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Catheterization of the subclavian vein approaches. Anatomy: subclavian vein

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

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

Treat the skin with a solution of iodine or chlorhexidine.

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

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

After aspiration of venous blood, turn the bevel of the needle towards the heart. This will make it easier to insert the guide into the brachiocephalic trunk.

The guidewire should move freely into the vein. If resistance is felt, try to advance it during the inhalation or exhalation phase.

After advancing the guidewire, the guidewire needle is removed and the dilator is inserted along the guidewire. After removing the dilator, pay attention to its shape; it should be slightly curved downwards. If it is bent upward, this means that the conductor was inserted into the internal jugular vein (hereinafter referred to as IJV). If fluoroscopic guidance is possible, the guidewire position can be corrected, otherwise it will be safer to remove the guidewire and attempt catheterization again.

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

After catheterization of the subclavian vein, in order to exclude pneumothorax and confirm the correct position of the needle, a chest x-ray must be performed, especially in the absence of fluoroscopic control.

Ultrasound-guided central venous catheterization

Traditionally, when catheterizing central veins, anatomical landmarks are used to determine the course of the vein. However, even in healthy people, the location of the vein in relation to these landmarks can change significantly, which causes a certain frequency of failures and serious complications during its puncture and catheterization. The introduction of portable ultrasound equipment into medical practice has made it possible to perform catheterization of central veins under the control of two-dimensional ultrasound images.

Advantages of this method:

  • determination of the actual location of the vein in relation to adjacent anatomical structures;
  • identification of anatomical features;
  • confirmation of patency of the vein chosen for puncture. According to the National Institute for Clinical Excellence (September 2002), “two-dimensional ultrasound imaging is recommended in some situations as the preferred method for IJV catheterization in both adults and children.” However, the requirements for the equipment and the medical experience required to carry it out limit the widespread use of this technique at present.

Required equipment and personnel:

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

Ultrasound equipment

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

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

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

The device operates on a battery or mains power.

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

Preparing for catheterization

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

Turn the head away from the site of intended catheterization and cover it with sterile material. In order to increase blood supply to the IJV, the patient’s lower limbs are raised or the head is lowered slightly if the patient’s condition allows this. Cover the treated skin with sterile linen.

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

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

The film is placed over the sensor and connecting cable.

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

Again, squeeze out a certain amount of gel onto the transducer to ensure good ultrasound performance and reduce discomfort for the patient when the transducer moves.

Scanning

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

The tip of the sensor is applied to the neck outside the place of pulsation of the carotid artery at the level of the cricoid cartilage or in the triangle formed by the heads of the sternocleidomastoid muscle.

Keep the sensor positioned perpendicular to the skin throughout the entire study.

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

If the vessels are not immediately visualized, move the sensor left and right, maintaining its perpendicular position relative to the skin, until the vessels are detected.

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

After visualization of the IJV:

Place the sensor so that the IJV is visible in the central part of the display.

The position of the sensor is fixed.

Direct the needle (bevel toward the sensor) in the caudal direction immediately below the marked middle of the sensor apex at an angle of 90° to the skin.

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

Advance the needle towards the internal jugular vein.

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

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

When the posterior wall of the vein is punctured, the needle is slowly removed from the vein, performing constant aspiration, and the extraction is stopped when blood is received in the syringe, which means the needle enters the lumen of the vein.

Pass the conductor through the guide needle in the usual way.

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

Maintain sterility throughout the entire procedure and secure the catheter in the most convenient way for the patient. Most often, especially when catheterizing the IJV and keeping the catheter in the vein for some time, a situation arises when, due to partial or complete blockage of the catheter, difficulties arise in determining the central venous pressure. Having attached the pressure gauge, you should ensure the patency of the catheter by compressing the rubber bulb of the pressure gauge, which simultaneously leads to the elimination of minimal blockages caused by the bending of the proximal part of the catheter. CVP is measured with orientation to the zero point located along the anterior axillary line. CVP decreases when the body position changes to vertical or semi-vertical. If this does not happen, raise the console with the central venous pressure monitor approximately 10 cm and then lower it to the floor. If the central venous pressure rises to the same level, then the results detected by the device correspond to reality. In this way, you can make sure that the CVP value measured by the device increases and decreases by the same values.

Medicines and drugs:

    novocaine solution 0.25% - 100 ml;

    heparin solution (5000 units in 1 ml) – 5 ml (1 bottle) or 4% sodium citrate solution – 50 ml;

    antiseptic for treating the surgical field (for example, 2% solution of iodine tincture, 70% alcohol, etc.);

Stack of sterile instruments and materials:

    syringe 10-20 ml – 2;

    injection needles (subcutaneous, intramuscular);

    needle for puncture catheterization of a vein;

    intravenous catheter with cannula and plug;

    a guide line 50 cm long and thickness corresponding to the diameter of the internal lumen of the catheter;

    general surgical instruments;

    suture material.

Sterile material in box:

    sheet – 1;

    cut diaper 80 X 45 cm with a round cutout with a diameter of 15 cm in the center - 1 or large napkins - 2;

    surgical mask – 1;

    surgical gloves – 1 pair;

    dressing material (gauze balls, napkins).

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

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

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

Anesthesia

    Local infiltration anesthesia with a 0.25% solution of novocaine - in adults.

    General anesthesia:

a) inhalation anesthesia - usually in children;

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

Select access

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

Length supraclavicular zone is 2-3 cm. Its boundaries: medially - 2-3 cm outward from the sternoclavicular joint, laterally - 1-2 cm inward from the border of the medial and middle third of the clavicle. The needle is inserted 0.5-0.8 cm upward from the upper edge of the collarbone. During puncture, the needle is directed at an angle of 40-45 degrees in relation to the collarbone and at an angle of 15-25 degrees in relation to the anterior surface of the neck (to the frontal plane). Most often, the point where the needle is inserted is Joffe, which is located in the angle between the lateral edge of the clavicular leg of the sternocleidomastoid muscle and the upper edge of the clavicle (Fig. 4).

The supraclavicular approach has certain positive aspects.

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

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

    There is no need to place a cushion under the patient's shoulder girdle.

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

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

Figure 3. Subclavian zone:

1 – point No. 1; 2 – point No. 2.

The angle of inclination of the needle in relation to the collarbone is 30-45 degrees, in relation to the surface of the body (to the frontal plane - 20-30 degrees). The general landmark for puncture is the posterosuperior point of the sternoclavicular joint. When puncturing a vein using subclavian access, the following points are most often used (Fig. 4):

    dot Obanyaka , located 1 cm below the clavicle at the border of its medial and middle third;

    dot Wilson located 1 cm below the middle of the collarbone;

    dot Gilsa , located 1 cm below the collarbone and 2 cm outward from the sternum.

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

1 – Joffe point; 2 – Obanyak point;

3 – Wilson point; 4 – Giles point.

