borders of the sternum handle.

The length of the connected vein from the top edge of the corresponding small pectoral muscle to the outer edge of the venous angle at the allotted upper limb ranges from 3 to 6 cm. In the course of the plug-in veins in its upper semi-frequency, the following veins fall into its upper seaside: the neck, the neck, the outdoor, deep, cervical, vertebral. In addition, the finite department of the subclavian vein can be chest (left) or jugular (right) lymphatic ducts.

Topographic anatomical and physiological substantiation of the selection of a connectible vein for catheterization

1. Anatomical accessibility. The subclavian vein is located in a premium gap, separated from the artery of the same name and the braceless plexus stems by the front staircase.
2. Stability of the position and diameter of the lumen. As a result of the battle of the vagina of the subclavian vein with a deep leaflet of the neck of the neck, the perception of the first edge and the clavicle, the clarity-breast fascia, the lumen of the vein remains constant and it does not fall down even with the most severe hemorrhagic shock.
3. Significant (sufficient) Vienna diameter.
4. High speed blood flow (Compared with limb veins)

Based on the foregoing, the catheter supplied to Vienna almost does not concern its walls, and the fluid injected on it quickly reaches the right atrium and the right ventricle, which contributes to the active influence of hemodynamics and, in some cases (during resuscitation measures), it makes not even applied intraarterial Discharge of drugs. Hypertensive solutions entered into a subclavian vein are quickly mixed with blood, not irritating the intima veins, which allows you to increase the volume and duration of the infusion with the proper formulation of the catheter and the corresponding departure for it. Patients can be transported without danger of damage to the catheter endothelium veins, they can begin early motor activity.

Indications for catheterization of a subclavian vein

1. The ineffectiveness and impossibility of conducting infusion into peripheral veins (including during the venesection):

(a) due to severe hemorrhagic shock leading to a sharp drop in both arterial and venous pressure (peripheral veins, at the same time, the infusion in them is inefficient);

b) with a network-shaped structure, inexpressiveness and a deep lounge of surface veins.

2. The need for long and intensive infusion therapy:

a) in order to replenish the blood loss and restoring the liquid balance;

b) due to the danger of thrombing of peripheral venous stems at:

Long stay in the needle and catheters vessel (damage to the endothelium veins);

The need to administer hypertensive solutions (irritation of intima veins).

3. The need for diagnostic and control studies:

a) definition and subsequent observation in dynamics for central venous pressure, which allows you to set:

Temp and volume of infusion;

To diagnose heart failure in a timely manner;

b) sensing and contrasting of the cavities of the heart and trunk vessels;

c) multiple blood takes for laboratory research.

4. Electrocardilation with a transgeneous way.

5. Conducting extracorporeal detoxification by blood surgery methods - hemosorption, hemodialysis, plasmapheresis, etc.

Contraindications to catheterization of a subclavian vein

1. Syndrome of the upper hollow vein.
2. Syndrome of Pedge Schurtter.
3. Pronounced violations of the coagulation system of blood.
4. Wounds, glasses, infected burns in the field of puncture and catheterization (danger of generalization of infection and the development of sepsis).
5. Brushes injuries.
6. Bilateral pneumothorax.
7. Pronounced breathing failure with emphysema lungs.

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

Medicines and preparations:

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

Laying of sterile tools and materials:

1. syringe - 2;
2. injection needles (subcutaneous, intramuscular);
3. needle for puncture catheterization of veins;
4. intravenous catheter with cannula and plug;
5. lesk-conductor 50 cm long and thickness corresponding to the diameter of the internal lumen of the catheter;
6. community tools;
7. suture material.

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

Puncture catheterization of the subclavian vein should be performed in the procedural room or in a clean (ungounted) dressing. If necessary, it is produced before or during surgery on the operating table, on the sick bed, at the scene, etc.

The manipulation table is placed on the right of the operator in a convenient place and cover the sterile sheets folded twice. Sterile tools, suture material, sterile material from Bix, anesthetic are put on the sheet. The operator puts on sterile gloves and processes them with an antiseptic. Then twice is processed by an antiseptic operating field and is limited to a sterile diaper-cutting.

After these preparatory activities, the puncture catheterization of the subclavian vein proceeds.

