Bladder catheterization in men: procedure algorithm, tools. Remove a urinary catheter How to remove a catheter at home

In cases of serious illness, all pets need medical attention. And often it has to be done at home. If it is necessary to give an animal a dropper or remove fluid from the bladder, many owners are wondering how to insert and remove a catheter from a cat.

Thanks to this device, it is possible to avoid constant injections. The catheter allows you to give your pet a dropper or an injection at any time you need.

And in the postoperative period or in diseases of the urinary system, this device allows you to free the animal's bladder from excess fluid completely painlessly.

When is a catheter needed?

As a rule, a healthcare professional should insert and remove the catheter from the cat's body. But sometimes you have to carry out this operation without leaving your home.

• when the pet is prescribed enteral nutrition;
• the pet has hyperhydration or hydration of the body;
• the cat is prescribed regular multiple injections with the use of drugs;
• when the drug needs to be delivered to the body accurately and quickly and with a special concentration, in contrast to ingestion, when the drug can lose its properties.

After the correct introduction of the device into the vein, after some time it will have to be removed. And here, owners of purring pets always have a problem with how to remove an intravenous catheter from a cat.

How to remove an intravenous catheter

The owner of the cat has to carry out this procedure 5 days after installation, in case of mechanical damage to the catheter, or if the limb of the pet with branula is swollen.

The catheter is usually placed on the front paws of the cat. It is fixed with the turn of an ordinary adhesive plaster. In order to remove an intravenous catheter from a cat, it is enough to cut this dressing from the bottom up. Then the remnants of the patch must be carefully rid of the pet's hair. After carrying out this manipulation, you can remove the catheters from the cat's paws by pulling a plastic tube out of the vein. Apply a tight bandage soaked in alcohol to the previous location of the branula, and bandage the foot for the next hour.

When carrying out this procedure, you should pay attention to the fact that:

• when the device is pulled out, the animal may try to escape. Therefore, it is much easier to remove the catheter from a cat at home together;
• when pulling out the tube, the movement should be accurate, but as fast as possible;
• instead of alcohol, a solution of furatsilin or hydrogen peroxide can be used to wet the disinfectant swab;
• if suspicious symptoms appear after the removal of the catheter, it is better to seek help from a veterinarian. Such uncharacteristic signs when removing the device include: swelling of the limbs, discoloration of the skin, lameness or clenching of the paw, pain on palpation, development of hyperthermia, lack of appetite, weak and apathetic state;
• it is best to use nail scissors to cut the plaster, as they will more accurately remove the bandage. If the animal twitches, then it is better to give preference to a device with rounded ends.

Catheter for diseases of the urinary system

In case of problems with urination (oncological diseases, prostate pathologies, urolithiasis, etc.) in a cat or dog, a catheterization procedure is necessary. Only in this way, in some cases, it is possible to save the pet's life.

Insertion and removal of the catheter may be required in the following cases:

• When do you need to control your cat's urination?
• in the postoperative period;
• if there are injuries to the organs of the genitourinary system;
• to remove stones from the bladder;
• for therapeutic purposes (washing the organs of the urinary system);
• for one-time excretion of urine.

Removal of the urinary catheter

The Faley catheter is a thin tube that drains urine into a special bag. Its removal is necessary when:

• the catheter ceases to function;
• the animal was injured in the urethra or bladder;
• The problem causing the device to install has been resolved.

The procedure for its removal is carried out only by a veterinarian. Do not try to carry out such an operation at home by watching a video from the Internet. Self-extraction of the catheter is fraught with injuries to the mucous membrane of the urinary tract.

Instead of a conclusion

The catheter is an indispensable device in many therapeutic techniques. It can be intended both for the introduction of various substances, and for the removal of urine from the bladder. And, if in the first case it is possible to remove the device from the limb on its own and without harm to the pet, then in the second situation it will not be possible to cope without outside help, you will have to contact the veterinarian.

VETERINARY CONSULTATION REQUIRED. INFORMATION FOR INFORMATION ONLY.

Insertion of a urinary catheter- a procedure performed in a hospital by a nurse and urological doctors. Bladder catheterization in women, men and children is different, as are the devices themselves.

The placement of a urinary catheter can only be done in a hospital.

Indications for a urinary catheter

The installation of a urinary catheter is indicated in the following conditions:

1. Urinary retention due to infection and surgery.
2. Unconscious state of the patient with uncontrolled outflow of urine.
3. Acute inflammatory diseases of the urinary organs, requiring lavage and administration of drugs into the bladder.
4. Injury to the urethra, swelling, scars.
5. General anesthesia and postoperative period.
6. Spinal injuries, paralysis, temporary incapacity.
7. Severe circulatory disorders of the brain.
8. Tumors and cysts of the urinary organs.

Also, catheterization is carried out if it is necessary to take urine from the urinary bladder.

Types of catheters

The main type of device used in urology is the Foley catheter. It is used for urination, washing the urinary bladder for infections, to stop bleeding and injecting drugs into the genitourinary organs.

What this catheter looks like can be seen in the photo below.

Foley catheter comes in different sizes

There are the following subspecies of the Foley device:

1. Two-way. It has 2 holes: through one, urination and washing is performed, through the other, liquid is injected and pumped out of the balloon.
2. Three-way: in addition to standard moves, it is equipped with a channel for the introduction of medicinal preparations into the patient's urinary organs.
3. Foley-Timman: has a curved end, is used for prostate catheterization in men with a benign tumor of the organ.

A Foley catheter can be used for procedures on any urinary tract. Duration of operation depends on the material: devices are available in latex, silicone and silver-plated.

The following devices can also be used in urology:

1. Nelaton: straight, with a rounded end, consists of a polymer or rubber. It is used for short-term bladder catheterization in cases where the patient is unable to urinate on his own.
2. Timman (Mercier): silicone, elastic and soft, with a curved end. Used to drain urine in male patients suffering from prostate adenoma.
3. Pizzera: A rubber appliance with a bowl-shaped tip. Designed for continuous drainage of urine from the bladder through a cystostomy.
4. Ureteral: a long PVC tube 70 cm long placed with a cystoscope. It is used for catheterization of the ureter and renal pelvis, both for the outflow of urine and for the administration of drugs.

Nelaton's catheter is used for short-term bladder catheterization

All types of catheters are divided into male, female and children:

• female - shorter, wider in diameter, straight shape;
• male - longer, thinner, curved;
• children - have a smaller length and diameter than adults.

The type of device installed depends on the duration of catheterization, sex, age and physical condition of the patient.

Types of catheterization

According to the duration of the procedure, catheterization is divided into long-term and short-term. In the first case, the catheter is installed on a permanent basis, in the second - for several hours or days in a hospital.

Depending on the organ undergoing the procedure, the following types of catheterization are distinguished:

• urethral;
• ureteral;
• renal pelvis;
• bladder.

Urethral catheter in men

Further instructions depend on how long the catheter is placed. For short-term use, after the outflow of urine or the introduction of drugs, the device is removed. With prolonged use, catheterization ends after insertion.

If the procedure was carried out correctly, there is no pain.

How is a catheter placed in children?

The general algorithm for installing a catheter for children does not differ from the adult instructions.

There are important features when performing the procedure in children:

1. The urethral catheter for children should have a small diameter so as not to damage the genitourinary organs of the child.
2. The device is placed on a full bladder. You can check the fullness of the organ using ultrasound.
3. Treatment with medicines and strong antibacterial compounds is prohibited.
4. Pushing the labia in girls should be done carefully so as not to damage the frenulum.
5. The introduction of the tube should be soft, slow, without force.
6. It is necessary to remove the catheter as soon as possible so as not to provoke inflammation.

The procedure in children, especially in infants, should be handled by a urologist with a pediatric education.

Caring for your urinary catheter

An indwelling urinary catheter must be carefully cared for to avoid urinary tract infections. The processing algorithm looks like this:

1. Lay the patient on his back, place an oilcloth or vessel under the buttocks. Drain the drain fluid and carefully remove the device.
2. Drain the urine from the drainage bag, rinse it with water, treat with an antiseptic: Chlorhexidine, Miramistin, Dioxidine, boric acid solution.
3. Flush the catheter with a 50 or 100 mg syringe. Pour an antiseptic into it, and then rinse with running water.
4. In case of inflammatory processes of the urinary tract, treat the catheter with a solution of furacilin, diluting 1 tablet in a glass of hot water.

Miramistin - antiseptic for the treatment of the urinal

The urinal must be emptied 5-6 times a day, and washed with antiseptics at least 1 time per day. The catheter should be processed no more than 1-2 times a week.

In addition, it is necessary to thoroughly wash the patient's genitals.

How to change the catheter yourself at home?

Performing a catheter replacement at home is a dangerous procedure that can cause serious injury to the urinary organs. Self-administration of the procedure is only permissible for a soft urethral device, and with a serious need.