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

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

    large venous branches, thoracic (left) or jugular (right) lymphatic ducts flow into the upper semicircle of the subclavian vein;

    above the clavicle the vein is closer to the dome of the pleura, below the clavicle it is separated from the pleura by the first rib;

    It is much easier to secure a catheter and an aseptic bandage in the subclavian area than in the supraclavicular area; there are fewer conditions for the development of infection.

All this has led to the fact that in clinical practice, puncture of the subclavian vein from the subclavian access is more often performed. In this case, in obese patients, preference should be given to the access that allows the clearest identification of anatomical landmarks.

For central venous access, the right internal jugular vein or the right subclavian vein is most often used. This is due to the fact that the thoracic lymphatic duct passes on the left and can be damaged during catheterization. And also through the internal left jugular vein there is an outflow of blood from the dominant hemisphere of the brain. And in the event of purulent or thrombotic complications, the neurological consequences for the patient may be more serious.

It is believed that catheterization of the internal jugular vein is accompanied by fewer complications (thrombosis, bleeding) compared to catheterization of the subclavian vein. At the same time, in some cases it is more convenient to use the subclavian approach, for example: with hypovolemia, motor agitation, low blood pressure in the patient, etc.

Femoral vein catheterization is associated with an increased risk of infectious and thrombotic complications. And it is used as a backup option if it is impossible to perform central catheterization from another access. To facilitate the search for a vein and reduce the risk of complications, ultrasound examination allows us to clarify the individual characteristics of the location of the patient’s venous trunks.

Attention! If an attempt to catheterize a vein ends in failure, do not persist and immediately call a colleague for help - it often helps, if not to solve the problem, then at least to avoid troubles in the future.

Puncture of the right internal jugular vein through central access

Place the patient on his back, arms along the body, turn his head to the left. To increase the filling of the central veins and reduce the risk of air embolism, place the Trendelenburg position (the head end of the table is lowered 15° down), if the bed design does not allow this, place it horizontally.

Determine the position of the right carotid artery. The internal jugular vein is located more superficially, lateral and parallel to the carotid artery. Treat the skin with an antiseptic and limit the puncture site with sterile wipes. Infiltrate the skin and subcutaneous tissue over the anterior edge of the sternocleidomastoid muscle at the level of the thyroid cartilage with 5 ml of 1% lidocaine solution. A search puncture is performed with an intramuscular needle in order to localize the location of the vein with minimal risk of significant bleeding due to unintentional puncture of the artery.

You should also use a “search needle” if there is coagulopathy, or the puncture needle from the set is inconvenient for you, or you need to insert a large-diameter catheter. If you have good manual skills, you can naturally refuse to use the “search puncture”. With your left hand, determine the course of the carotid artery. Insert the needle slightly lateral (approximately 1 cm) of the artery at a 45° angle to the skin towards the right nipple in men or the right superior anterior iliac spine in women. Advance the needle slowly, maintaining a vacuum in the syringe, until blood is drawn. The vein is located superficially, so you should not insert the needle deeper than 3-4 centimeters.

If you do not find a vein, slowly withdraw the needle under the skin, maintaining a vacuum in the syringe (since the needle could accidentally puncture both walls of the vein). If you are unable to obtain blood, try again, this time taking a slightly more medial direction. Once you are sure that you have found a vein, you can remove the search needle, remembering the direction of the puncture, or leave it in place, removing it after the needle from the set hits the vein. Venous puncture with a needle from the set is performed in the direction determined during the search puncture.

Puncture of the right subclavian vein

Place the patient on his back, arms along the body, turn his head to the left. To move your shoulders back and down, place a bolster between your shoulder blades. To increase the filling of the central veins and reduce the risk, place the Trendelenburg position (the head end of the table is lowered 15° downwards), if the bed design does not allow this - horizontal.

Feel the jugular notch of the sternum, sternoclavicular and acromioclavicular joints. Next, treat the skin with an antiseptic solution and limit the puncture site with sterile wipes. The puncture point is located 2-3 cm below the clavicle, on the border of the middle and medial thirds of it. Infiltrate the skin and subcutaneous tissue around the puncture site with 5-10 ml of 1% lidocaine solution.

Insert the needle through the indicated point until it touches the collarbone. Gradually push the end of the needle down until it is just below your collarbone. Then rotate and point the needle at the jugular notch. Slowly advance the needle forward, maintaining a vacuum in the syringe, until blood is drawn. The cut end of the needle should be turned towards the heart - this increases the likelihood of correct installation of the catheter. Try to keep the needle parallel to the plane of the bed (to avoid puncture of the subclavian artery or pleura);

If you miss a vein, slowly withdraw the needle under the skin while maintaining vacuum in the syringe. Rinse the needle and make sure it is clear. Try again, taking the injection direction a little more cranially.

Puncture of the right femoral vein

Position the patient on his back, with a cushion placed under the buttocks. The leg should be slightly abducted and turned outward. Determine the pulsation of the femoral artery below the inguinal ligament: the femoral vein is located more medially. Treat the skin with an antiseptic and limit the puncture site with sterile wipes. Next, infiltrate the skin and subcutaneous tissue with 5 ml of 1% lidocaine solution. Incise the skin with a scalpel with a small blade.

2 cm below the inguinal ligament, determine the course of the femoral artery with two fingers of your left hand. The needle is inserted 1 cm medial to the femoral artery at an angle of 30° to the skin and directed along the vein, maintaining a vacuum in the syringe until blood is obtained. The vein is usually located at a depth of 2-4 cm from the surface of the skin. It is convenient to use a G14-16 peripheral venous catheter as a needle, after making sure that it passes the conductor.

If you do not find a vein, slowly remove the needle while maintaining a vacuum in the syringe. Rinse the needle and make sure it is clear. Try again, aiming the needle slightly to the right or left of the original puncture site.

Seldinger catheter insertion

Immediately after puncture of the vein, make sure that the blood flows easily into the syringe. Disconnect the syringe while holding the needle in place. Try to rest your hand on the patient’s body to minimize the risk of needle migration from the lumen of the vein. Close the needle pavilion with your finger to prevent air from entering;

Insert the flexible end of the guidewire into the needle. If there is any resistance to the conductor's advancement, carefully turn it and try to advance it. If this does not help, remove the metal conductor. Assess blood aspiration from the vein again. Change the angle of the needle or rotate it, check the flow of blood into the syringe. Please try again. If it was not possible to insert a plastic conductor, in order to avoid cutting, it must be removed along with the needle.

After inserting the guidewire halfway into the vein, remove the needle. Before inserting the dilator, incise the skin with a scalpel with a small blade; Insert a dilator through the guidewire. Try to take the dilator with your fingers closer to the skin to avoid bending the conductor and additional trauma to the tissue, or even the vein. There is no need to insert the dilator over its entire length; it is enough to create a tunnel in the skin and subcutaneous tissue without penetrating the lumen of the vein. Remove the dilator and insert the catheter. Remove the conductor. Perform an aspiration test. Free blood flow indicates that the catheter is in the lumen of the vein.