1. Local infiltration anesthesia.
2. General anesthesia:

a) Inhalation anesthesia - usually in children;

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

Different points for percutaneous puncture of the subclavian vein are proposed (Aubaniac, 1952; Wilson, 1962; YOFFA, 1965 et al.). However, the topographic-anatomical studies carried out to allocate not separate points, but entire zones, within which it is possible to punish Vienna. This expands the punctual access to the connector vein, since in each zone you can outset multiple points for puncture. Usually two such zones are distinguished: 1) included and 2) connectible.

Length included zone It is 2-3 cm. Its boundaries: medial - by 2-3 cm in front of the breast-clavical joint, laterally - by 1-2 cm knutrice from the border of the medial and middle third of the clavicle. Valka needles are produced by 0.5-0.8 cm up from the top edge of the clavicle. When puncture, the needle is directed under the alerts in relation to the clavicle and under the alerts in relation to the front surface of the neck (to the frontal plane). Most often, the spot of the needle is the point of Joffe, which is in the corner between the lateral edge of the clavical leg of the breast-curable-bed-like muscle and the top edge of the clavicle (Fig. 4).

Included access has certain positive sides.

1) The distance from the skin surface to the veins is shorter than with subclavian access: to achieve veins, the needle must pass through the skin with subcutaneous tissue, surface fascia and subcutaneous muscle of the neck, the surface sheet of the neck of the neck, a deep leaflet of the neck of the neck, loose fiber , Environmental Vienna, as well as pre-convertible fascia, participating in the formation of a fascial vienna vagina. This distance is 0.5-4.0 cm (on average, 1-1.5 cm).

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

1. There is no need to put the roller under the patient's shoulder belt.

However, due to the fact that a person has a screwdriver's shape constantly changes, certain difficulties can represent a reliable fixation of the catheter and protecting the bandage. In addition, the sweat and, therefore, infectious complications are often accumulated in the prescription jam.

Connect zone (Fig. 3) is limited: from above - the lower edge of the clavicle from its middle (point number 1) and not reaching 2 cm to its sort of sorted end (point number 2); lateral - vertical descending by 2 cm down from point number 1; medial - vertical descending by 1 cm down from point number 2; The bottom is the line connecting the lower ends of the vertical. Consequently, when puncture of veins from subclavian access, the spacing of the needle can be put in the boundaries of the wrong quadrangle.

Figure 3. Connect zone:

The angle of inclination of the needle in relation to the clavicle -Gradusov, in relation to the body of the body (to the frontal plane of the modes). A general landmark during puncture is the rear-top point of the breast-clearable articulation. When entering the veins, the following points are most often used by connectible access (Fig. 4):

• point of Owaniac, located 1 cm below the clavicle on the boundary of the medial and middle third;
• wilson's point, located 1 cm below the middle of the clavicle;
• gilsa point, located 1 cm below the clavicle and 2 cm in front of the sternum.

Figure 4. Points used for puncture of the connector vein.

1 - point Joffe; 2 - Point of Owaniac;

3 - Wilson's point; 4 - Point of Jils.

With subclavian access, the distance from the skin to veins is larger than during the percussion, and the needle must go through the skin with subcutaneous tissue and surface fascia, breast fascia, greater breast muscle, loose fiber, clarity-breasts (rude), gap between the first edge and the clavicle, the connective muscle with its fascial case. This distance is 3.8-8.0 cm (an average of 5.0-6.0 cm).

In general, the topographic-anatomically more substantiated puncture of the connector vein from the connector access, as:

1. in the upper semicircle of the connector vein, large venous branches, chest (left) or jugular (right) lymphatic ducts fall into the upper limit;
2. above the clavicle of Vienna is closer to the dome of the pleura, below the clavicle it is separated from the pleura by the first edge;
3. fasten the catheter and aseptic bandage in the plug-in area is much easier than in the percussion, conditions for the development of an infection here less.

All this led to the fact that in clinical practice, a subclavian vein from subclavian access is often made. At the same time, obese patients should be preferred to those access at which the most clearly determination of anatomical benchmarks is possible.

Machinery of percutaneous puncture and catheterization of the subclavian vein according to the Salfinger Method from Plug-in Access

The success of puncture and catheterization of the subclavian vein is largely due to the observance all Requirements for this manipulation. Of particular importance proper laying of the patient.

Patient position Horizontal with underlined under the shoulder belt ("under the blades") roller, altitudes. The head end of the table is omitted awards (the situation of Trendelenburg). The upper limb on the puncture side is given to the body, the adapter is omitted (with the assistant of the upper limb down), the head is rotated in the opposite direction by 90 degrees. In the event of a severe condition of the patient, it is possible to produce a puncture in a semi-dying position and without lining a roller.

