A central venous catheter (CVC) is not required in awake patients with stable circulation and in patients not receiving high osmolarity solutions. Before placing such a catheter, it is necessary to weigh all possible complications and risks. In this article, we will look at how central venous catheterization is performed.
Select installation location
When choosing a place for installing a catheter (puncture), first of all, the experience of a he alth worker is taken into account. Sometimes the type of surgical intervention, the nature of the damage and anatomical features are taken into account. In particular, for male patients, a catheter is placed in the subclavian vein (because they have a beard). If the patient has high intracranial pressure, do not place a catheter in the jugular vein, as this may impede the outflow of blood.
Alternative puncture sites are the axillary, medial and lateral saphenous veins of the arms, which alsoplacement of a central catheter is possible. PICC catheters are in a special category. They are installed in the vein of the shoulder under the control of ultrasound and may not change for several months, representing, in fact, an alternative version of the port. Complications of a specific type are thrombosis and thrombophlebitis.
Indications
Central vein catheterization is performed according to the following indications:
- Need to administer hyperosmolar solutions (more than 600 mosm/L) to the patient.
- Hemodynamic monitoring - measurement of central venous pressure (CVP), PICCO hemodynamic monitoring. CVP measurement alone is not an indication for catheter placement, as measurements do not give an accurate result.
- Measuring the level of carbon dioxide saturation in the blood (in individual cases).
- Use of catecholamines and other vein irritants.
- Prolonged, more than 10 days, infusion treatment.
- Venous dialysis or venous hemofiltration.
- Prescribing fluid therapy for poor peripheral vein condition.
Contraindications
Contraindications for catheter insertion are:
- Infectious lesion in the puncture area.
- Thrombosis of the vein in which the catheter is planned to be inserted.
- Impaired coagulation (condition after system failure, anticoagulation). In this case, it is possible to install a catheter in the peripheral veins on the arms or thigh.
Site selection and precautions
Before catheterization of the central vein, it is necessary to observe somerules:
- Precautions: use sterile gloves, mask, cap, sterile gown and wipes, special attention should be paid to skin disinfection.
- Patient posture: The head down position is the best option, as this facilitates the insertion of the catheter into the jugular and subclavian veins. It also reduces the risk of developing a pulmonary embolism. However, it should be borne in mind that such a position of the body can provoke an increase in intracranial pressure. See below for the Seldinger Central Vein Catheter Kit.
Restrictions
Choosing a puncture site is an important step in the procedure and has the following limitations:
- An alternative to the method of orientation by anatomical features is the puncture of the jugular and subclavian veins under 1/3 control. This method visualizes anatomical features and reduces the risk of complications such as erratic catheter position or incorrect puncture (with hematoma).
- Local anesthesia. If the patient is conscious, then light anesthesia is administered to him before the procedure, in some cases light sedation with an injection of midazolam.
- Venous puncture. If we are talking about the external, anterior or internal jugular vein, then the puncture is performed with a syringe half-filled with saline. CVC in this case is established by the Seldinger method. If a subclavian vein is to be placed, the j-wire is guided downward. The catheter is at 3-4centimeter under the clavicle to the right of the parasternal line. Constant monitoring of electrocardiogram parameters is necessary, since too deep insertion of the catheter can disrupt the heart rhythm. The pediatric central venous catheterization kit will help with this.
- Aspiration test. After installing the catheter, the syringe is withdrawn to understand whether arterial or venous blood comes from the puncture site. If there is any doubt, the blood is taken for analysis. If aspiration occurs freely, then the installed catheter can be used for infusion therapy. It is necessary to check the correctness of the installed catheter using an x-ray and only then fix it.
- Monitoring the patient's condition. Immediately after the installation of the catheter, the patient requires intensive monitoring in order to timely determine the complications that have arisen, which may be pneumothorax.
- TsVK. Each catheter placed must be marked on a special schedule indicating the date, location and type of catheter. In case of emergency catheter insertion without aseptic conditions, it should be removed and sent for analysis as soon as possible. The Seldinger Central Vein Set is the most popular.