To replace the device, the old catheter must be removed:

1. Empty the urinal. Wash your hands with soap and put on gloves.
2. Lie in a horizontal position, bend and spread your legs to the sides.
3. Flush the tube of the device and genitals with an antiseptic or saline solution.
4. Locate the bottle opening of the device. This is the second hole not used for urine output and bladder lavage.
5. Empty the balloon with a 10 ml syringe. Insert it into the hole and pump out the water until the syringe is completely filled.
6. Gently pull the tube out of the urethra.

Correct position for catheter replacement

After removing the device, a new one is inserted into the urethra, according to the above instructions for representatives of different sexes.

The nurse should change the ureteral and renal pelvic catheters. The replacement and removal of the suprapubic (bladder) device is handled by the attending physician.

Possible complications after the procedure

Pathologies resulting from catheterization include:

• damage and perforation of the urethral canal;
• trauma to the urethral bladder;
• urethral fever;
• urinary tract infections.

Incorrect catheterization may cause inflammation of the urethra

You can avoid these complications if you use a soft catheter and carry out the procedure in medical institutions, with the help of a nurse or attending physician.

Bladder catheterization is used for stagnation of urine and infections of the genitourinary system. With a properly selected device and compliance with its setting, the procedure is unable to harm the patient and cause discomfort.

The bladder is an organ that is a reservoir for collecting urine and performs the function of removing it from the body. This organ does not always cope with its function; in some cases, doctors have to resort to.

Also, the device is installed during operations and some diagnostic procedures. The urinal consists of special tubes through which urine is removed from the body.

When are urinals installed?

Urinary receivers are inserted into the bladder through the urethra. They are installed in the case when the patient needs to reduce pressure in the bladder area, for example, in the postoperative period with or with other injuries, during operations, or when urination is difficult. But there are cases when the installation of a urinal through the urethra is prohibited or irrational. These cases include:

• installation for a long time;
• rupture of the urethra as a result of trauma;
• operations on the urethra;
• benign tumors of the prostate.

In such a situation, doctors resort to the removal of an artificial channel - a cystostomy surgically. It is located above the pubic area.

Caring for a urinal at home

A catheter located in the bladder, like any other medical equipment, requires special care. This is necessary in order to avoid malfunction of the device, as well as to exclude the development of infectious diseases of the urinary tract. For proper care, it is enough to follow the following recommendations in a timely manner:

If the patient is excreted, then the bladder should be washed periodically. It is recommended to do this twice a week. The procedure must be carried out by a medical professional to rule out damage to the bladder. And you should change the device once every four weeks. All manipulations are performed only in medical gloves.

To replace the catheter, follow these steps:

1. The area around the outlet of the urinal should be treated to prevent dirt from entering.
2. Next, you need to deflate the balloon from the old catheter. This must be done with a syringe.
3. Slowly and carefully remove the catheter. You can use special anesthetic gels prescribed by a doctor.
4. After that, it is necessary to replace the gloves with clean ones.
5. Next, a new catheter should be inserted.
6. We are waiting for the next withdrawal of urine.
7. We fill the balloon again with a syringe. The volume of serial water introduced into the cylinder is about five or eight milliliters.
8. The last step is to attach the urinal to the catheter.

How to flush the Foley device?

To flush the Foley catheter, large-volume syringes are used - fifty or one hundred milliliters. Immediately before washing the device, the syringe must be scalded with boiling water. Washing is carried out with warm saline.

If blood or some sediment was noticed in the urine, then a warm solution of furacilin will be used for washing at the rate of two tablets per one and a half cups of warm boiled water. It is important to strain the solution to get rid of undissolved pieces of tablets. The resulting solution is drawn into a syringe.

The urinal tube is disconnected. Its end is wiped with a solution of furacilin. We insert the syringe and inject the solution, this should be done slowly. After entering the entire contents, the syringe is removed, and the liquid itself flows out of the catheter.

Replacement of the urinal

In order to replace the urinal, you must:

1. Prepare a clean urinal in advance.
2. Separate the tube from the catheter.
3. Drain the urine from the urinal, if the device is to be reused, then it must be rinsed and soaked for a while in a solution of chloramine, then rinsed again with water.
4. Connect the urinal to the catheter.

When installing a catheter, you need to follow a diet. It is forbidden to use pickles, spicy, smoked meats, alcohol, as well as smoking. important to do

The catheter is fixed to the skin (Fig. 19.26).

Rice. 19.26. through a needle

Possible complications of catheterization of the subclavian vein:

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

2. The development of hemo- or pneumothorax when the needle enters 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 plunger. The likelihood of complications with pneumothorax is increased with deformities of the chest (emphysematous), shortness of breath with deep breathing. Pneumothorax can develop both in the next few minutes and several hours after vein puncture. 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 the piston is pulled towards itself, which should be done during vein puncture;

weakening of respiratory sounds during auscultation on the side of pneumothorax;

boxed sound on percussion in that half of the chest where pneumothorax developed;

On plain chest X-ray, the lung field has increased transparency, there is no lung pattern on the periphery;

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

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

The development of hemothorax can occur not only as a result of damage to the apex of the lung with a needle, but also as a result of perforation of the wall of the innominate vein with a rigid catheter. Hemothorax requires a 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, followed by the introduction of fluids into them. Manifested by a gradual deterioration of the patient's condition - chest pain, cyanosis, tachycardia, shortness of breath, lowering blood pressure. Stop the infusion and take a chest x-ray. Remove the fluid through the existing catheter, and from the pleural cavity - by puncturing it.

5. Formation of extensive hematomas (paravasal, in the mediastinum, intradermal, subcutaneous). The main causes are accidental injury to an artery or poor blood clotting. Sometimes this is due to the fact that the doctor, after entering the vein, draws blood into the syringe and injects it back into the vein. If the cut of the needle is not completely in the lumen of the vein, then part of the blood, when it is reintroduced, will enter 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 its puncture or catheterization, the lack of tightness between the catheter and the transfusion system or their unnoticed separation. It is clinically manifested by sudden shortness of breath, cyanosis of the upper half of the body, swelling of the jugular veins, a sharp decrease in blood pressure, and often loss of consciousness. The patient is laid on the left side, cardiotropic agents are administered, mechanical ventilation, and, if necessary, resuscitation measures.

Prevention of air embolism:

during catheterization, give the patient the Trendelenburg position - lower the head end of the awards table;

Holding the patient's breath on a deep breath at the moment the syringe is disconnected from the needle or when the catheter is open (removing the conductor, changing the plug);

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

Care of the patient (making the bed, changing linen, etc.) should be done carefully with a focus on the condition of the catheter.

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

8. Migration of the conductor, catheter or its fragments into large vessels and cavities of the heart. There are severe violations of the heart, thromboembolism of the pulmonary artery.

Reasons for catheter migration:

Rapid 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 the 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 to the skin;

Insufficiently strong fixation of the catheter to the skin.

DO NOT remove the guidewire from the needle. If necessary, remove the needle together with the conductor.

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

The location of the migrated conductor or catheter is difficult to establish. Often, revision of the subclavian, superior vena cava, or right heart is required, sometimes using a heart-lung machine.

9. Thrombosed catheter. The reason is insufficient heparinization of the catheter. This leads to the ingress of blood into the lumen of the catheter with its subsequent coagulation. Manifested by obstruction of the catheter. It is necessary to remove the catheter and, if necessary, catheterize the subclavian vein from the other side.

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

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

10. Thromboembolism of the pulmonary artery. It develops in patients with increased blood clotting. For prevention, it is necessary to administer anticoagulants and agents that improve the rheological properties of blood.

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

12. Thrombosis of the subclavian vein. Manifested by the "syndrome of the superior vena cava" - swelling of the neck and face, upper limbs. Anticoagulant and thrombolytic therapy is required.

How is the catheter removed from the neck?

The catheter is in the jugular vein in the neck, as it will be removed.

Will they give painkillers? How will the bleeding be stopped?

The subclavian catheter is removed very simply and does not hurt at all .. Even an experienced nurse can do this. An anesthetic injection is not required. A sticker is removed, the skin around the catheter is treated with an antiseptic (alcohol, iodine), then the sutures (usually, their or two), are removed, then, with a quick movement, the catheter is removed from the artery or vein. A sterile dense cotton-gauze swab is applied, a sterile sticker is made. five minutes.

CPV - catheterization of the subclavian vein is placed in the patient in the absence of a peripheral venous system (more simply, the cubital vein in the cubital fossa) and an extensive and prolonged infusion of drugs is expected.

Manipulation is carried out by anesthesiologists - resuscitators. Now venous catheters are very comfortable, they are quickly placed, rather painlessly, and removed easily. After treating the skin, the threads fixing the catheter to the skin are cut with a scalpel or scissors, it is pulled out, the puncture site is treated and closed with a bactericidal plaster.