Position of the doctor - Standing on the side of puncture.

Preferred side: Right, since in the final department of the left connector vein can be chest or jugular lymphatic ducts. In addition, when carrying out electrocardialism, sensing and contrasting the cavities of the heart, when the need to advance the catheter in the upper hollow vein, it is easier to right, since the right shoulder shoulder vein is shorter than the left and the direction of it approaches the vertical, while the direction of the left shoulder shoulder vein closer to horizontal.

After handling the hands and corresponding half of the front area of \u200b\u200bthe neck and the plug-in antiseptic area and restrictions on the operating field with a diaper-cutting or napkins (see the "Fixed assets and the organization of the puncture catheterization of the central veins"), an anesthesia is carried out (see the "Anesthetic" section).

The principle of conducting the catheterization of the central veins is laid by the Selderger (1953).

The puncture is carried out by a special needle from a set for catheterization of central veins, placed on a syringe with a 0.25% solution of novocaine. Patients in consciousness, needle for puncture of a subclavian vein show extremely undesirable Since this is a powerful stress factor (a needle of 15 cm long and more with sufficient thickness). When a skin needle proceeds, significant resistance is observed. This moment is the most painful. Therefore, it must be carried out as quickly as possible. This is achieved by receiving the restriction of the depth of the needle. The doctor who performs manipulation limits the needle's finger at a distance of 0.5-1 cm from its island. This prevents deeply uncontrolled administration of the needle in the fabric when applying considerable effort during the skin puncture. The lumen of the puncture needle is often clogged with tissues when skin crossing. Therefore, immediately after passing the needle of the skin, it is necessary to restore its permeability, the release of a small amount of novocaine solution. Fombing needles produced by 1 cm below the clavicle on the boundary of the medial and middle third (point of the Obanka). The needle should be given the direction to the rear-top edge of the breast-clavical joint or, according to V.N. Rodionova (1996), in the middle of the width of the clavical leg of the breast-curable-bed-like muscle, that is, a few lancer. This direction remains profitable and with different positions of the clavicle. As a result, the vessel is punctured in the region of the venous corner of Pirogov. The needle promotion follows the premium of novocaine. After a puncture of the piston, the piston should be sipped on himself, promoting the needle in a given direction (creating a discharge in the syringe only after the release of a small amount of novocaine solution for the prevention of scoring scabs to the needle of the needle with tissues). After entering the vein in the syringe, a trickle of dark blood appears in the syringe and further to the needle to promote a vessel due to the possibility of damage to the opposite wall of the vessel with the subsequent output of the conductor there. If the patient is in consciousness, it must be asked to delay their breath on the breath (prevention of an air embolism) and through the surveillance of the needle, removed from the syringe, enter the lastic conductor at depths, after which the needle is removed, and the conductor is adhered to and remains in Vienna. Then the catheter is moving clockwise by rotational motions clockwise to the depth previously specified. In each particular case, the principle of choosing the catheter of the maximum possible diameter (for adult inner diameter is 1.4 mm). After that, the conductor is removed, and the heparin solution is introduced into the catheter (see the "Care Care" section) and a cannula-plug is inserted. In order to avoid an air embolism, the lumen of the catheter during all manipulations should be covered with a finger. If the puncture failed, it is necessary to bring the needle to the subcutaneous tissue and move forward in another direction (changes in the direction of the needle in the process of puncture lead to additional damage to the tissues). The catheter is fixed to the skin one of the listed methods:

1. a strip of a bactericidal plaster with two longitudinal slots is pasted around the catheter on the skin with two longitudinal slots, after which a thorough fixation of the catheter of the middle strip of the leukoplower is carried out;
2. to ensure reliable fixation of the catheter, some authors recommend to sow it to the skin. To do this, in the immediate vicinity of the way out of the catheter, the skin is flashed with ligature. The first double knot of the ligature is tied on the skin, the second catheter is fixed to the skin seam, the third knot is tied over the ligature at the level of the cannula and the fourth - around the cannula, which prevents the displacement of the catheter along the axis.

Technique of percutaneous puncture and catheterization of the subclavian vein according to the method of ancient surchantry

Patient position: Horizontal, under the shoulder belt ("under the blades") roller can not be laid. The head end of the table is omitted awards (the situation of Trendelenburg). The upper limb on the puncture side is given to the body, the adapter is omitted, with pulling the upper limb to the assistant down, the head is rotated in the opposite direction by 90 degrees. In the case of severe patient's condition, it is possible to make a puncture in a semi-time position.