Catheter care
Disconnecting and manipulating the system must be avoided. Kinks and unsanitary condition of the catheter are unacceptable. The system is fixed in such a way that there are no displacements in the puncture area. The development of complications and the risk of their occurrence shouldchecked daily. The best option is to apply a transparent bandage to the catheter insertion site. The catheter is subject to urgent removal in case of systemic or local infection during central vein catheterization.
Hygiene Standards
In order to avoid urgent removal of the catheter, strict adherence to hygienic standards and asepsis during its installation is necessary. If the CVC was installed at the scene of an accident, it is removed after the patient is taken to the hospital. It is necessary to exclude any unnecessary manipulations with the catheter and observe the rules of asepsis when taking blood and injections. Disconnection of the catheter from the infusion set requires disinfection of the CVC handpiece with a special solution. It is essential to use sterile disposable dressings and stoppers for the three-way stopcock, minimize the number of tees and connections, and strictly control blood protein, leukocyte, and fibrinogen levels to avoid infection.
Following all these rules, you can not change the catheter often. After removal of the CVC, the syringe is sent for a special examination, even if there are no symptoms of infection.
Replacement
The length of stay of the needle for central venous catheterization is not regulated, it depends on the patient's susceptibility to infections and the body's response to the introduction of CVC. If the catheter is installed in a peripheral vein, then replacement is necessary every 2-3 days. If placed in a central vein, the catheter is removed at the first symptoms of sepsis or fever. The syringe, removed under sterile conditions, is sent tomicrobiological research. If the need to replace the CVC occurs within the first 48 hours, and there is no irritation or signs of infection at the puncture point, a new catheter is placed using the Seldinger method. Observing all the asepsis requirements, the catheter is pulled back a few centimeters so that it, together with the syringe, still remains in the vessel, and only after that the syringe is removed. After the gloves are changed, a guidewire is inserted into the lumen and the catheter is removed. Next, a new catheter is inserted and fixed.
Possible Complications
After the procedure, the following complications are possible:
- Pneumothorax.
- Hematoma, hemomediastinum, hemothorax.
- Arterial puncture with the risk of damage to the integrity of blood vessels. Hematomas and bleeding, false aneurysms, strokes, arteriovenous fistulas and Horner's syndrome.
- Pulmonary embolism.
- Puncture of lymph vessels with chylomediastinum and chylothorax.
- Incorrect position of the catheter in the vein. Infusothorax, catheter in the pleural cavity or too deep in the ventricle or atrium on the right side, or misdirection of the CCV.
- Injury to the brachial or cervical plexus, phrenic or vagus nerves, stellate ganglion.
- Sepsis and catheter infection.
- Vein thrombosis.
- Irregular heart rhythm while advancing the Seldinger central vein catheter.
Installation of the Central Exhibition Center
There are three main options for placing a central venous catheterarea:
- Subclavian vein.
- Jugular internal vein.
- Femoral vein.
A qualified person should be able to place a catheter in at least two of the listed veins. When catheterizing the central veins, ultrasonic guidance is especially important. This will help localize the vein and identify the structures associated with it. Therefore, it is important to be able to use the ultrasound machine whenever possible.
The sterility of the central venous catheterization kit is of paramount importance to minimize the risk of infection. The skin must be treated with special antiseptics, the injection site should be covered with sterile wipes. Sterile gowns and gloves are strictly required.
The patient's head goes down, which allows you to fill the central veins, increasing their volume. This position facilitates the catheterization process, minimizing the risk of pulmonary embolism during the procedure itself.
The internal jugular vein is most commonly used to place a central venous catheter. With this type of access, the risk of pneumothorax is reduced (compared to subclavian catheterization). In addition, in case of bleeding, it is stopped by clamping the vein by compression hemostasis. However, this type of catheter is uncomfortable for the patient and can dislodge the wires of the temporary pacemaker.
Protocol actions
The protocol for central venous catheterization involves the following steps:
- The most optimal is the use of a Seldinger needle for catheterization (introduction along the conductor). Peripheral-like catheters are more difficult to place.
- Before injection, it is necessary to anesthetize the skin and fiber with lidocaine (1-2% solution).
- The needle is put on a syringe with sodium chloride solution.
- The conductor is located in a sterile place for free access.
- An incision is made in the skin with a small scalpel. This is done to facilitate the insertion of the cannula.
- Next, you need to move the needle forward, pulling the piston to maintain negative pressure.