Monitoring the correct position of the distal end of the jugular or subclavian catheter

The end of the catheter should be in the vena cava. If the catheter is located high in the upper part of the vena cava, its end may rest against the opposite wall of the vein, which complicates infusions and contributes to the formation of a parietal thrombus. The presence of a catheter in the cavities of the heart causes rhythm disturbances and increases the risk of cardiac perforation.

Installation of a catheter under ECG control allows you to optimize its position and reduce the likelihood of complications.

1. The catheter is washed with saline solution. A metal conductor is inserted into the catheter so that it does not extend beyond the catheter (some conductors have a special mark). Or a metal intramuscular needle is inserted through the catheter plug and the catheter is filled with a 7.5% solution. A plug is put on the needle;

2. Attach the chest lead “V” wire of the electrocardiograph or cardioscope to the needle or conductor using an alligator clip. And turn on the “thoracic abduction” mode on the recording device. Or connect the wire of the right hand to the distal electrode and turn on the second (II) lead on the cardioscope or cardiograph;

3. If the end of the catheter is in the right ventricle, we see a high-amplitude (5-10 times larger than usual) QRS complex on the monitor screen. Slowly tightening the catheter, we see a decrease in the amplitude of the QRS complex, but the P wave remains very high, which indicates that the catheter is in the atrium.

Further tightening of the catheter leads to normalization of the amplitude of the P wave. We tighten the catheter approximately 1 cm more - this is the optimal position of the catheter in the superior vena cava.

4. Secure the catheter to the skin with a suture or adhesive tape. Apply a sterile dressing.

X-ray control of the position of the central catheter

After catheterization of the internal jugular or subclavian vein, a chest x-ray should be obtained to confirm correct placement of the catheter and exclude pneumothorax. If the patient is undergoing mechanical ventilation, radiography is performed immediately after catheterization. If the patient breathes independently - after 3-4 hours. If there are signs of hemothorax or pneumothorax, radiography is performed immediately.

Determining the correct position of the distal end of the catheter on the X-ray image

On an anterior chest radiograph in adults, the tip of the catheter should be located no more than 2 cm below the line connecting the lower ends of the clavicle. This line divides the superior vena cava into two sections located below and above the superior border of the pericardium. If the catheter is inserted into the inferior vena cava, its end should be located below the level of the diaphragm.

Complications

Arterial puncture

If you accidentally puncture an artery, apply pressure to the puncture site for 5-10 minutes, then repeat venipuncture.

Pneumothorax/hydrothorax

A patient on mechanical ventilation may develop tension pneumothorax. In this case, even with a small pneumothorax, drainage of the pleural cavity is necessary. If the patient is breathing on his own, with a small pneumothorax, dynamic observation is carried out. If there are large signs of respiratory failure, drain the pleural cavity.

Hydrothorax is most often associated with the end of the catheter being in the pleural cavity. Sometimes the fluid can be evacuated through this incorrectly installed catheter by lowering the head end of the table or bed.

Displacement of the subclavian catheter into the internal jugular vein

The position of the catheter should be changed, since the introduction of hypertonic solutions into the internal jugular vein can cause venous thrombosis.

Frequent ventricular extrasystoles or ventricular tachycardia

The development of these arrhythmias may indicate that the tip of the catheter is directly on the tricuspid valve. Pull the catheter back a few centimeters.

Catheter infection

The most common infection occurs Staphylococcus aureus And S. epidermidis, but in patients with immunodeficiency, gram-negative bacilli or fungi can become causative agents of infection.

Clear signs of infection catheter: soreness, redness of the skin and purulent discharge at the site of the catheter.

Possible catheter infection: in the presence of fever or other systemic signs, but no signs of infection at the catheter site.

In In all cases, the catheter must be removed, and send its end for bacteriological culture and prescribe antibiotics.

Central venous puncture catheterization is not absolutely safe. Thus, according to publications, the frequency of various complications during puncture catheterization of the superior vena cava through the subclavian varies from 2.7% to 8.1%.

The problem of complications during central venous catheterization is extremely significant. This problem was central to the 7th European Congress on Intensive Care and, above all, such issues as catheter-associated sepsis and catheter-associated venous thrombosis.

1) Entry into an artery during puncture of a vein (into the subclavian during puncture of the subclavian vein, into the common carotid during puncture of the internal jugular vein, into the femoral artery during puncture of the femoral vein).

Damage to the arteries is the main cause of the formation of widespread hematomas in the puncture areas, as well as complications of puncture catheterization of the superior vena cava with hemothorax (with simultaneous damage to the dome of the pleura) and hemorrhage into the mediastinum.

The complication is recognized by the flow of scarlet blood under pressure into the syringe and the pulsation of the flowing stream of blood.

In case of this complication, the needle should be removed and the puncture site should be pressed. When puncturing the subclavian artery, this does not allow effective pressure on the site of its injury, but reduces the formation of hematomas.

2). Damage to the dome of the pleura and the apex of the lung with the development of pneumothorax and subcutaneous emphysema.

When puncture of the subclavian vein, both above and subclavian access, in one to four percent of cases, the apex of the lung is injured by a needle with the development of pneumothorax.

In case of late diagnosis, lung volume and pressure in the pleural cavity increase and tension pneumothorax occurs, leading to severe hypoventilation, hypoxemia, and hemodynamic instability.

Obviously, pneumothorax must be diagnosed and eliminated at an early stage of its occurrence.

The likelihood of complications with pneumothorax is increased with various deformities of the chest (emphysematous, etc.), with shortness of breath with deep breathing. In these same cases, pneumothorax is most dangerous.

Lung puncture is recognized by the free flow of air into the syringe when sucked with a piston. Sometimes the complication remains unrecognized and manifests itself as pneumothorax and subcutaneous emphysema, developing after puncture percutaneous catheterization of the superior vena cava. Sometimes an erroneous puncture of the lung does not lead to pneumothorax and emphysema.

It is important to consider that if the lung is damaged by a needle, pneumothorax and emphysema can develop both in the next few minutes and several hours after the manipulation. Therefore, during difficult catheterization, and even more so during accidental puncture of the lung, it is necessary to specifically exclude the presence of pneumothorax and emphysema, not only immediately after puncture, but also over the next 24 hours (frequent auscultation of the lungs over time, serial X-ray monitoring, etc.).

The dangers of developing severe bilateral pneumothorax encourage us to believe that attempts at puncture and catheterization of the subclavian vein should be made on one side only.

1. The appearance of air in the syringe with the solution during an aspiration test during vein puncture.

2. Weakening of respiratory sounds on the side of development of pneumothorax.

3. Boxed sound during percussion on the side of the damaged lung.

4. X-ray - pulmonary field of increased transparency, there is no pulmonary pattern on the periphery. With tension pneumothorax, there is a shift of the mediastinal shadow towards the healthy lung.

5. Aspiration of air during a test puncture of the pleural cavity in the second intercostal space along the midclavicular line with a syringe with liquid confirms the diagnosis.

1. Pneumothorax requires puncture or drainage of the pleural cavity in the second intercostal space along the midclavicular line or in the 5th intercostal space along the midaxillary line. Rice. 14.