Position of the doctor - Standing on the side of puncture.

Preferred side: Right (justification - see above).

Valka needles are produced at the point of Joffe, which is located in the corner between the lateral edge of the clavical leg of the breast-curable-bed-like muscle and the top edge of the clavicle. The needle is directed under the alerts in relation to the clavicle of the players in relation to the front surface of the neck. During the needle in the syringe creates a small discharge. Usually in Vienna can be reached at a distance of 1-1.5 cm from the skin. Through the surveillance of the needle, a flattery conductor is introduced at depths, after which the needle is removed, and the conductor is adhered to and remains in Vienna. Then the catheter is moving on the conductor to the insertion movements to the depth previously. If the catheter is free to Vienna, it can promote its turns around its axis (carefully). After that, the conductor is removed, and a cannula-plug is inserted into the catheter.

The photo shows the main benchmarks used to select the puncture point - the municipal muscle, its sternum and crooking legs, the outer jugular vein, the clavicle and the jugular clipping. The most commonly used puncture point is shown, which is located at the location of the lateral edge of the glossy leg of the mouse muscle and the clavicle (red label). As a rule, alternative points of puncture are located on the interval between the intersection of the outer edge of the glossy head of the mouse muscle with the clavicle and the intersection of the outer jugular vein with the clavicle. It is also reported on the execution of puncture from a point of 1-2 cm above the edge of the clavicle. Vienna goes under the clavicle, ribbing the first edge, descends into the chest, where it is connected to the ipsilateral inner jugular vein approximately at the level of the breast-cleaned articulation.

Search puncture is performed by intramuscular needle in order to localize the location of the veins with minimal risk to damage light or massive bleeding at an unintentional artery puncture. The needle is installed at the point of puncture in the plane parallel floor, the direction of caudal. After that, the syringe deviates laterally awards, while the needle is heading towards the sternum, then the syringe bends down the book of approximately awards, i.e. The needle should go under the worship, gliding along its inner surface.

The needle is smoothly carried out in the selected direction, while in the syringe is supported by a vacuum. The picture is schematically continued by the needle movement (blue arrow), as can be seen, its direction approximately indicates the breast-clearing articulation, which is recommended to be used as a benchmark for the primary search puncture. As a rule, Vienna is at a distance of 1-3 cm from the skin. If you spend the search needle on the very pavilion, you could not find a vein, also smoothly output it back, not forgetting to maintain a vacuum in the SHRC, because The needle could pass through the two veins walls and in this case you will get blood in the syringe on the return traction.

Having received blood in the syringe, appreciate its color, if doubt that the blood is venous, you can try to carefully disconnect the syringe while holding the needle in place to estimate the nature of the blood expiration (explicit pulsation, it is clear, indicates an artery puncture). After making sure that you found Vienna, you can remove the search needle by remembering the direction of puncture, or leave it on the spot, slightly pulling back that the needle would come out from Vienna.

If it is impossible to determine the Vienna when puncture in the selected direction, you can try other options for puncture from the same point. I recommend reducing the angle of the lateral deviation of the needle and send it a slightly lower than the breastworking. The next step can be reduced the angle of deviation from the horizontal plane. In the third place among alternative methods, I put an attempt to puncture from another point located laterally from the angle of intersection of the globular head of the mouse muscle with the top edge of the clavicle. In this case, the needle should also be initially directed towards the breast-clavical joint.

Puncture of the vein needle from the set is performed in the direction determined when searching for puncture. In terms of reducing the risk of pneumothorax, it is recommended to perform progressive promotion of a syringe with a needle between the breaths, which is fair both for spontaneous breathing and for artificial ventilation of the lungs in patients on the IVL. It is unnecessarily to mention the maintenance of pouring in the syringe and the opportunity to be in Vienna during the reverse traction of the syringe.

Having received blood in the syringe, appreciate 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 estimate the nature of the expiration of blood (the ripple of the scarlet blood, it is clear, indicates an artery puncture). Sometimes, with a high central venous pressure, the blood can be poured from the needle with a characteristic pulsation, which can be misleading and forced a doctor to repeat punctures with raising risk of punitive complications. A method of registration of blood pressure in the needle has sufficient specificity in the needle in Vienna, for the use of which a sterile highway is necessary, the corresponding end of which is pulled by an assistant, which will connect it to the pressure sensor and fill with a solution. The lack of an arterial pressure curve and a curve characteristic of venous pressure testify to Vienna.