The main thing is to monitor the catheter during treatment. Since there is a risk of thrombosis, the nurse flushes the catheter with heparin after each manipulation. And the danger of developing phlebitis of the subclavian vein.

After the catheter is removed, the puncture site heals for a day.

This is not a very painful procedure.

Pain relief is not needed.

Sharply pull out the needle and the prepared cotton swab with alcohol

applied to the injection site. Keep it up to 20 minutes.

Then they will bandage it and it will hurt a little, tolerably. You can make a warming compress on the bandage.

The procedure is fast and painless. After treatment, the catheter is removed, and the puncture method is pressed down with a gauze pad. You can apply ice.

Other methods of venous access: removal of the hickman catheter

a. infected catheter.

b. Unrecoverable thrombosed catheter.

c. End of therapy.

a. Increased bleeding (prothrombin index > 1.3).

b. The need for continued treatment.

a. Antiseptic solution of betadine.

b. Sterile wipes.

c. Sterile instruments.

d. Hemostatic clamps.

e. Bladed scalpel.

g. Suture material (nylon 4-0).

a. Apply antiseptic to the catheter and the skin where the Hickman catheter exits.

b. Inject the anesthetic intradermally and infiltrate the tissues along the catheter up to and including the cuff.

c. Gently pull the Hickman catheter towards you. Sometimes this is enough to remove the cuff from the surrounding fibrous tissue.

d. When the cuff appears in the area of ​​the skin incision, insert a hemostatic forceps to separate the fibrous tissue (Fig. 2.15).

e. If necessary, widen the skin incision. Use the scalpel, being careful not to damage the catheter. If necessary, make an incision just above the cuff, then peel the tissue with a forceps to release the cuff.

f. When the cuff is free of fibrous tissue, pull the catheter out gently and without jerking.

i. Apply a sterile dressing to the wound.

a. Air embolism

Unlikely when a tunneled catheter is removed.

In unstable hemodynamics (cardiac arrest), start resuscitation and call a thoracic

Calic surgeon for consultation.

If hemodynamically stable, place the patient on the left side and in the Trendelenburg position to ensure that air is trapped in the right ventricle.

Take a series of chest x-rays.

The air will eventually dissipate.

Press with your finger for S min.

If it is external, take precautions to prevent an air embolism by clamping the catheter proximal to the breakage and continue to withdraw the catheter as described above.

If the catheter breaks under the skin and the end is stuck in the tunnel, perform X-ray guided surgery to remove the catheter.

This is one of the most serious complications; To avoid this, do not pull too hard on the catheter or use sharp instruments to remove it from the tunnel.

1. Indications: a. Complete or partial upper airway obstruction. b. Clenched jaws in unconscious or intubated patients. c. The need for aspiration from the oropharynx.

1. Indications: a. CVP monitoring. b. parenteral nutrition. c. Prolonged drug infusion. d. Introduction of inotropic agents. e. Hemodialysis. f. Difficulties in puncturing peripheral veins.

1. Indications: a. Inability to catheterize the subclavian or internal jugular veins to measure CVP or administer inotropic agents. b. Hemodialysis.

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Algorithm for removing a venous catheter.

1. Assemble a standard venous catheter removal kit:

sterile gauze balls;

· waste tray;

sterile test tube, scissors and tray (used if the catheter is thrombosed or if infection is suspected).

3. Stop the infusion, remove the protective bandage.

4. Treat your hands with an antiseptic, put on gloves.

5. Moving from the periphery to the center, remove the fixing bandage without scissors.

6. Slowly and carefully withdraw the catheter from the vein.

7. Carefully for 2-3 minutes. press the catheterization site with a sterile gauze pad.

8. Treat the catheterization site with a skin antiseptic.

9. Apply a sterile pressure bandage to the catheterization site and fix it with adhesive tape.

10. Check the integrity of the catheter cannula. In the presence of a thrombus or suspected infection of the catheter, cut off the tip of the cannula with sterile scissors, place it in a sterile tube and send it to a bacteriological laboratory for examination (as prescribed by a doctor).

11. Record the time, date, and reason for removal of the catheter in the documentation.

12. Dispose of waste in accordance with the safety regulations and the sanitary and epidemiological regime.

Complications with parenteral administration of drugs

The technique of any manipulation, including the parenteral administration of drugs, must be strictly observed, since the effectiveness of medical care largely depends on the quality of the manipulations. Most of the complications after parenteral injections arise as a result of not fulfilling in full the necessary requirements for observing asepsis, methods of manipulation, preparing the patient for manipulation, etc. Exceptions are allergic reactions to the administered drug.

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

For puncture and catheterization of the central veins, the right subclavian vein or internal jugular vein is most often used.

A central venous catheter is a long, flexible tube used to catheterize the central veins.

The central veins include the superior and inferior vena cava. From the name it is clear that the inferior vena cava collects venous blood from the lower parts of the body, the upper one, respectively, of the head and the upper part. Both veins empty into the right atrium. When placing a central venous catheter, preference is given to the superior vena cava, because access is closer and at the same time the mobility of the patient is preserved.

The right and left subclavian veins, and the right and left internal jugular veins drain into the superior vena cava.

Shown in blue are the right and left subclavian, internal jugular, and superior vena cava.

Indications and contraindications

There are the following indications for central venous catheterization:

• Complex operations with possible massive blood loss;
• Operations on the open heart with AIK and in general on the heart;
• The need for intensive care;
• parenteral nutrition;
• Ability to measure CVP (central venous pressure);
• Possibility of multiple blood sampling for control;
• Insertion of a cardiac pacemaker;
• X-ray - contrast study of the heart;
• Probing of the cavities of the heart.

Contraindications

Contraindications for central venous catheterization are:

• Violation of blood clotting;
• Inflammatory at the puncture site;
• Collarbone injury;
• Bilateral pneumothorax and some others.

However, you need to understand that contraindications are relative, because. if the catheter needs to be placed for health reasons, then this will be done under any circumstances, because. venous access is needed to save a person's life in an emergency)

For catheterization of the central (main) veins, one of the following methods can be chosen:

1. Through the peripheral veins of the upper limb, often the elbow. The advantage in this case is the ease of execution, the catheter is passed to the mouth of the superior vena cava. The disadvantage is that the catheter can stand for no more than two to three days.

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

3. Through the internal jugular vein, also on the right or left.

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

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

1. A vein is punctured with a needle, a conductor is passed through it to a depth of 10 - 12 cm,

3. After that, the conductor is removed, the catheter is fixed to the skin with a plaster.

Subclavian vein catheterization

Puncture and catheterization of the subclavian vein can be performed supra- and subclavian access, on the right or on the left - it does not matter. The subclavian vein has a diameter in an adult mm., It is fixed by the musculo-ligamentous apparatus between the clavicle and the first rib, practically does not collapse. The vein has good blood flow, which reduces the risk of thrombosis.

The technique for performing catheterization of the subclavian vein (subclavian catheterization) involves the introduction of local anesthesia to the patient. The operation is carried out under conditions of complete sterility. Several access points have been described for catheterization of the subclavian vein, but I prefer the Abaniak point. It is located on the border of the inner and middle thirds of the clavicle. The percentage of successful catheterizations reaches %.

After processing the surgical field, cover the surgical field with a sterile diaper, leaving only the operation site open. The patient lies on the table, the head is maximally turned in the opposite direction from the operation, the hand is on the side of the puncture along the torso.

Let us consider in detail the stages of subclavian catheterization:

1. Local anesthesia of the skin and subcutaneous tissue in the puncture area.

2. With a 10 ml syringe from a special kit with novocaine and a needle 8-10 cm long, we pierce the skin, constantly injecting novocaine to anesthetize and flush the needle lumen, move the needle forward. At a depth of 2 - 3 - 4 cm, depending on the constitution of the patient and the point of injection, there is a feeling of piercing the ligament between the first rib and the clavicle, carefully continue, at the same time we pull the syringe plunger towards ourselves and forward in order to flush the needle lumen.

3. Then there is a feeling of piercing the vein wall, while pulling the syringe plunger towards ourselves, we get dark venous blood.

4. The most dangerous moment is the prevention of air embolism: we ask the patient, if he is conscious, not to breathe deeply, disconnect the syringe, close the needle pavilion with your finger and quickly insert the conductor through the needle, now it is a metal string, (formerly just a fishing line) similar to a guitar one, to the required depth, see 10-12.

5. Remove the needle, rotate the catheter along the guidewire to the desired depth, remove the guidewire.

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

7. We fix the catheter with a silk suture to the skin, i.e. we sew the skin, tie knots, then we tie knots around the catheter, and for reliability we tie knots around the catheter pavilion. All with the same thread.

8. Done. Attach the drip. It is important that the tip of the catheter should not be in the right atrium, the risk of arrhythmia. Good and enough at the mouth of the superior vena cava.