When using the first point, the patient should be placed in the Fawler position.

2. With minor pneumothorax (up to 0.25 percent of the volume of the pleural cavity), immediate evacuation of air is possible through a 16-18G needle or cannula connected to an aspiration system with a vacuum of cm of water column. Visualization of the air outlet is ensured by the creation of underwater drainage. Rice. 15

Some options for underwater drainage are shown in Fig. 16, 17.

Simple systems are also produced that allow creating the necessary safe vacuum when suctioning the contents of the pleural cavity, as well as collecting and measuring the volume of exudate. Rice. 18.

3. If dynamic physical and radiological monitoring reveals a recurrence of pneumothorax, drainage of the pleural cavity should be performed.

Active aspiration with vacuum is required, see. water column and underwater drainage to control air evacuation.

Means for draining the pleural cavity.

1. The most accessible and widespread is a domestically produced catheter with a diameter of 1.4 mm, intended for catheterization of central veins. Its introduction into the pleural cavity is carried out using the Seldinger technique.

Disadvantages of the catheter are rigidity, fragility, lack of side holes, and rapid occlusion by fibrin. When pneumothorax is eliminated within 1-3 days, these shortcomings, as a rule, do not have time to be realized.

2. Trocar-catheter, which is a polyvinyl chloride elastic drainage tube mounted on a trocar with a smooth atraumatic transition.

To insert it, it is necessary to make a small skin incision in the puncture area and create a certain pressure on the trocar. After perforation of the chest wall, the trocar is removed, the tube is left in the pleural cavity for the required amount of time. Rice. 19, 20.

3. Special pleural drainage made of polyurethane, installed according to the Seldinger technique using a Tuohy needle, string and dilator. Placement of drainage is atraumatic and elegant. The drainage is equipped with a three-way valve and a special adapter adapted to the aspiration system. Rice. 21, 22.

Any drainage must be fixed to the skin with a ligature.

4. As a container Timing of drainage removal.

Drainage should continue until air removal stops. Removal of the drainage should be performed against the background of a deep breath to avoid air entering the pleural cavity. The drainage exit area is covered with a bandage and adhesive tape.

If the release of air does not stop within a day, the question of promptly eliminating the cause of pneumothorax should be raised. Today it is possible to use minimally invasive thoracoscopic intervention.

In case of hemilateral pathology of one of the pleural cavities (pneumo-, hemothorax) and the need for catheterization of the central vein, this should be done from the side of the injury. The cause of hemothorax may be perforation of the wall of the innominate vein and parietal pleura by a very rigid conductor for domestically produced catheters. These same conductors occasionally preforate the myocardium with the development of tamponade. Their use should be prohibited!

3). Puncture and catheterization of central veins through the subclavian and jugular veins and with the subsequent use of central catheters can be complicated, as already indicated, by hemothorax, as well as chylothorax and hydrothorax.

Development of hemothorax (may be combined with pneumothorax) Cause: damage during puncture of the dome of the pleura and surrounding vessels with prolonged leakage of blood. Hemothorax can be significant when the arteries are damaged and the blood's ability to clot is weakened.

When puncturing the left subclavian vein in case of damage to the thoracic lymphatic duct and pleura, chylothorax may develop.

To avoid damage to the thoracic lymphatic duct, preference should be given to catheterization of the right subclavian vein.

There is a complication of hydrothorax as a result of installation of a catheter in the pleural cavity with subsequent transfusion of various solutions.

When clinical and radiological detection of hemothorax, hydrothorax or chylothorax requires a puncture in the 5-6 intercostal space along the posterior axillary line of the pleural cavity and removal of accumulated fluid.

Sometimes it is necessary to resort to drainage of the pleural cavity.

4). The occurrence of extensive hematomas during puncture catheterization (paravasal, intradermal, subcutaneous, in the mediastinum).

Most often, hematomas occur during erroneous punctures of the arteries and especially in patients with poor blood clotting.

The formation of extensive hematomas is sometimes due to the fact that when a needle enters a vein, the doctor draws blood into a syringe and injects it back into the vein. This is some kind of downright “favorite” action of some doctors, which they repeat several times when injecting it into a vein. This is unacceptable, since the cut of the needle may not be completely in the vein and part of the blood, when reintroduced, enters paravasally and forms hematomas spreading through the fascial spaces.

5) Air embolism that occurs during puncture and catheterization of the superior vena cava, as well as during work with the catheter.

The most common cause of air embolism is the absorption of air into the veins through open needle or catheter pavilions when breathing. This danger is most likely during severe shortness of breath with deep breaths, during puncture and catheterization of veins with the patient sitting or with the torso elevated.

An air embolism is possible when there is an unreliable connection between the catheter pavilion and the nozzle for the needles of transfusion systems: leakage or undetected separation during breathing is accompanied by air being sucked into the catheter.

It happens that an air embolism occurs when the patient, taking off his shirt, takes a breath and at the same time tears the plug off the catheter with the collar of his shirt.

Clinically, air embolism is manifested by sudden shortness of breath, noisy deep breathing, cyanosis of the upper body, in cases of massive air embolism, listening to squelching noises during auscultation of the heart (the sound of a “mill wheel”), frequent loss of consciousness, swelling of the jugular veins, a sharp drop in blood pressure, etc. Air embolism sometimes passes without a trace, sometimes leads to the development of ischemic stroke, myocardial or pulmonary infarction, and can instantly cause cardiac arrest.

There is no effective treatment. An attempt is made to evacuate air from the superior vena cava and right ventricle through the installed catheter. The patient is immediately placed on his left side. Oxygen therapy and cardiotropic therapeutic measures are carried out.

Prevention of air embolism: during catheterization of the superior vena cava, the “Trendelenburg” position with the head end of the awards table tilted, legs raised or bent at the knees; when catheterizing the inferior vena cava, tilt the awards, the foot end of the table.

Prevention is also ensured by holding the patient's breath while deeply exhaling at the moment the syringe is disconnected from the needle or at the moment when the catheter pavilion becomes open (removing the guidewire, changing the plug). Closing the open needle or catheter pavilion with your finger prevents air embolism.

During mechanical ventilation, prevention of air embolism is ensured by ventilation of the lungs with increased volumes of air with the creation of positive end-expiratory pressure.

When carrying out infusions into a venous catheter, constant close monitoring of the tightness of the connection between the catheter and the transfusion system is necessary.

If a patient has a catheter in the central vein, then all measures to care for the patient (changing linen, shifting the patient, etc.) should be carried out carefully, paying attention to the condition of the catheter.

6) Damage to nerve trunks, brachial nerve plexus, trachea, thyroid gland, arteries. The occurrence of an arteriovenous fistula and the appearance of Horner's syndrome are described. These injuries occur when the needle is inserted deeply with the wrong direction of injection, or with a large number of attempts to puncture (“find”) the vein in different directions with the needle inserted deeply.

The occurrence of tachycardia, arrhythmias, and pain in the heart during deep insertion of a conductor or catheter.