After making sure you find Vienna, disconnect the syringe while holding the needle on the spot. Try to rely on the brush on any fixed structure (clavicle), to minimize the risk of migration of the needle from the lumen of the vein due to the microtreser of the fingers at the moment when you take the conductor. The conductor should be placed in the immediate vicinity of you, so that you would not have to bend and reach in an attempt to get it, because at the same time the concentration on the fixed retention of the needle is most often lost and it comes out of the lumen of the vein.

The conductor under the introduction should not meet significant resistance, sometimes you can feel the characteristic friction of the corrugated surface of the conductor about the edge of the needle cut, if it goes at a large angle. With the feeling of resistance, do not try to pull the conductor, you can try to brighten it and if it rests on the wall of the vein, it is possible to slip further. When removing the conductor, it can cling to the braid over the edge of the cut and at best "smash", in the worst version - the conductor will move and you will get problems incommensurable with conveniently check the needle position without removing it, but removing the conductor. Thus, with resistance, remove the needle with the conductor and try again, already knowing where Vienna passes. The conductor starts in the needle for no further than the second tag (from the needle pavilion) ICSM to prevent him into the cavity of the atrium and flotation there, which can provoke arrhythmias.

A conductor is entered on the conductor. Try to take your finger dlystators closer to the skin, to avoid the inflection of the conductor and the additional injury of fabrics, and even the veins. There is no need to introduce a pavilion into the most 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 dlyatator, you need a finger to press the place of puncture, because From there, abundant blood flow is possible.

The catheter starts at depths. After the introduction of the catheter, its position in Vienna is traditionally verified by aspiration of blood, the free outflow of blood indicates that the catheter is in the lumen of the vein.

Technique of percutaneous puncture and catheterization of the subclavian vein on the principle of "catheter through a catheter"

Puncture and catheterization of the subclavian vein can be carried out not only on the principle of the Selfger ("Catheter on the conductor"), but also on the principle of "catheter through a catheter". The latter technique was possible thanks to new technologies in medicine. The puncture of the subclavian vein is carried out using a special plastic cannula (outer catheter), bowed to the needle for the catheterization of central veins, which serves as a puncturing stilette. In this technique, the onravitivity of the transition from the needle on the cannula, A, as a result, is extremely important, as a result, a small resistance to the catheter through fabrics and, in particular, through the wall of the subclavian vein. After the cannula with needle-stilette fell into Vienna, the syringe with the needle pavilion takes off the syringe, the cannula (outer catheter) is held, and the needle is removed. Through the outer catheter, a special internal catheter with Mandren on the desired depth is carried out. The thickness of the inner catheter corresponds to the diameter of the enlightenment of the outer catheter. The exterior catheter pavilion is connected using a special retainer with an internal catheter pavilion. Mandren is extracted from the latter. The pavilion is put on hermetic cap. The catheter is fixed to the skin.

The use of ultrasound control is promoted as a method that reduces the risk of complications during the catheterization of the central veins. According to this technique, the ultrasound sample is used to localize veins and measure the depth of its location under the skin. Over the control of ultrasonic visualization, the needle is carried out through the tissues in the vessel. Ultrasonic control during catheterization of the inner jugular vein reduces the number of mechanical complications, the number of failures during the installation of the catheter and the time required for catheterization. The fixed anatomical connection of the subclavian vein with the clavicle makes catheterization under ultrasonic control more complex than catheterization on the basis of external benchmarks. As in the case of all new techniques, catheterization under ultrasound control requires training. If in the hospital, ultrasound equipment and doctors are adequately prepared, ultrasonic control should usually be assumed.

Catheter Care Requirements

Before each introduction to the catheter of the medicinal substance, it is necessary to obtain a syringe with a free blood flow. If it fails, the liquid is fluid free into the catheter, it may be connected:

• with the yield of catheter from 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 cutter slice rests on the wall of the vein.

It is impossible to carry out infusion in such a catheter. It is necessary first to slightly pull it out and again try to get blood out of it. If it fails, the catheter is subject to unconditional removal (the danger of paravenous administration or thromboembolism). Extract the catheter from veins need very slow, creating a negative pressure in the catheter With the help of a syringe. This technique is sometimes possible to remove a suspension thrombus from veins. In this situation, it is categorically unacceptable to extract the catheter with rapid movements from the vein, as it can cause thromboembolism.