When catheterizing the subclavian vein, complications are possible, in the hands of an experienced specialist they are minimal, but we will consider them:

• Puncture of the subclavian artery;
• Injury of the brachial plexus;
• Damage to the dome of the pleura with subsequent pneumothorax;

Damage to the trachea, esophagus and thyroid gland;

Air embolism;

On the left is a lesion of the thoracic lymphatic duct.

Complications may also be related to the position of the catheter:

• Perforation of the wall of a vein, either atrium or ventricle;
• Paravasal administration of fluid;
• Arrhythmia;
• thrombosis of a vein;
• Thromboembolism.

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

By the way, a catheter in a vein with good care can be up to two to three months. It is better to change more often, once every one to two weeks, the change is simple: a conductor is inserted into the catheter, the catheter is removed and a new one is installed along the conductor. The patient can even walk with a drip in hand.

Catheterization of the internal jugular vein

Indications for catheterization of the internal jugular vein are similar to those for catheterization of the subclavian vein.

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

The disadvantage is that the vein is mobile, so the puncture is more difficult, while the carotid artery is nearby.

Technique for puncture and catheterization of the internal jugular vein: the doctor stands at the patient's head, the needle is injected into the center of the triangle, which is surrounded by the legs of the sternocleidomastoid muscle (in the people of the sternocleidomastoid muscle) and 0.5 - 1 cm laterally i.e. outward from the sternal end of the clavicle. The direction is caudal i.e. approximately on the coccyx, at an angle of degrees to the skin. Local anesthesia is also necessary: ​​a syringe with novocaine, the technique is similar to a subclavian puncture. The doctor feels two "failures" of the puncture of the cervical fascia and the wall of the vein. Entering a vein at a depth of 2 - 4 cm. Further, as with catheterization of the subclavian vein.

It is interesting to know: there is a science of topographic anatomy, and so, the point of confluence of the superior vena cava into the right atrium in projection onto the surface of the body corresponds to the place of articulation of the second rib on the right with the sternum.

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Performing infusions and caring for the subclavian catheter

Manipulations with the subclavian catheter require the responsibility of the nurse, certain practical skills. Otherwise, complications such as air embolism, thrombophlebitis, sepsis, thrombosis and catheter prolapse may develop.

To prevent complications, the nurse must strictly follow the instructions for operating the catheter in the main vein.

Equipment: sterile gloves, tweezers, syringe and needles, heparin solution, sterile wipes, alcohol 70%.

1. Treat hands, put on gloves.

2. Remove the aseptic bandage covering the catheter.

3. Treat the plug on the catheter with 70% alcohol.

4. With a single injection of a medicinal substance, puncture the plug with a needle with a syringe with a medicinal substance.

5. Pull the syringe plunger towards you until blood appears in the syringe barrel.

6. Enter the medicinal substance and remove the needle without removing the plug.

7. When connecting the system to an infusion catheter, ask the patient to hold their breath at inspiratory height.

8. Remove the plug and place it in a sterile napkin. Connect the catheter to a syringe containing isotonic sodium chloride solution and pull the plunger of the syringe towards you until blood appears in it.

9. Remove the syringe and connect the catheter to the infusion set.

10. Cover the cannula of the catheter and the injection site of the system with a sterile drape.

11. To prevent thrombosis of the catheter, the infusion of solutions must be carried out at a sufficient rate.

12. At the end of the infusion, disconnect the system in the same way and close the cannula with a sterile plug.

13. The catheter is washed with 1-2 ml of isotonic sodium chloride solution and 0.2 ml of heparin is injected (1000 IU per 5 ml of saline).

14. After removing the catheter, the skin is treated with a 5% alcohol solution of iodine or 70% alcohol, covered with a sterile napkin, which is fixed with an adhesive plaster.

15. Until complete healing, the wound is treated with an antiseptic during daily dressings.

20. Charging the needle holder

It may be necessary to suture the skin not only in the operating room, but also in the dressing room. Charging the needle holder is carried out only with sterile gloves and only with sterile instruments.

Equipment: anatomical tweezers, needle holder, needle, scissors, suture material. If the manipulation is not carried out in the operating room, a sterile tray is also needed.

1. If suturing is performed in the dressing room, then it is necessary to treat the hands and put on sterile gloves.

2. Take the needle holder in your left hand so that the first finger is in one ring, and the third and fourth in the other.

3. Take anatomical tweezers in your right hand and grab the needle with them.

4. Position the needle in the beak of the needle holder so that its sharp end is to the left of the needle holder and faces the loader, and the needle itself is 2-3 mm below the tip of the clamping part of the needle holder (beak). To the right of the needle holder should be 1/3 of the needle with an eye. Clamp the needle in the needle holder.

5. Using anatomical tweezers, grab the ligature by the tip and fix its second end on the shoulder of the needle holder with the second finger of the left hand. The length of the thread should be no more than cm.

6. Wrap the thread around the beak of the needle holder and guide it into the eye of the needle (away from you) while slightly pressing on the spring. In this case, one end of the thread should be 3-4 times longer than the other.

7. Release the lower fixed end of the thread and use tweezers to transfer it behind the needle holder.

8. Deploy the needle holder with rings away from you and give it to the surgeon. The hanging end of the thread must be held with tweezers, not allowing it to fall on the skin.

21. Imposing an interrupted suture on the skin

Before suturing the skin, the third lubrication of the skin of the surgical field with an antiseptic solution is performed. Equipment: surgical tweezers, needle holder, needle, suture material, scissors, dressing material, antiseptic for processing the surgical field.

1. Take a needle holder with a needle and thread ready for use in your right hand, take surgical tweezers in your left hand.

2. Grasp the far edge of the wound with surgical tweezers. The sutures are placed from left to right relative to who is suturing.

3. Inject the needle into the entire depth of the skin at a distance of 0.5-1 cm from the edge of the wound.

The needle should be directed perpendicular to the skin.

4. Remove the needle with a needle holder through the wound and slightly tighten the thread.

5. Grasp the near edge of the wound with surgical tweezers and inject the needle from the side of the wound (from the inside out) strictly opposite the previous injection and at a distance of 0.5-1 cm from the edge of the wound.

6. Remove the needle from the tissues using the needle holder and carefully, holding the thread, remove it.

7. Take the near end of the thread in the right hand, the far end in the left and wrap the near end around the far end twice.

8. Tie the thread, directing it perpendicular to the course of the wound, move the knot to the place where the thread exits from the skin.

9. Without loosening the tension of the thread, tie a second knot with one twist of the thread.

10. Cut off the thread at a distance of 1-1.5 cm from the knot.

11. Apply all other sutures in the same order. The distance between the seams should be within 1 cm.

12. Treat the sutures and skin of the surgical field with an antiseptic solution and apply a sterile bandage.

22. Removal of the skin suture

The timing of the removal of skin sutures is determined by the attending physician. On average, with an uncomplicated course, the sutures are removed for 7-8 days. The stitches on the face are removed for 5-6 days. In oncological patients, patients with severe intoxication, tissue regeneration slows down, and the timing of suture removal is postponed to a day.

Equipment: sterile tweezers, sterile scissors with one sharp end, sterile dressings, antiseptics for skin and gloves, adhesive plaster, rubber gloves.

1. It is convenient to seat or lay down the patient. Explain to him the essence of the upcoming manipulation.

2. Treat hands, put on and process gloves.

3. Treat the postoperative sutures twice with an antiseptic solution.

4. With anatomical tweezers, grab the knot of one seam, pull it up so that a white (clean) section of the thread appears from under the skin. To make it easier to move the ligature on the skin, you can lightly press with the tips of the scissors.

5. Use scissors to cross the thread in a clean area.

6. Pull out the ligature and put it on a napkin.

7. In the same sequence, remove the remaining seams.

8. Treat the postoperative scar with an antiseptic solution and apply a sterile bandage.

9. Fix the bandage with adhesive tape.

23. Observation and care of postoperative sutures

Equipment: dry sterile dressing, sterile tweezers, ice pack, antiseptic solutions, rubber gloves.

1. Transfer the patient delivered from the operating room to the prepared bed. Place the bed in such a way that the approach to the patient is possible from any direction.

2. Remove the pillow and turn the patient's head on its side (to prevent retraction of the tongue and aspiration of vomit).

3. Place an ice pack on the area of ​​postoperative sutures through a diaper (the ice should be in small pieces with the addition of water at room temperature).

4. Ensure continuous monitoring of the patient until full awakening from narcotic sleep.

5. Examine the bandage immediately after the patient is delivered and 2-4 hours after the operation. In an uncomplicated course, the bandage remains clean or moderately wet with blood or ichor and dries up from the edges.

6. If the bandage is profusely soaked with blood and wet (signs of ongoing bleeding!), cover it with a dry sterile napkin and immediately invite a doctor. After examining him, the bandage is either changed or bandaged, after wetting the bottom napkin 700 with alcohol. With continued massive bleeding, it is stopped in the operating room.