Rigid polyethylene conductors and catheters, when inserted deeply during catheterization, can cause through puncture of the vein walls, severe damage to the heart and its tamponade with blood, and can penetrate into the mediastinum and pleural cavity.

Prevention: mastering the method and technique of percutaneous catheterization of central veins; excluding the introduction of conductors and catheters deeper than the mouth of the vena cava (level of articulation of the second rib with the sternum); use only soft catheters that meet medical requirements. It is recommended to subject excessively elastic conductors to prolonged boiling before use: this removes the rigidity of the polyethylene.

If, when inserted through the needle, the conductor does not go through, or rests against something, you need to use a syringe to make sure that the needle is in the vein, slightly change the position of the needle and again try to insert the conductor without violence. The conductor must enter the vein absolutely freely.

7) Severe damage can result from changing the direction of the needle after it has been inserted into the tissue. For example, if the needle does not hit a vein and attempts are made to find it in another place. In this case, the piercing-cutting tip of the needle describes a certain arc and cuts tissue along its path (muscles, nerve trunks, arteries, pleura, lung, etc.).

To avoid this complication, if a vein puncture attempt is unsuccessful, the needle must first be completely removed from the tissue and only then inserted in a new direction.

8). Embolism of large vessels and cavities of the heart with a conductor or catheter, or their fragments. These complications carry the threat of severe cardiac dysfunction and pulmonary embolism.

Such complications are possible: when quickly pulling a conductor deeply inserted into the needle (a “pulsating” conductor), the conductor is easily cut off by the edge of the needle tip with subsequent migration of the cut fragment of the conductor into the heart cavity; in case of accidental cutting of the catheter and its slipping into the vein while crossing the long ends of the fixing ligature with scissors or a scalpel or when removing the ligature.

To prevent this complication, remove the guidewire from the needle. IT IS FORBIDDEN!

In this situation, the needle should be removed along with the guidewire.

It happens that a conductor is inserted into a vein, but it is not possible to pass a catheter through it into the vein due to the resistance of the costoclavicular ligament and other tissues. In this situation, it is unacceptable and extremely dangerous to make a puncture in the ligament along the conductor with a puncture needle or a needle even with a transverse section of the tube. Such manipulation creates a real threat of cutting off the conductor with a bougie needle.

Topical diagnosis of a conductor or catheter that has migrated into the vascular bed is extremely difficult. To remove them, it is necessary to widely expose and inspect the subclavian, brachiocephalic, and, if necessary, the superior vena cava, as well as inspect the cavities of the right parts of the heart, sometimes under I.K.

9) Paravasal administration of infusion-transfusion media and other medications as a result of unrecognized exit of the catheter from the vein.

This complication leads to compression syndrome of the brachiocephalic and superior vena cava with the development of edema of the limb, disruption of blood flow in it, hydromediastinum, etc. Fascial structures contribute to the initially imperceptible development of complications. Migration of the catheter into the fascial space of the neck was noted.

The most dangerous are paravenous injections of irritating liquids (calcium chloride, solutions of some antibiotics, concentrated solutions, etc.) into the mediastinum.

Prevention: strict adherence to the rules for working with a venous catheter (see below).

10) Damage to the thoracic lymphatic duct during puncture of the left subclavian vein. This complication can manifest itself as abundant external lymphatic leakage along the catheter wall. Lymphorrhea usually resolves quickly. Sometimes this requires removing the catheter and aseptically closing the injection site.

Prevention: in the absence of contraindications, preference should always be given to puncture of the right subclavian vein.

11). After installation of a subclavian catheter, the appearance of pain on the corresponding side of the neck and limitation of its mobility, increased pain during infusions, their irradiation into the ear canal and lower jaw, and sometimes the occurrence of local swelling and pain. Thrombophlebitis may develop as the outflow from the jugular veins is disrupted.

This complication is most often caused by the entry of a conductor (and then a catheter) from the subclavian vein into the jugular veins (internal or external).

If there is a suspicion that the subclavian catheter has entered the jugular veins, X-ray control is performed. When the disposition of the catheter is identified, it is tightened and installed under the control of the free flow of blood from the catheter when sucked with a syringe into the superior vena cava.

12). Catheter obstruction.

This may be due to blood clotting in the catheter and thrombosis.

Blood clotting with obstruction of the catheter lumen by a thrombus is one of the common complications of central venous catheterization.

With complete obstruction, it is impossible to introduce transfused media through the catheter.

Often, transfusion through a catheter occurs without significant difficulties, but blood cannot be obtained from the catheter. As a rule, this indicates the appearance of a blood clot at the tip of the catheter, which acts like a valve when sucking blood.

If a blood clot is suspected, the catheter should be removed. It is a serious mistake to force or attempt to force a blood clot into a vein by “flushing” the catheter by introducing liquids under pressure into it or by clearing the catheter with a guidewire. Such manipulation threatens pulmonary embolism, heart attacks and lungs, and the development of infarction pneumonia. If massive thromboembolism occurs, immediate death is possible.

To prevent the formation of blood clots in catheters, it is necessary to use high-quality (polyurethane, fluoroplastic, siliconized) catheters, wash them regularly and fill them in between drug administrations with an anticoagulant (heparin, sodium citrate, magnesium sulfate). Maximum limitation of the time the catheter remains in the vein also prevents the formation of blood clots.

Catheters installed in veins must have a cross-section at the end. It is unacceptable to use catheters with oblique cuts and with side holes at the end. When an oblique cut is made and holes are created in the walls of the catheter, a zone of catheter lumen without anticoagulant appears, on which hanging thrombi form.

Sometimes catheter obstruction may be due to the fact that the catheter is bent or rests against the wall of the vein. In these cases, a slight change in the position of the catheter allows you to restore the patency of the catheter, freely obtain blood from the catheter and inject medications into it.

13). Thromboembolism of the pulmonary arteries. The risk of this complication is real in patients with high blood clotting. To prevent complications, anticoagulant therapy and therapy that improves the rheological properties of blood are prescribed.

14). Infectious complications (local, intracatheter, general). According to various publications, the overall incidence of infectious complications (from local to sepsis) during catheterization of the superior vena cava ranges from 5.3% to 40%. The number of infectious complications increases with the duration of stay of the catheter in the vein, and their danger decreases with effective prevention and timely therapy.

Catheters in the central veins are usually placed for a long time: for several days, weeks and even months. Therefore, systematic aseptic care, timely detection and active treatment of the slightest manifestations of infection (local inflammation of the skin, the appearance of unmotivated low-grade fever, especially after infusions through a catheter) are of great importance in the prevention of severe infectious complications.

If infection of the catheter is suspected, it should be removed immediately.

Local suppuration of the skin and subcutaneous tissue occurs especially often in seriously ill patients with purulent-septic diseases.

Prevention: compliance with asepsis, avoidance of long-term fixation of the catheter with adhesive tape, which causes maceration of the skin; constant monitoring of the condition of tissues at the injection and catheterization sites with regular changes of aseptic dressings; prescription of antibiotics.