To avoid thrombing of the catheter after diagnostic blood fences and after each infusion, it should be immediately rinsed with any infusable solution and be sure to introduce an anticoagulant to it (0.2-0.4 ml). The formation of thrombos may be observed with a strong cough of the patient due to blood cast in the catheter. It is more often noted against the background of slow infusion. In such cases, heparin must be added to the transfimony solution. If the fluid was introduced in a limited amount and there was no constant infusion of the solution, it is possible to use the so-called heparin castle ("heparin plug"): after the end of the infusion, 2000 - 3000 units (0.2 - 0.3 ml) of heparin in 2 ml is introduced into the catheter. Physiological solution and it is closed by a special cork or plug. Thus, it is possible to preserve the vascular fistula for a long time. The stay of the catheter in the Central Vienna provides for careful skin care at the point of puncture (daily processing of the antiseptic of puncture and daily change of aseptic dressing). The duration of the stay of the catheter in a subclavian vein according to different authors ranges from 5 to 60 days and should be determined by therapeutic testimony, and not preventive measures (V.N. Rodionov, 1996).

Ointment, subcutaneous cuffs and dressings. Mazi application with an antibiotic (for example, basitormicin, Mupirocyne, neomycin or Polymixin) to the installation of the catheter increases the frequency of colonizations of the catheter mushrooms, contributes to the activation of antibiotic-systemic bacteria and does not reduce the number of catheter infections involving blood flow. Such ointments cannot be used. The use of impregnated silver subcutaneous cuffs also does not reduce the number of catheter infections with the involvement of blood flow and, therefore, is not recommended. Since data on the optimal type of bandage (gauze against transparent materials) and the optimal dressing frequency, contradictory.

Sleeves and systems for uncoole injections. Catheter plugs are a frequent source of the scenario, especially with long-term catheterization. It was shown that the use of two types of stubs treated with an antiseptic reduces the risk of catheter infections with the involvement of blood flow. In some hospitals, the introduction of systems for uncoole injections was associated with an increase in the number of such infections. Such an increase was the result of non-compliance with the manufacturer's requirements to change the plug after each injection and the entire system for unless injection every 3 days due to the fact that the more frequent change of the plug was required before the frequency of catheter infections with the involvement of blood flow returned to the initial level.

Change catheter. Since the risk of catheter infection increases over time, each catheter must be removed as soon as it is necessary. In the first 5-7 days of catheterization, the risk of catheter colonization and catheter infections with the involvement of blood flow is low, but then begins to rise. Multiple studies have studied strategies to reduce catheter infections, including reinstalling the catheter with a wire conductor, and the planned routine reinstalling of the catheter to a new place. However, none of these strategies demonstrated a decrease in catheter infections with the involvement of blood flow. In fact, the planned routine replacement of the catheter on the conductor was accompanied by a tendency to increase the number of catheter infections. In addition, the production of a new catheter to a new place was more frequent in the event that the patient had mechanical complications during catheterization. The metaanalysis of the results of 12 studies of strategies for the replacement of catheters showed that the data does not testify nor in favor of reinstalling the catheter using a wire conductor or in favor of the planned routine reinstalling the catheter to a new place. Accordingly, the central venous catheter should not be rearranged without a reason.