7. The first dressing after the operation is performed together with the doctor one day after the operation.

8. In the following days, when performing dressings, pay attention to the color of the skin around the sutures, its temperature, the presence of tissue edema, or fluctuations. The appearance of skin hyperemia, tissue infiltration or fluctuation symptom indicates infection or suppuration of the postoperative suture. The appearance of these signs must be urgently reported to the doctor. Together with the doctor, all sutures are removed or through one, the edges of the wound are parted, the wound is washed with antiseptics and drained.

24. Applying an elastic bandage to the shin

Most often, an elastic bandage is applied to the lower limb with varicose veins. Bandaging with an elastic bandage should not be used if there are purulent formations, eczema, bleeding wounds and ulcers on the skin.

Equipment: roller, elastic bandage.

1. Apply the bandage in the morning, before the patient gets out of bed.

2. Explain to the patient the purpose of this manipulation.

3. Invite the patient to relax. Place the leg to be bandaged on a roller height cm.

4. Make fixing tours of the bandage around the foot.

5. Apply spiral tours of the bandage from the bottom up slightly stretching the bandage. Strong stretching of the bandage is not permissible, as this can lead to impaired blood circulation in the limb.

6. Finish bandaging either below the knee joint or above it. Secure the bandage with a pin, or by tucking it under the edge of the last round. Explain to the patient that the bandage must be removed in the evening before going to bed (unless otherwise instructed by the doctor).

Caring for your subclavian (venous) catheter

Target: prevention of complications: air embolism, infection of the vein and skin at the site of catheter insertion.

Indications: a subclavian catheter is inserted for the purpose of long-term infusion therapy.

Equipment: sterile dressing material, skin antiseptic, sterile syringe, heparin, isotonic solution.

You are an Admissions Nurse. A patient was admitted with arterial bleeding from the middle third of the right leg. You need to apply a tourniquet.

The imposition of a hemostatic tourniquet for arterial bleeding.

Target: temporary stop of bleeding.

Indications: arterial bleeding.

Equipment: hemostatic tourniquet, napkin, paper, pencil, IPP, Cramer's splint.

You are a nurse in the Department of Purulent Surgery. The patient applied on the 3rd day after the opening of the boil on the left cheek. You need to bandage a purulent wound.

Target: removal of purulent contents from the wound, prevention of secondary

infection, creating conditions for wound healing.

Indications: the presence of a purulent wound.

Equipment: goggles, mask, oilcloth apron, gloves, leather

antiseptic, sterile tweezers - 3, bellied probe, rubber drains.

sterile dressings, antiseptic solutions, ointments,

hypertonic solution, container with disinfectant.

You are a trauma nurse. A patient was brought to you with a closed fracture of the middle third of the right ulna. It is necessary to carry out therapeutic immobilization.

You need to start by providing lighting for the place of manipulation. Hands are washed and dried. A tourniquet of centimeters is applied above the catheterization zone and a vein is selected by palpation. Next, you need to choose the right size catheter, while taking into account the size of the vein, the rate of insertion and the schedule of intravenous injections. Then they treat their hands with an antiseptic and put on gloves. The catheterization site must also be treated with any disinfectant for seconds and allowed to dry. It is not necessary to palpate the vein again. Simply fixing it, a catheter of the selected diameter is taken and the protective cover is removed. If an additional plug is installed on it, then it is not thrown away, but held between the fingers of the free hand. The catheter is inserted on the needle at an angle of 15 degrees to the skin, while observing the indicator chamber. When blood appears in it, then you need to reduce the angle of the stylet needle and lead the needle into the vein by a few millimeters. Having fixed the stylet needle, slowly and completely move the camera from the needle into the vein and remove the tourniquet. Then you need to clamp the vein and finally remove the needle from the catheter. Dispose of the needle using safety rules. And finally, you need to remove the plug from the protective sheath and close the catheter, or insert the infusion set. Fix the catheter on the limb.

Wash your hands and urethral area. Open the catheter package 2-3 cm. Fill the catheter package with plain water up to the tip. The catheter must be in the water for at least 30 seconds. Attach the catheter with an adhesive circle to a flat surface. The catheter is stiffer in cold water and softer in warm water. For women: remove the catheter from the package. Part your labia and insert the catheter into your urethra with your other hand. For men: With one hand, lift the penis and straighten the urethra. Insert the catheter with the other hand, advance it 2 cm each time. Move it around until urine starts to flow. When the bladder is completely empty, slowly remove the catheter.

• placement of a urinary catheter

• Cotton swab and any oil for baby skin, soap, water.

In no case, do not peel off the patch if you experience severe pain, it is possible that the wound has not yet healed, and you risk damaging the skin again.

Tip 5: How to Use the Pezzer and Subclavian Catheters

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Subclavian vein catheterization

Punctures and catheterizations of veins, in particular central veins, are widely used manipulations in practical medicine. Currently, very broad indications are sometimes given for catheterization of the subclavian vein. Experience shows that this manipulation is not safe enough. It is extremely important to know the topographic anatomy of the subclavian vein, the technique for performing this manipulation. In this teaching aid, much attention is paid to the topographic-anatomical and physiological substantiation of both the choice of access and the technique of vein catheterization. Clearly formulated indications and contraindications, as well as possible complications. The proposed manual is designed to facilitate the study of this important material through a clear logical structure. When writing the manual, both domestic and foreign data were used. The manual, no doubt, will help students and doctors to study this section, and also increases the effectiveness of teaching.

In one year, more than 15 million central venous catheters are installed in the world. Among the venous tributaries available for puncture, the subclavian vein is most often catheterized. In this case, various methods are used. The clinical anatomy of the subclavian vein, accesses, as well as the technique of puncture and catheterization of this vein are not fully described in various textbooks and manuals, which is associated with the use of various techniques for this manipulation. All this creates difficulties for students and doctors in studying this issue. The proposed manual will facilitate the assimilation of the studied material through a consistent systematic approach and should contribute to the formation of strong professional knowledge and practical skills. The manual is written at a high methodological level, corresponds to a typical curriculum and can be recommended as a guide for students and doctors in the study of puncture and catheterization of the subclavian vein.

Percutaneous puncture and catheterization of the subclavian vein is an effective, but not safe manipulation, and therefore only a specially trained doctor with certain practical skills can be allowed to perform it. In addition, it is necessary to familiarize nursing staff with the rules for using and caring for catheters in the subclavian vein.

Sometimes, when all the requirements for puncture and catheterization of the subclavian vein are met, there may be repeated unsuccessful attempts to catheterize the vessel. At the same time, it is very useful to “change hands” - to ask another doctor to perform this manipulation. This in no way discredits the doctor who unsuccessfully performed the puncture, but, on the contrary, will exalt him in the eyes of his colleagues, since excessive perseverance and "stubbornness" in this matter can cause significant harm to the patient.

The first puncture of the subclavian vein was performed in 1952 by Aubaniac. He described the technique of puncture from the subclavian access. Wilson et al. in 1962, a subclavian access was used to catheterize the subclavian vein, and through it, the superior vena cava. Since that time, percutaneous catheterization of the subclavian vein has been widely used for diagnostic studies and treatment. Yoffa in 1965 introduced into clinical practice the supraclavicular approach for inserting a catheter into the central veins through the subclavian vein. Subsequently, various modifications of the supraclavicular and subclavian approaches were proposed in order to increase the likelihood of successful catheterization and reduce the risk of complications. Thus, at present, the subclavian vein is considered a convenient vessel for central venous catheterization.

Clinical anatomy of the subclavian vein

subclavian vein(Fig.1,2) is a direct continuation of the axillary vein, passing into the latter at the level of the lower edge of the first rib. Here it goes around the top of the first rib and lies between the posterior surface of the clavicle and the anterior edge of the anterior scalene muscle, located in the prescalene gap. The latter is a frontally located triangular gap, which is bounded behind by the anterior scalene muscle, in front and inside by the sternohyoid and sternothyroid muscles, in front and outside by the sternocleidomastoid muscle. The subclavian vein is located in the lowest part of the gap. Here it approaches the posterior surface of the sternoclavicular joint, merges with the internal jugular vein and forms with it the brachiocephalic vein. The fusion site is designated as Pirogov's venous angle, which is projected between the lateral edge of the lower part of the sternocleidomastoid muscle and the upper edge of the clavicle. Some authors (I.F. Matyushin, 1982) distinguish the clavicular region when describing the topographic anatomy of the subclavian vein. The latter is limited: above and below - by lines running 3 cm above and below the clavicle and parallel to it; outside - the front edge of the trapezius muscle, the acromioclavicular joint, the inner edge of the deltoid muscle; from the inside - by the inner edge of the sternocleidomastoid muscle until it intersects at the top - with the upper border, at the bottom - with the lower one. Behind the clavicle, the subclavian vein is first located on the first rib, which separates it from the dome of the pleura. Here the vein lies posterior to the clavicle, in front of the anterior scalene muscle (the phrenic nerve passes along the anterior surface of the muscle), which separates the subclavian vein from the artery of the same name. The latter, in turn, separates the vein from the trunks of the brachial plexus, which lie above and behind the artery. In newborns, the subclavian vein is at a distance of 3 mm from the artery of the same name, in children under 5 years old - 7 mm, in children over 5 years old - 12 mm, etc. Located above the dome of the pleura, the subclavian vein sometimes covers with its edge the artery of the same name by half its diameter.