In order to reduce the number of infectious complications and for ease of operation of the catheter installed in the subclavian vein, it is proposed to pass its outer end under the skin from the injection site to the axillary area, where it is strengthened with a silk suture or adhesive tape (C. Titine et all.).

15). Phlebothrombosis, thrombosis and thrombophlebitis of the subclavian, jugular, brachiocephalic and superior vena cava. Manifestations: fever, pain and swelling of tissues on the side of catheterization in the supraclavicular and subclavian areas, in the neck with swelling of the corresponding arm; development of superior vena cava syndrome.

The occurrence of these dangerous symptoms is an absolute indication for removing the catheter and prescribing anticoagulant, anti-inflammatory and antibacterial therapy.

The incidence of these complications is reduced if high-quality non-thrombogenic catheters of sufficient length are used. The catheter must ensure the administration of drugs directly into the superior vena cava, which has a large volume of blood flow. The latter ensures rapid dilution of medicinal substances, which eliminates their possible irritating effect on the vascular wall.

During prolonged placement of a catheter in a central vein, antibiotic prophylaxis is usually indicated.

Regular flushing of the catheter with heparin reduces the incidence of phlebothrombosis, not only after infusions, but during long intervals between them.

With rare transfusions, the catheter is easily clogged with clotted blood. Obviously, with rare infusions that are sometimes not performed every day, there are no indications for central venous catheterization. In these cases, it is necessary to decide on the advisability of maintaining the catheter in the central vein.

Thrombosis and purulent-septic complications during central venous catheterization mutually sharply increase the incidence and severity of the course.

16) Catheterization of the internal jugular vein and external jugular vein often causes pain when moving the head and neck. May be accompanied by pathological flexion of the neck, which contributes to the development of thrombosis of catheterized veins.

Catheterization of the inferior vena cava through the femoral vein, as a rule, limits movements in the hip joint (flexion, etc.).

The main thing in the prevention of technical complications and errors is strict adherence to the methodological rules for puncture and catheterization of veins.

Persons who are not fluent in the technique of the procedure and who do not have the necessary knowledge should not be allowed to perform puncture catheterization of the central veins.

Complications during catheterization of the subclavian vein

Complications associated with CCV can be divided into early complications, related to the insertion procedure, and late complications, related to improper use, placement, or operation of the catheters. Complications are divided into technical, septic and thrombotic.

Early complications

Early complications are mainly technical and include:

  • impossibility of catheterization;
  • incorrect placement;
  • artery puncture;
  • thromboembolism, the source of which is the catheter;
  • air embolism;
  • arrhythmia;
  • hemothorax;
  • pneumothorax;
  • hemo- and hydropericardium and cardiac tamponade;
  • central vein thrombosis and/or thromboembolism;
  • damage to the phrenic, vagus nerve, recurrent laryngeal nerve and brachial plexus;
  • subarachnoid hemorrhage;
  • osteomyelitis of the clavicle or first rib;
  • damage to the thoracic lymphatic duct and chylothorax.

Proper placement and care of a central venous catheter by a trained professional following proper care techniques and protocols reduces the risk of complications. Adequate hydration, correction of coagulopathy, Doppler ultrasound of the anatomical features of the vein and appropriate patient positioning, lowering PEEP, using a small bore needle to locate the vein and using the Seldinger technique during catheter insertion are important.

Late mechanical complications

When catheters are blocked, depending on the cause of the blockage, urokinase, sodium hydroxide, hydrochloric acid, or 70% ethanol can be used. For permanent catheters, in case of rupture of their outer part, special repair kits are used.

Thrombosis

Central vein thrombosis is the most common (above 50% of cases) and dangerous complication of severe thrombosis, leading to a high incidence of complications and mortality in 25% of cases. It may occur in a vein proximal (eg, jugular, subclavian, axillary, or femoral veins) and/or distal (eg, superior or inferior vena cava, iliac vein) to the puncture site. Sometimes a blood clot near the tip of the catheter can form in the right atrium; in some cases it is found in the pulmonary artery or its branches.

Prevention of thrombosis is achieved by appropriate placement of the catheter tip, very careful insertion, infusion, irrigation and subcutaneous administration of heparin immediately after catheter placement. Patients at high risk of thrombosis should receive regular anticoagulants, such as minimal doses of zoocoumarin. It is currently unknown whether attempts should be made to dissolve the clot in all cases. If thrombolytic therapy with plasminogen activator, urokinase or streptokinase is started, removal of the catheter is not always necessary.

Septic complications

Infection remains the most serious complication of CCV. This is a dynamic process and therefore there is no universally accepted definition or classification of CCV infection.

From a practical point of view, complications can be divided into:

  • catheter infection, when there is growth of pathogenic microbes found in the sample (blood taken from the catheter, adapter, endoluminal lubricant or removed catheter), without general or local signs of infection;
  • infections localized at the puncture site, under the skin or pocket of a fully implanted device. They are treated by removal of the catheter or port and appropriate topical treatments;
  • Catheter-associated bacteremia and sepsis are the most dangerous complications of CCV.

Etiology

The catheter may be infected on the outer surface, in the inner lumen, or in both parts. Colonization is probably the first step, and when the number of microorganisms increases, clinical symptoms of infection may appear (Fig. 1). Depending on the portal of infection, they can be divided into those occurring from within and those occurring from outside the catheter.

Typical causes of luminal infection are:

  • infection of the catheter adapter;
  • kinks or leakage of the system due to poor connections;
  • infected nutritional mixture (during preparation, connecting the system, adding other liquids in the compartment);
  • using a catheter for other purposes (measuring central venous pressure, taking a blood sample).

Typical causes of external infection are:

  • migration of microorganisms along the catheter from the puncture site;
  • direct contamination during catheter insertion – “surgical fever of the third day”;
  • hematogenous contamination.

It is extremely important to understand the mechanisms mentioned above and also to keep in mind that the phase of CCV infection may change over time. For example, colonization or infection of the exit site can rapidly cause bacteremia and severe sepsis within hours.

The clinical picture of catheter infection can be local and/or general.

  • Local signs include: redness, pain, or leakage of serous or purulent fluid at the exit site. Suppuration of the subcutaneous tunnel manifests itself as painful inflammation along it, often associated with the leakage of purulent fluid.
  • General symptoms may be nonspecific and are often not initially recognized as signs of catheter-related sepsis. The clinical picture is varied, ranging from subfibril fever to signs of septic shock and multiple organ failure. Early nonspecific symptoms may include fever, negative nitrogen balance, mild elevations in serum C-reactive protein, urea, and liver enzymes, and abdominal or swallowing pain.

If microbes enter the bloodstream, the symptoms are similar to those of an endogenous infection. Endogenous infection often manifests as fever and chills, most often within 1–3 hours after closure of the catheter or connection of a new system. There is evidence of such nonspecific symptoms as gastroduodenal bleeding, nausea, vomiting, mental and visual disturbances, stupor, arrhythmia, renal and respiratory failure.