1. Wounding the plug-in artery. This is detected by the pulsating jet of the scarlet blood flowing into the syringe. The needle is extracted, the place of puncture is pressed for 5-8 minutes. Typically, the erroneous puncture of the artery is subsequently accompanied by any complications. However, the formation of hematoma in the anterior mediastinum is possible.
2. Purpose of the dome of the pleura and the tops of the lung with the development of pneumothorax. The unconditional sign is injured of the lung - the emergence of subcutaneous emphysema. The probability of complication with pneumothorax is increased with different deformations of the chest and when breathing with deep breathing. In the same cases, Pneumothorax is most dangerous. At the same time, damage to the subclavian vein with the development of hemopneumothrax is possible. This usually happens with multiple unsuccessful attempts to puncture and coarse manipulation. The cause of the hemotorax may 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 should be prohibited. The development of hemotorax can be associated with damage to the plug-in artery. In such cases, the hemotorax is significant. When puncture of the left connectible vein, in the event of damage to the breast lymphatic duct and the pleura is possible the development of the chylotorax. The latter can manifest itself with abundant outer lymphosterapetion on the wall of the catheter. The complication of the hydrotorax is found as a result of the installation of the catheter in the pleural cavity, followed by the transfusion of various solutions. In this situation, after conducting the catheterization of the connector vein, it is necessary to perform a chest control radiography in order to eliminate these complications. It is important to take into account that when the needle is damaged by a light pneumothorax and emphysema, it can develop both in the next few minutes and a few hours after the manipulation. Therefore, with difficult catheterization, and even more so with a random puncture of the lung, it is necessary to purposefully exclude the presence of these complications not only immediately after puncture, but also during the next day (frequent auscultation of the lungs in the dynamics, radiological control, etc.).
3. With an over-deep introduction of the conductor and catheter, damage to the walls of the right atrium is possible, as well as a triton valve with severe cardiac disorders, the formation of cloth thrombones that can serve as an emblem source. Some authors observed a spherical thrombus, which performed the entire cavity of the right ventricle. This is observed more often when using rigid polyethylene conductors and catheters. Their application must be prohibited. Excessively elastic conductors are recommended before use to undergo long-term boiling: it reduces the stiffness of the material. If there is no possibility of choosing a suitable conductor, and the standard conductor is very hard, some authors recommend to perform the following intake - the distal end of the polyethylene conductor is pre-slightly begins to formed a stupid angle. Such a conductor is often much easier to spend in the lumen of the vein, not traumating its walls.
4. Embolism conductor and catheter. The embolism of the conductor arises due to the cutting of the conductor to the edge of the needle is the edge with quick pulling into itself deeply entered in the needle of the conductor. The embolism of the catheter is possible in case of accidental cutting of the catheter and its gradation in Vienna during the intersection with scissors or scalpel of the long ends of the fixing thread or when removing the thread fixing the catheter. It is impossible to extract the conductor from the needle. If necessary, you should remove the needle together with the conductor.
5. Aerial embolism. In the subclavian vein and the upper hollow vein, the pressure may be negative. Causes of embolism: 1) sucking when air breathing in Vienna through open needles or catheter pavilions (this danger is most likely with pride with deep breaths, when puncture and catheterization of veins in the patient's position sitting or with a raised torso); 2) the unreliable compound of the pavilion of the catheter with a nozzle for the needles of overflowing systems (not a tightness or not seen separation of them during breathing, is accompanied by sucking air into the catheter); 3) Random breakdown of the cork with a catheter with a simultaneous breath. To prevent an air embolism during an needle puncture, a syringe must be connected to the syringe, and the introduction of a catheter in Vienna, disconnecting the syringe from the needle, the opening of the pavilion of the catheter should be made during apnea (delay in breathing patient on the breath) or in the Trendenelburg position. Prevents air embolism. Closing an open needle pavilion or catheter with a finger. During the artificial ventilation of the lungs, the prevention of an air embolism is provided by ventilation of the lungs with increased air volumes with the creation of positive pressure at the end of the exhalation. When carrying out infusion to the venous catheter, constant careful tracking of the tightness of the compound of the catheter and the transfusing system is necessary.
6. Watching shoulder plexus and neck organs (rarely observed). These damage occurs with the deep introduction of the needle with an incorrectly selected deposit direction, with a large number of attempts to puncture Vienna in different directions. This is especially dangerous when the needle direction changes after its deep administration in the tissue. At the same time, the sharp end of the needle injures the fabrics on the principle of the car wiper. To exclude this complication, after an unsuccessful attempt to puncture Vienna, the needle must be fully removed from the tissue, to change the angle of its introduction to the clavicle of the awards and only after that the puncture. At the same time the needle gain point does not change. If the conductor does not pass through the needle, it is necessary to make sure that the needle is in Vienna, and again, slightly tightening the needle for himself, try without violence to enter the conductor. In Vienna, the conductor must pass absolutely freely.
7. Inflammation of soft tissues At the point of puncture and intracerete infection - a rare complication. It is necessary to remove the catheter and more strictly comply with the requirements of aseptics and antiseptics when performing puncture.
8. Phlebotromboosis and thrombophlebitis of the subclavian vein. It is extremely rare, even with long-term (several months) administration of solutions. The frequency of these complications is reduced if high-quality non-brine catheters are used. Reduces the frequency of phlebotomability Regular flushing of the catheter with an anticoagulant not only after infusion, but also in long interruptions between them. With rare transfuses, the catheter is easily blocked by rolled blood. In such cases, it is necessary to resolve the appropriateness of saving the catheter in a subclavian vein. When signs of thrombophlebitis appear, the catheter must be extracted, appropriate therapy is assigned.
9. Disposition of the catheter. It consists in the exit of the conductor, and then the catheter from the connector vein in the jugular (in the inner or outer). If the catheter is suspected, X-ray control is performed.
10. Non-promotability catheter. This may be due to blood coagulation in the catheter and its thrombosis. When simply on the formation of a thrombus, the catheter should be removed. A rough mistake is to press the thrombus in Vienna by "washing" a catheter by introducing fluid in pressure into it or by cleaner a catheter conductor. The obstruction may also be associated with the fact that the catheter is driving or rests on the end into the wall of the vein. In these cases, a slight change in the position of the catheter allows you to restore its permeability. Catheters installed in a plug-in vein should have a cross-cut on the end. It is unacceptable to use catheters with slices and with side holes at the distal end. In such cases, the scope of the catheter of the catheter without anticoagulants arises, on which the hanging swarms are formed. It is necessary to strict compliance with the Catheter Care Rules (see the section "Care Care Requirements").
11. Pharalose introduction of infusion transfusion environments and other drugs. The introduction of irritant liquids (calcium chloride, hyperosmolar solutions, etc.) to the mediastinum is most dangerous. Prevention is obligatory compliance with the rules for working with venous catheter.