The subclavian vein is projected along a line drawn through two points: the upper point is 3 cm downward from the upper edge of the sternal end of the clavicle, the lower one is 2.5-3 cm medially from the coracoid process of the scapula. In newborns and children under 5 years of age, the subclavian vein is projected to the middle of the clavicle, and at an older age, the projection shifts to the border between the inner and middle thirds of the clavicle.

The angle formed by the subclavian vein with the lower edge of the clavicle in newborns is equal to degrees, in children under 5 years old - 140 degrees, and at an older age - degrees. The diameter of the subclavian vein in newborns is 3-5 mm, in children under 5 years old - 3-7 mm, in children over 5 years old - 6-11 mm, in adults - mm in the final section of the vessel.

The subclavian vein runs in an oblique direction: from bottom to top, from the outside inwards. It does not change with the movements of the upper limb, since the walls of the vein are connected to the deep sheet of the own fascia of the neck (the third fascia according to the classification of V.N. Shevkunenko, the scapular-clavicular aponeurosis of Richet) and are closely connected with the periosteum of the clavicle and the first rib, as well as with fascia of the subclavian muscles and the clavicular-thoracic fascia.

Figure 1 Veins of the neck; on the right (according to V.P. Vorobyov)

1 - right subclavian vein; 2 - right internal jugular vein; 3 - right brachiocephalic vein; 4 - left brachiocephalic vein; 5 - superior vena cava; 6 - anterior jugular vein; 7 - jugular venous arch; 8 - external jugular vein; 9 - transverse vein of the neck; 10 - right subclavian artery; 11 - anterior scalene muscle; 12 - posterior scalene muscle; 13 - sternocleidomastoid muscle; 14 - clavicle; 15 - the first rib; 16 - handle of the sternum.

Figure 2. Clinical anatomy of the superior vena cava system; front view (according to V.P. Vorobyov)

1 - right subclavian vein; 2 - left subclavian vein; 3 - right internal jugular vein; 4 - right brachiocephalic vein; 5 - left brachiocephalic vein; 6 - superior vena cava; 7 - anterior jugular vein; 8 - jugular venous arch; 9 - external jugular vein; 10 - unpaired thyroid venous plexus; 11 - internal thoracic vein; 12 - the lowest thyroid veins; 13 - right subclavian artery; 14 - aortic arch; 15 - anterior scalene muscle; 16 - brachial plexus; 17 - clavicle; 18 - the first rib; 19 - borders of the manubrium of the sternum.

The length of the subclavian vein from the upper edge of the corresponding pectoralis minor muscle to the outer edge of the venous angle with the upper limb retracted is in the range of 3 to 6 cm. cervical, vertebral. In addition, the thoracic (left) or jugular (right) lymphatic ducts can flow into the final section of the subclavian vein.

Topographic-anatomical and physiological substantiation of the choice of the subclavian vein for catheterization

1. Anatomical accessibility. The subclavian vein is located in the prescalene space, separated from the artery of the same name and the trunks of the brachial plexus by the anterior scalene muscle.
2. Stability of the position and diameter of the lumen. As a result of fusion of the subclavian vein sheath with a deep leaf of the own fascia of the neck, the periosteum of the first rib and the clavicle, the clavicular-thoracic fascia, the lumen of the vein remains constant and it does not collapse even with the most severe hemorrhagic shock.
3. Significant(sufficient) vein diameter.
4. High blood flow rate(compared to limb veins)

Based on the foregoing, the catheter placed in the vein almost does not touch its walls, and the fluids injected through it quickly reach the right atrium and right ventricle, which contributes to an active effect on hemodynamics and, in some cases (during resuscitation), even allows you not to use intra-arterial drug injection. Hypertonic solutions injected into the subclavian vein quickly mix with blood without irritating the intima of the vein, which makes it possible to increase the volume and duration of infusion with the correct placement of the catheter and appropriate care for it. Patients can be transported without the risk of damage to the endothelium of the vein by the catheter, they can begin early motor activity.

Indications for catheterization of the subclavian vein

1. Inefficiency and impossibility of infusion into peripheral veins (including during venesection):

a) due to severe hemorrhagic shock, leading to a sharp drop in both arterial and venous pressure (peripheral veins collapse and infusion into them is ineffective);

b) with a network-like structure, lack of expression and deep occurrence of superficial veins.

2. The need for long-term and intensive infusion therapy:

a) in order to replenish blood loss and restore fluid balance;

b) due to the risk of thrombosis of peripheral venous trunks with:

Prolonged stay in the vessel of needles and catheters (damage to the endothelium of the veins);

The need for the introduction of hypertonic solutions (irritation of the intima of the veins).

3. The need for diagnostic and control studies:

a) determination and subsequent monitoring in dynamics of the central venous pressure, which allows you to establish:

Rate and volume of infusions;

Early diagnosis of heart failure

b) probing and contrasting the cavities of the heart and great vessels;

c) repeated blood sampling for laboratory research.

4. Electrocardiostimulation by transvenous way.

5. Carrying out extracorporeal detoxification by methods of blood surgery - hemosorption, hemodialysis, plasmapheresis, etc.

Contraindications for catheterization of the subclavian vein

1. Syndrome of the superior vena cava.
2. Paget-Schretter Syndrome.
3. Severe disorders of the blood coagulation system.
4. Wounds, abscesses, infected burns in the area of ​​puncture and catheterization (danger of generalization of infection and development of sepsis).
5. Clavicle injury.
6. Bilateral pneumothorax.
7. Severe respiratory failure with emphysema.

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

Medications and preparations:

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

Laying of sterile instruments and materials:

1. syringeml - 2;
2. injection needles (subcutaneous, intramuscular);
3. needle for puncture vein catheterization;
4. intravenous catheter with cannula and plug;
5. a guide line 50 cm long and with a thickness corresponding to the diameter of the inner lumen of the catheter;
6. general surgical instruments;
7. suture material.

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

Puncture catheterization of the subclavian vein should be performed in a procedure 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, 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, 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 is started.

1. Local infiltration anesthesia.
2. General anesthesia:

a) inhalation anesthesia - usually in children;

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

Various points for percutaneous puncture of the subclavian vein have been proposed (Aubaniac, 1952; Wilson, 1962; Yoffa, 1965 et al.). However, the conducted topographic and anatomical studies make it possible to single out not individual points, but entire zones within which it is possible to puncture a vein. This expands the 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 are: 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 injected 0.5-0.8 cm up from the upper edge of the clavicle. When puncturing, the needle is directed at an angle of degrees with respect to the collarbone and at an angle of degrees with respect to the anterior surface of the neck (to the frontal plane). Most often, the needle injection site is the Yoffe point, which is located in the angle between the lateral edge of the clavicular pedicle of the sternocleidomastoid muscle and the upper edge of the clavicle (Fig. 4).

Supraclavicular access 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 sheet of the own fascia of the neck, the deep sheet of the own fascia of the neck, the loose fiber layer surrounding the vein, as well as the prevertebral fascia involved 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.

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

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

Subclavian zone(Fig. 3) 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 - a vertical descending 2 cm down from point No. 1; medially - a vertical descending 1 cm down from point No. 2; bottom - a line connecting the lower ends of the verticals. Therefore, when puncturing a vein from the subclavian access, the needle injection site can be placed within the borders of an irregular quadrangle.

Figure 3. Subclavian zone:

The angle of inclination of the needle in relation to the clavicle - degrees, in relation to the surface of the body (to the frontal plane - degrees). The general guideline for puncture is the posterior superior point of the sternoclavicular joint. When puncturing a vein with subclavian access, the following points are most often used (Fig. 4):

• Aubanyac's point, located 1 cm below the clavicle on the border of its medial and middle thirds;
• Wilson's point, located 1 cm below the middle of the clavicle;
• Giles point, located 1 cm below the clavicle and 2 cm outward from the sternum.

Figure 4. Points used to puncture the subclavian vein.

1 – Yoffe point; 2 – Aubanyac point;

3 – Wilson point; 4 - Giles point.