The likelihood of sepsis depends on the length of time the catheter is used, so the best way to express it is to calculate the incidence of sepsis as the number of cases occurring in a given time interval. It is generally accepted that the relative probability of catheter-related sepsis is 0.45–1 case/catheter/year for hospitalized patients receiving PN and 0.1–0.5 case/catheter/year for outpatients. Currently, most catheter-associated infections are caused by Gram-positive organisms, especially Staph. epidermidis and Staph. aureus.

Preventing Catheter Infection

The most important measures are complete barrier prophylaxis during catheter insertion, aseptic processing of all connections and changes of dressings in accordance with the developed protocol, and monitoring the work of the nutrition team. Prophylactic use of antibiotics and in-line filters is generally not recommended. Passing the catheter under the skin reduces the risk of microbes migrating from the exit site. The use of antimicrobial-impregnated CCVs for short-term catheters should be considered if the likelihood of catheter infection is high despite other preventive measures. Other methods aimed at minimizing catheter-related infections, for example, by reducing the time of use, changing the CCV after a certain period, even if there is no obvious infection when the catheter is removed and inserted in a new location, are now considered to be less effective.

Rice. 1. The most common causes of catheter infection

Diagnosis and treatment

In most cases of localized infection, the catheter should be removed and cultures taken from the tip of the catheter, rinsing off the skin and blood collected from the catheter.

If non-specific clinical symptoms (fever, chills, etc.) begin to appear after CCV insertion, it is not necessary to remove the CCV, exposing the patient to the risk of reintroduction, as up to 50% of removed CCVs have been shown to be non-infectious. If infection of the catheter lumen is suspected, a different approach is recommended today:

  • The infusion is temporarily stopped and blood samples obtained from the catheter, as well as samples obtained from the adapter and/or endoluminal smears are checked for rapid culture and/or Gram stain without removing the catheter. If necessary, intravenous fluids or peripheral PN are given for 24–48 hours.
  • If CCV infection is not confirmed, then PP through CCV begins again.
  • If the source of infection is confirmed and recognized, then treatment depends on the diagnosis and the following measures are necessary:
    • when a fungal, staphylococcal, mycobacterial or Pseudomonas infection is detected, which is accompanied by a high risk of organ complications and its eradication is difficult, the catheter is removed (at least in the case of a fungal infection) and antibacterial therapy is started in accordance with the results of flora sensitivity tests;
    • For catheters with a short lifespan, the risk and cost of removal must be considered;
    • in all other cases, the catheter is filled with a highly concentrated solution of a suitable antibiotic in an amount corresponding to the internal volume of the individual catheter and closed for 12–24 hours (antibiotic seal).

This treatment lasts 7–10 days, and during this time CCV should not be used (Figure 2). This method is especially valuable for patients receiving home PN, since up to 80% of cases of CCV infection are observed in them, and the catheter can be preserved.

Rice. 2. Treatment regimen for suspected catheter infection

There is no evidence yet as to whether so-called “antibiotic gates” should be enhanced by systemic antibiotic therapy.

Resume

Complications associated with CCVs can cause significant clinical problems during insertion, use, or after removal. A brief description of early insertion-related and late major infections and thrombotic complications is provided. Knowledge of etiology and prevention rules are essential for their prevention, diagnosis and treatment.

Catheterization of the subclavian vein through a needle

After the subclavian vein has been catheterized, a catheter is inserted through its lumen to a depth of cm. Having fixed the catheter above the needle, it is carefully removed from the lumen of the vein. The catheter is fixed to the skin (Fig. 19.26).

Rice. 19.26. Catheterization of the subclavian vein through a needle

Possible complications of subclavian vein catheterization:

1. Puncture of the subclavian artery. It is manifested by the appearance of a scarlet pulsating stream of blood in the syringe. Remove the needle. Press the puncture site for a minute or place a weight (bag of sand) for 1 hour.

2. Development of hemo- or pneumothorax when the needle penetrates the pleural cavity with damage to the lung. Puncture of the lung is manifested by the free flow of air when sucked by the syringe piston. The likelihood of complications with pneumothorax is increased with chest deformities (emphysematous), shortness of breath with deep breathing. Pneumothorax can develop both in the next few minutes and several hours after venipuncture. Due to the risk of developing bilateral pneumothorax, it is advisable to attempt puncture and catheterization of the subclavian vein only on one side.

· the appearance of air in the syringe when pulling the piston towards you, which should be done during vein puncture;

· weakening of breath sounds during auscultation on the side of pneumothorax;

· box sound during percussion in the half of the chest where pneumothorax developed;

· with a plain X-ray of the chest, the pulmonary field is highly transparent, there is no pulmonary pattern on the periphery;

· the appearance of air in the syringe during diagnostic puncture of the pleural cavity in the second or third intercostal space along the midclavicular line.

When the lung collapses with air, a pleural puncture is performed in the second or third intercostal space along the midclavicular line, leaving Bulau drainage or connecting active aspiration.

The development of hemothorax can occur not only as a result of needle damage to the apex of the lung, but also as a result of perforation of the wall of the innominate vein with a rigid catheter. Hemothorax requires pleural puncture in the 7-8 intercostal space along the posterior axillary or scapular line with aspiration of accumulated blood.

3. Chylothorax (damage to the thoracic lymphatic duct). To prevent this complication, preference should be given to catheterization of the right subclavian artery.

4. Hydrothorax, hydromediastinum. The reason is an unrecognized puncture of the pleural cavity or mediastinum with subsequent injection of fluids into them. They manifest themselves as a gradual deterioration of the patient’s condition - chest pain, cyanosis, tachycardia, difficulty breathing, decreased blood pressure. Stop the infusion and perform a chest x-ray. Remove the liquid through the existing catheter, and from the pleural cavity by puncture.

5. Formation of extensive hematomas (paravasal, in the mediastinum, intradermal, subcutaneous). The main causes are accidental injury to the artery or poor blood clotting. Sometimes this is due to the fact that the doctor, after entering the vein, draws blood into a syringe and injects it back into the vein. If the needle section is not completely in the lumen of the vein, then part of the blood, when reintroduced, will flow extravasally and lead to the formation of a hematoma spreading through the fascial spaces.

6. Air embolism. Occurs when air is sucked into the subclavian vein during puncture or catheterization, a lack of tightness between the catheter and the transfusion system, or their unnoticed separation. Clinically manifested by sudden shortness of breath, cyanosis of the upper half of the body, swelling of the neck veins, a sharp decrease in blood pressure, and often loss of consciousness. The patient is placed on his left side, cardiotropic drugs, mechanical ventilation, and, if necessary, resuscitation measures are administered.

Prevention of air embolism:

· during catheterization, give the patient a Trendelenburg position - lower the head end of the reward table;

· holding the patient's breath while taking a deep breath while disconnecting the syringe from the needle or when the catheter is opened (removing the guidewire, changing the plug);

· during infusion, monitor the tightness of the connection between the catheter and the transfusion system;

· patient care (changing the bed, changing linen, etc.) should be carried out carefully, concentrating on the condition of the catheter.