Algorithm of conducting patients with catheter - Blood flow rate (CaIC)

AMP - Antimicrobial Preparations

Algorithm for maintaining patients with bacteremia or fungemia.

AMP - Antimicrobial Preparations

"Antibacterial Castle" - the introduction of small volumes of antibiotic solutions in high concentration In the lumen of the Catterera Fair, followed by exposure within a few hours (for example, 8-12 hours at night, when the Fair does not appropriate). As a "lock" can be used: vancomycin at a concentration of 1-5 ml / ml; Gentamine or amicocine at a concentration of 1-2mg / ml; Ciprofoloksacin at a concentration of 1-2mg / ml. Antibiotics are dissolved in 2-5 ml isotonic NAcl with the addition of heparin. Before the use of the Fair "Antibacterial Castle" is removed.

Features of puncture and catheterization of subclavian veins in children

1. Puncture and catheterization must be carried out under conditions of perfect anesthesia, ensuring the absence of motor reactions in a child.
2. The body of the child during the puncture and catheterization of the subclavian vein should necessarily be given the position of the Trendelenburg with a high roller under the blades; The head leans back and turns to the side opposite to the punctured.
3. Change of aseptic dressing and skin treatment around the place of the inside should be made daily and after each procedure.
4. In children up to 1 year, a subclavian vein is more advantageous to punish a connector 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 medium thirds of the clavicle (point of the Obanka).
5. The puncture needle should not have a diameter of more than 1-1.5 mm, and the length is more than 4-7 cm.
6. Puncture and catheterization should be performed as atraly as possible. When conducting puncture to prevent an air embolism on the needle, a syringe with a solution must be put on (0.25% novocaine solution).
7. In newborns and children of the first years of life, blood often appears in the syringe during slow removal of the needle (with simultaneous aspiration), as the puncture needle, especially not sharply sharpened, due to the elasticity of the child's tissues easily pierces the front and rear walls of the vein. In this case, in the lumen of the vein, the tip of the needle may be only when it is removed.
8. Conductors for catheters should not be rigid, introduce them to Vienna is very careful.
9. With the deep introduction of the catheter, it can easily get into the right heart departments, into the inner jugular vein, and, both on the side of puncture and on the opposite side. With any suspicion of the improper position of the catheter in Vienna, x-ray control should be carried out (2-3 ml of the X-ray-repeat substance is introduced into the catheter and take a picture in the front-rear projection). It is recommended as the optimal aspect depth of the catheter:

• premature newborn - 1.5-2.0 cm;
• funny newborns - 2.0-2.5 cm;
• breast children - 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 a subclavian vein in elderly

In the elderly, after the puncture of the subclavian veins and conduct the conductor through it, the introduction of a catheter often meets significant difficulties. This is due to age-related fabric changes: small elasticity, reduced skin turgor and deleting tissue declaration. At the same time, the likelihood of the success of the catheter rises when it wetting (physiological solution, novocaine solution), as a result of which the friction of the catheter decreases. Some authors to eliminate resistance are recommended to cut the distal end of the catheter under an acute angle.