With subclavian access, the distance from the skin to the vein is greater than with supraclavicular, and the needle must pass through the skin with subcutaneous tissue and superficial fascia, pectoral fascia, pectoralis major muscle, loose tissue, clavicular-thoracic fascia (Gruber), a 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, the puncture of the subclavian vein from the subclavian access is more justified topographically and anatomically, since:

1. large venous branches, thoracic (left) or jugular (right) lymphatic ducts flow into the upper semicircle of the subclavian vein;
2. 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;
3. fixing the catheter and aseptic dressing in the subclavian region is much easier than in the supraclavicular region, there are fewer conditions for the development of infection.

All this has led to the fact that in clinical practice the puncture of the subclavian vein is more often performed from the subclavian access. At the same time, in obese patients, preference should be given to the access that allows the most clear definition of anatomical landmarks.

The technique of percutaneous puncture and catheterization of the subclavian vein according to the Seldinger method from the subclavian access

The success of puncture and catheterization of the subclavian vein is largely due to compliance with all requirements for this operation. Of particular importance is correct positioning of the patient.

The position of the patient horizontal with a roller placed under the shoulder girdle (“under the shoulder blades”), height cm. The head end of the table is lowered with awards (Trendelenburg position). The upper limb on the side of the puncture is brought to the body, the shoulder girdle is lowered (with the assistant pulling the upper limb down), the head is turned in the opposite direction by 90 degrees. In the case of a serious condition of the patient, it is possible to perform a puncture in a semi-sitting position and without placing a roller.

Physician position- standing on the side of the puncture.

Preferred Side: right, since the thoracic or jugular lymphatic ducts can flow into the final section of the left subclavian vein. In addition, when performing pacing, probing and contrasting the heart cavities, when it becomes necessary to advance the catheter into the superior vena cava, this is easier to do on the right, since the right brachiocephalic vein is shorter than the left one and its direction approaches vertical, while the direction of the left brachiocephalic vein is closer to horizontal.

After treating the hands and the corresponding half of the anterior neck and subclavian region with an antiseptic and limiting the surgical field with a cutting diaper or napkins (see the section “Basic equipment and organization of puncture catheterization of the central veins”), anesthesia is performed (see the section “Pain relief”).

The principle of central venous catheterization was laid down by Seldinger (1953).

The puncture is carried out with a special needle from the central vein catheterization kit, attached to a syringe with a 0.25% novocaine solution. For conscious patients, show the subclavian vein puncture needle highly undesirable , as this is a powerful stress factor (needle 15 cm long or more with sufficient thickness). When a needle is punctured into the skin, there is significant resistance. This moment is the most painful. Therefore, it must be carried out as quickly as possible. This is achieved by limiting the depth of needle insertion. The doctor performing the manipulation limits the needle with a finger at a distance of 0.5-1 cm from its tip. This prevents the needle from penetrating the tissue deeply and uncontrollably when a significant amount of force is applied during the puncture of the skin. The lumen of the puncture needle is often clogged with tissues when the skin is punctured. Therefore, immediately after the needle passes through the skin, it is necessary to restore its patency by releasing a small amount of novocaine solution. The needle is injected 1 cm below the clavicle at the border of its medial and middle thirds (Aubanyac's point). The needle should be directed to the posterior superior edge of the sternoclavicular joint or, according to V.N. Rodionov (1996), in the middle of the width of the clavicular pedicle of the sternocleidomastoid muscle, that is, somewhat lateral. This direction remains beneficial even with a different position of the clavicle. As a result, the vessel is punctured in the region of Pirogov's venous angle. The advance of the needle should be preceded by a stream of novocaine. After the needle pierces the subclavian muscle (feeling of failure), the piston should be pulled towards itself, moving the needle in a given direction (you can create a vacuum in the syringe only after releasing a small amount of novocaine solution to prevent clogging of the needle lumen with tissues). After entering the vein, a trickle of dark blood appears in the syringe, and further the needle should not be advanced into the vessel because of the possibility of damage to the opposite wall of the vessel with the subsequent exit of the conductor there. If the patient is conscious, he should be asked to hold his breath while inhaling (prevention of air embolism) and through the lumen of the needle removed from the syringe, insert the line conductor to a depth of cm, after which the needle is removed, while the conductor adheres and remains in the vein. Then the catheter is advanced along the conductor with rotational movements clockwise to the previously indicated depth. In each case, the principle of choosing a catheter of the largest possible diameter (for adults, the inner diameter is 1.4 mm) must be observed. After that, the guidewire is removed, and a heparin solution is introduced into the catheter (see the section “care of the catheter”) and a cannula-stub is inserted. To avoid air embolism, the lumen of the catheter during all manipulations should be covered with a finger. If the puncture is not successful, it is necessary to withdraw the needle into the subcutaneous tissue and move it forward in the other direction (changes in the direction of the needle during the puncture lead to additional tissue damage). The catheter is fixed to the skin in one of the following ways:

1. a strip of a bactericidal patch with two longitudinal slots is glued to the skin around the catheter, after which the catheter is carefully fixed with a middle strip of adhesive tape;
2. to ensure reliable fixation of the catheter, some authors recommend suturing it to the skin. To do this, in the immediate vicinity of the exit site of the catheter, the skin is stitched with a ligature. The first double knot of the ligature is tied on the skin, the catheter is fixed to the skin suture with the second, the third knot is tied along the ligature at the level of the cannula, and the fourth knot is around the cannula, which prevents the catheter from moving along the axis.

The technique of percutaneous puncture and catheterization of the subclavian vein according to the Seldinger method from the supraclavicular approach

Patient position: horizontal, under the shoulder girdle (“under the shoulder blades”), the roller can not be placed. The head end of the table is lowered with awards (Trendelenburg position). The upper limb on the side of the puncture is brought to the body, the shoulder girdle is lowered, with the assistant pulling the upper limb down, the head is turned 90 degrees in the opposite direction. In the case of a serious condition of the patient, it is possible to perform a puncture in a semi-sitting position.

Physician position- standing on the side of the puncture.

Preferred Side: right (justification - see above).

The needle is injected at the Yoffe point, which is located in the angle between the lateral edge of the clavicular pedicle of the sternocleidomastoid muscle and the upper edge of the clavicle. The needle is directed at an angle of degrees relative to the collarbone and degrees relative to the anterior surface of the neck. During the passage of the needle in the syringe, a slight vacuum is created. Usually it is possible to get into a vein at a distance of 1-1.5 cm from the skin. Through the lumen of the needle, a guidewire is inserted to a depth of cm, after which the needle is removed, while the guidewire adheres and remains in the vein. Then the catheter is advanced along the conductor with screwing movements to the previously indicated depth. If the catheter does not pass freely into the vein, its rotation around its axis can help advance (carefully). After that, the conductor is removed, and a plug cannula is inserted into the catheter.

The photo shows the main landmarks used to select the puncture point - the sternocleidomastoid muscle, its sternal and clavicular pedicles, external jugular vein, clavicle and jugular notch. The most commonly used puncture point is shown, which is located at the intersection of the lateral edge of the clavicular pedicle of the sternocleidomastoid muscle and the clavicle (red mark). As a rule, alternative puncture points are located in the interval between the intersection of the outer edge of the clavicular head of the sternocleidomastoid muscle with the clavicle and the intersection of the external jugular vein with the clavicle. It is also reported that a puncture is performed from a point 1-2 cm above the edge of the clavicle. The vein runs under the clavicle, around the first rib, descends into the chest, where it joins the ipsilateral internal jugular vein at approximately the level of the sternoclavicular joint.

An exploratory puncture is performed with an intramuscular needle in order to localize the location of the vein with minimal risk of damaging light or massive bleeding if the artery is inadvertently punctured. The needle is placed at the puncture point in a plane parallel to the floor, the direction is caudal. After that, the syringe is deflected laterally with awards, while the needle is directed towards the sternum, then the syringe is tilted downwards at approximately awards, i.e. the needle should go under the collarbone, sliding along its inner surface.

The needle is smoothly guided in the selected direction, while the vacuum is maintained in the syringe. The picture schematically continues the movement of the needle (blue arrow), as you can see, its direction approximately indicates the sternoclavicular joint, which is recommended to be used as a guide for the primary search puncture. As a rule, the vein is located at a distance of 1-3 cm from the skin. If, after passing the search needle along the very pavilion, you did not manage to find a vein, also smoothly withdraw it back, not forgetting to maintain a vacuum in the syringe, because. the needle may have passed through two walls of the vein, in which case you will receive blood in the syringe on reverse traction.

Having received blood in the syringe, evaluate its color, in case of doubt that the blood is venous, you can try to carefully disconnect the syringe while holding the needle in place to assess the nature of the outflow of blood (obvious pulsation, of course, indicates an arterial puncture). After making sure that you have found a vein, you can remove the search needle, remembering the direction of the puncture, or leave it in place, slightly pulling it back so that the needle leaves the vein.