7. Through puncture of the vein wall, damage to the heart and its tamponade with blood, penetration of the vessel into the mediastinum or pleura. Prevention: mastering the catheterization technique, do not insert the guidewire and catheter deeper than the mouth of the vena cava (level of articulation of the 2nd ribs with the sternum), do not use rigid guidewires and catheters.

8. Migration of a conductor, catheter or its fragments into large vessels and cavities of the heart. Severe cardiac dysfunction and pulmonary embolism occur.

Reasons for catheter migration:

· quick pulling of the conductor deeply inserted into the needle, as a result of which it is cut off by the edge of the needle tip with migration of the cut fragment into the cavity of the heart;

· accidental cutting of the catheter with scissors and its slipping into the vein when removing the ligature fixing it to the skin;

· insufficiently strong fixation of the catheter to the skin.

It is IMPOSSIBLE to remove the conductor from the needle. If necessary, remove the needle along with the guidewire.

Sometimes it is not possible to pass a catheter into a vessel through a guidewire located in a vein due to resistance from soft tissues and the costoclavicular ligament. In these cases, the catheter should be removed and the puncture and catheterization of the subclavian vein repeated. It is unacceptable to bougie the puncture hole with a needle along the guidewire. This creates a risk of cutting the conductor with the bougie needle.

The location of a migrated guidewire or catheter is difficult to determine. Often, revision of the subclavian, superior vena cava, or right heart is required, sometimes with the use of a heart-lung machine.

9. Catheter thrombosis. The cause is insufficient heparinization of the catheter. This leads to blood entering the catheter lumen with subsequent coagulation. Manifested by catheter obstruction. It is necessary to remove the catheter and, if necessary, catheterize the subclavian vein on the other side.

It is unacceptable to clean or flush the lumen of a thrombosed catheter under pressure. This poses a risk of developing pulmonary embolism, infarction, pneumonia, and myocardial infarction.

Prevention of this complication consists of filling the catheter with heparin after infusion and in between. If the intervals between infusions are long, then the question of the advisability of central vein catheterization should be reconsidered, giving preference to infusions into peripheral veins.

10. Pulmonary embolism. Develops in patients with increased blood clotting. For prevention, it is necessary to introduce anticoagulants and agents that improve the rheological properties of blood.

11. “Catheter sepsis.” It is a consequence of poor catheter care or prolonged standing in the vein. Daily treatment of the skin around the catheter with an antiseptic is necessary.

12. Thrombosis of the subclavian vein. It manifests itself as “superior vena cava syndrome” - swelling of the neck, face, and upper extremities. Anticoagulant and thrombolytic therapy is required.

Topography of the subclavian vein:

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

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

Subclavian vein puncture technique:

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

The Abaniak point is widely used, which is located 1 cm below the collarbone along the line dividing the inner and middle third of the clavicle (in the subclavian fossa). Direct the needle for PV puncture at an angle of 45° to the clavicle into the projection of the sternoclavicular joint between the clavicle and 1st rib (along the line connecting the first and second fingers); it should not be punctured deeper.

Wilson's point is located below the clavicle on the midclavicular line. The direction of the PV puncture is between the clavicle and the 1st rib in the projection of the belt notch. The Giles point is determined 2 cm outward from the sternum and 1 cm below the clavicle. The needle path should be behind the collarbone in the projection of the upper edge of the sternoclavicular joint.

With the supraclavicular approach, the Ioffe point is determined in the angle formed by the outer edge of the lateral head of the sternocleidomastoid muscle and the upper edge of the clavicle. The needle is positioned at an angle of 45° to the sagittal plane and 15° to the frontal plane to a depth of usually 1 - 1.5 cm.

Topography of the subclavian artery:

The right subclavian artery arises from the brachiocephalic trunk, the left - directly from the aortic arch. The left subclavian artery is 2-2.5 cm longer than the right one. Throughout P. a. three parts are distinguished: the first - from the place of origin of the artery to the inner edge of the anterior scalene muscle, the second - limited by the limits of the interscalene space, and the third - from the outer edge of the anterior scalene muscle to the middle of the clavicle., where P. a. passes into the axillary a.


The first part of the subclavian artery is located on the dome of the pleura and is covered in front by the anastomosis of the internal jugular vein and on the right by the subclavian vein or the initial part of the brachiocephalic vein and the thoracic duct (on the left). To the anterior surface of the P. a, the vagus nerve and the thoracoabdominal nerve are adjacent from the inside. Behind the artery is the lower cervical sympathetic node, which, connecting with the first thoracic node, forms the stellate node; medially from P. a. The common carotid artery is located. Right P. a. the loop encircles the recurrent laryngeal nerve, a branch of the vagus nerve. From the first part of P. a. The following branches arise: the vertebral artery, the internal thoracic artery and the thyrocervical trunk.

The second part of the subclavian artery is located directly on the first rib between the anterior and middle scalene muscles. In this part from P. a. The costocervical trunk departs, dividing into the superior intercostal artery and the deep artery of the neck, as well as the transverse artery of the neck. The third part of P. a. located relatively superficially and most accessible for surgical interventions. Anterior to the artery is the subclavian vein. The bundles of the brachial plexus are adjacent to it above, in front and behind.

Surgical tactics for wounds:

In case of damage and bleeding, it is necessary to ligate the subclavian artery or apply a suture to it in one of three zones: above, below and behind the collarbone.

The patient's position is on his back, a cushion is placed under his shoulders, his head is thrown back and turned in the direction opposite to the one on which the operation is being performed. Anesthesia - general or local.

Access to the artery above the clavicle:

When ligating the arteries or placing a vascular suture on it above the collarbone, an incision 8-10 cm long is made 1 cm above the collarbone, which reaches the outer edge of the sternocleidomastoid muscle. The tissues are cut layer by layer. It is necessary to strive to manipulate the rib to avoid injury to the dome of the pleura and the thoracic duct. The exposed artery is isolated, a Deschamps needle is placed under it, ligated and cut between two ligatures. The central segment must be stitched and tied with two ligatures. The wound is sutured. distal to the thyrocervical trunk, as it is the main collateral of the upper limb.

Access to the artery under the collarbone:

1. When dressing under the collarbone, an incision up to 8 cm long is made parallel to the lower edge of the collarbone and 1 cm below. The tissues are dissected layer by layer. They bluntly penetrate the adipose tissue until they find the inner edge of the pectoralis minor muscle, under which the artery is located. Using a Deschamps needle, strong ligatures are placed, tied, and the artery is cut between them.

2. According to Dzhanilidze: arcuate incision. from gr-kl considered 2 cm above to the coracoid process of the scapula, then downwards along the sulcus deltoideopectoralis. cut with a gigli saw. collarbone, push its edges apart. Having found the RCA, perform the necessary manipulation. and connect the edges of the clavicle with a wire suture or knitting needle. According to Petrovsky T-arr access