- If it was not possible to get into the vein, you need to slowly pull up the needle, continuing to maintain negative pressure in the syringe. There are cases of vein puncture through. In this case, pulling up the needle helps.
- If the attempt to insert the catheter fails, the needle is flushed to remove particles blocking the lumen. Next, the location of the veins is reassessed and a new tactic for introducing the catheter is determined.
- As soon as the needle enters the vein and blood enters the syringe, you need to move the needle back or forward a little so that the blood can flow smoothly.
- Supporting the needle with one hand, remove the syringe.
- Then a flexible wire guide is inserted. It passes into the pavilion of the needle with the least possible resistance. You can make this procedure a little easier by changing the bevel angle.
- If the resistance when moving the conductor is strong enough,needle position should be checked by aspirating blood.
- As soon as the larger half of the guidewire is inserted into the vein, the needle must be removed and the catheter with dilator placed over the guidewire.
- The sheath should not be advanced until a small length of guidewire protrudes beyond the distal end of the dilator and is firmly secured.
- If there is resistance to CVC insertion, the incision can be enlarged. If there is resistance in the deep layers, you can first insert a small diameter expander to open the passage.
- After the catheter is fully inserted, the dilator is removed and the CVC is secured with a transparent bandage and ligature.
- At the end, an X-ray examination is performed to control the position of the catheter. If placed without complications, the catheter can be used immediately without additional supervision.
Access to the subclavian vein
Installation of a catheter into the subclavian vein is used when there is no access to the patient's neck. This is possible with cardiac arrest. The catheter installed in this place is located on the front of the chest, it is convenient to work with it, it does not cause inconvenience to the patient. The disadvantages of this type of access are the high risk of developing pneumothorax and the inability to clamp the vessel if it is damaged. If it was not possible to insert a catheter on one side, you should not immediately try to insert it on the other side, as this dramatically increases the risk of developing pneumothorax.
Installation of a catheter involves the followingactions:
- There is a point at the top of the rounded edge of the clavicle between one third of the medial and two thirds of the lateral.
- The injection site is located 2 centimeters below this point.
- Next, anesthesia is administered, and both the puncture site and the collarbone area around the initial point are anesthetized.
- The catheterization needle is inserted in the same way as anesthesia.
- As soon as the end of the needle is under the collarbone, you need to turn it to the lower point of the jugular notch of the sternum.
Access through the femoral artery is especially often used in emergency cases, as it helps to enter a large vein for further manipulations. In addition, with this type of access, it is easy to stop bleeding by clamping the vein. This access allows you to put a temporary pacemaker. The main complication of this type of catheterization is the high risk of infection and the required immobility of the patient.
How is the catheter inserted?
The catheter is inserted as follows:
- The patient is in a horizontal position. The leg turns and moves to the side.
- The groin area is shaved, the skin is treated with an antiseptic and covered with sterile wipes.
- The femoral artery is palpable at the crease at the base of the leg.
- Anesthetize the area where the catheter is inserted.
- The needle is inserted at an angle of 30-45 degrees.
- The vein is usually located at a depth of about 4 cm.
Central venous catheterization is a complicated and dangerous medical procedure.manipulation. It should be carried out only by an experienced and qualified specialist, since a mistake in this case can cost the patient life and he alth.
What's in the Dual Channel Central Vein Catheterization Kit?
Includes sterile (disposable) insertion kits - port chamber, port catheter, thin-walled needle, 10 cm syringe3, two locking locks, guidewire with soft J-tip in unwinder, two Huber needles without catheter, vein lifter, one Huber needle with fixing wings and attached catheter, bougie dilator, tunneler, split sheath.
Central vein kit
The kit is designed for catheterization of the superior vena cava using the Seldinger method. May require long-term drug administration, parenteral nutrition, invasive blood pressure monitoring.
Known set for catheterization of central veins "Certofix".
As part of the set you can see:
- Polyurethane radiopaque catheter with extensions and clamp.
- Seldinger needle (introducer).
- Straight nylon conductor.
- Dilator (expander).
- Additional mount for fixation to the patient's skin.
- Plug with injection membrane.
- Mobile clamp.
Certofix is the most commonly used set for central venous catheterization.