If it is impossible to determine the vein during puncture in the selected direction, you can try other options for puncture from the same point. I recommend reducing the lateral angle of the needle and pointing it slightly below the sternoclavicular joint. The next step is to reduce the angle of deviation from the horizontal plane. In third place among alternative methods, I put an attempt to puncture from another point located laterally from the angle of intersection of the clavicular head of the sternocleidomastoid muscle with the upper edge of the clavicle. In this case, the needle should also be directed primarily towards the sternoclavicular joint.

The puncture of the vein with a needle from the set is performed in the direction determined during the search puncture. In terms of reducing the risk of pneumothorax, it is recommended to advance the syringe with the needle between breaths, which is true for both spontaneous breathing and mechanical ventilation in mechanically ventilated patients. Needless to mention further the maintenance of vacuum in the syringe and the possibility of being in a vein when the syringe is retracted.

Having received the blood in the syringe, evaluate its color, in case of doubt that the blood is venous, you can try to carefully disconnect the syringe while holding the needle in place in order to assess the nature of the outflow of blood (a pulsation of scarlet blood, of course, indicates an arterial puncture). Sometimes, with high central venous pressure, blood can flow from the needle with a characteristic pulsation, which can be misleading and force the doctor to repeat punctures with an increased risk of puncture complications. Sufficient specificity in relation to the verification of being in a vein has a technique for recording blood pressure in a needle, for the application of which a sterile line is required, the corresponding end of which is extended to an assistant, who will connect it to a pressure sensor and fill it with a solution. The absence of an arterial pressure curve and a characteristic curve for venous pressure are indicative of venous entry.

Once you are sure you have found the vein, remove the syringe while holding the needle in place. Try to rest your hand on some immovable structure (collarbone) in order to minimize the risk of needle migration from the lumen of the vein due to microtremor of the fingers at the moment when you take the guidewire. The guidewire should be placed in close proximity to you, so that you do not have to bend and reach in an attempt to get it, as this most often loses concentration on still holding the needle and it leaves the lumen of the vein.

The conductor should not encounter significant resistance during insertion, sometimes you can feel the characteristic friction of the corrugated surface of the conductor on the edge of the cut of the needle if it exits at a large angle. If you feel resistance, do not try to pull out the conductor, you can try to rotate it and if it rests against the wall of the vein, it may slip further. When the conductor is pulled back, it can catch on the edge of the cut with a braid and, at best, “get tattered”, in the worst case, the conductor will be cut off and you will get problems incommensurable with the convenience of checking the position of the needle without removing it, but removing the conductor. Thus, with resistance, remove the needle with the conductor and try again, already knowing where the vein passes. The conductor is inserted into the needle no further than the second mark (from the needle pavilion) or sm to prevent it from entering the atrial cavity and flotation there, which can provoke arrhythmias.

A dilator is inserted along the conductor. Try to take the dilator with your fingers closer to the skin in order to avoid bending the conductor and additional tissue injury, and even a vein. There is no need to insert the dilator right up to the pavilion, it is enough to create a tunnel in the skin and subcutaneous tissue without penetrating into the lumen of the vein. After removing the dilator, it is necessary to press the puncture site with your finger, because. from there, a copious flow of blood is possible.

The catheter is inserted to a depth cm. After the introduction of the catheter, its position in the vein is traditionally verified by blood aspiration, free outflow of blood indicates that the catheter is in the lumen of the vein.

The technique of percutaneous puncture and catheterization of the subclavian vein according to the principle of "catheter through catheter"

Puncture and catheterization of the subclavian vein can be carried out not only according to the Seldinger principle (“catheter through the conductor”), but also according to the principle “catheter through the catheter”. The latest technique has become possible thanks to new technologies in medicine. The puncture of the subclavian vein is carried out using a special plastic cannula (external catheter), put on a needle for catheterization of the central veins, which serves as a puncturing stylet. In this technique, the atraumaticity of the transition from the needle to the cannula is extremely important, and, as a result, there is little resistance to passing the catheter through the tissues and, in particular, through the wall of the subclavian vein. After the cannula with the stylet needle has entered the vein, the syringe is removed from the needle pavilion, the cannula (outer catheter) is held, and the needle is removed. A special internal catheter with a mandrel is passed through the external catheter to the desired depth. The thickness of the inner catheter corresponds to the diameter of the lumen of the outer catheter. The pavilion of the external catheter is connected with the help of a special clamp to the pavilion of the internal catheter. The mandrin is extracted from the latter. A sealed lid is put on the pavilion. The catheter is fixed to the skin.

The use of ultrasound guidance has been promoted as a method to reduce the risk of complications during central venous catheterization. According to this technique, an ultrasound test is used to localize the vein and measure the depth of its location under the skin. Then, under the control of ultrasound imaging, the needle is passed through the tissue into the vessel. Ultrasound guidance during internal jugular vein catheterization reduces the number of mechanical complications, the number of catheter insertion failures, and the time required for catheterization. The fixed anatomical connection of the subclavian vein to the clavicle makes ultrasound-guided catheterization more difficult than catheterization based on external landmarks. As with all new techniques, ultrasound-guided catheterization requires practice. If ultrasound equipment is available in the hospital and clinicians are adequately trained, ultrasound guidance should usually be considered.

Requirements for catheter care

Before each introduction of a medicinal substance into the catheter, it is necessary to obtain free blood flow from it with a syringe. If this fails, and fluid is freely introduced into the catheter, this may be due to:

• with the exit of the catheter from the vein;
• with the presence of a hanging thrombus, which, when trying to get blood from the catheter, acts as a valve (rarely observed);
• so that the cut of the catheter rests against the wall of the vein.

It is impossible to infuse into such a catheter. It is necessary first to slightly tighten it and again try to get blood from it. If this fails, then the catheter must be unconditionally removed (danger of paravenous insertion or thromboembolism). Remove the catheter from the vein very slowly, creating negative pressure in the catheter with a syringe. In this way, it is sometimes possible to extract a hanging thrombus from a vein. In this situation, it is strictly unacceptable to remove the catheter from the vein with quick movements, as this can cause thromboembolism.

To avoid thrombosis of the catheter after diagnostic blood sampling and after each infusion, immediately rinse it with any infused solution and be sure to inject an anticoagulant (0.2-0.4 ml) into it. The formation of blood clots can be observed with a strong cough of the patient due to the reflux of blood into the catheter. More often it is noted against the background of slow infusion. In such cases, heparin must be added to the transfused solution. If the liquid was administered in a limited amount and there was no constant infusion of the solution, the so-called heparin lock ("heparin plug") can be used: after the end of the infusion, 2000 - 3000 IU (0.2 - 0.3 ml) of heparin in 2 ml are injected into the catheter physiological saline and it is closed with a special stopper or plug. Thus, it is possible to keep the vascular fistula for a long time. The stay of the catheter in the central vein provides for careful skin care at the puncture site (daily antiseptic treatment of the puncture site and daily change of aseptic dressing). The duration of the catheter stay in the subclavian vein, according to different authors, ranges from 5 to 60 days and should be determined by therapeutic indications, and not by preventive measures (V.N. Rodionov, 1996).

Ointments, subcutaneous cuffs and dressings. Applying an antibiotic ointment (eg, Bazithramycin, Mupirocin, Neomycin, or Polymyxin) to the site of the catheter increases the incidence of fungal colonization of the catheter, promotes the activation of antibiotic-resistant bacteria, and does not reduce the number of catheter infections involving the bloodstream. Such ointments should not be used. The use of silver-impregnated hypodermic cuffs also does not reduce catheter infections involving the bloodstream and is therefore not recommended. Because data on the optimal type of dressing (gauze vs. transparent materials) and the optimal dressing frequency are conflicting.

Sleeves and systems for needleless injections. Catheter plugs are a common source of contamination, especially during prolonged catheterization. The use of two types of antiseptic-treated plugs has been shown to reduce the risk of catheter infections involving the bloodstream. In some hospitals, the introduction of needle-free systems has been associated with an increase in these infections. This increase was due to non-compliance with the manufacturer's requirement to change the plug after each injection and the entire system for needleless injection every 3 days, due to the fact that more frequent change of the plug was required before the frequency of catheter infections involving the bloodstream returned to baseline.

Change of catheter. Because the risk of catheter infection increases over time, each catheter should be removed as soon as it is no longer needed. In the first 5–7 days of catheterization, the risk of catheter colonization and catheter infections involving the bloodstream is low, but then begins to increase. Multiple studies have investigated strategies to reduce catheter infections, including catheter repositioning with a guidewire, and planned routine catheter repositioning at a new site. However, none of these strategies has been shown to reduce catheter infections involving the bloodstream. In fact, the planned routine replacement of the catheter over the guidewire was accompanied by a trend towards an increase in the number of catheter infections. In addition, placement of a new catheter in a new site was more frequent if the patient had mechanical complications during catheterization. A meta-analysis of results from 12 studies of catheter replacement strategies showed that the evidence does not support either guidewire catheter repositioning or planned routine catheter repositioning at a new site. Accordingly, the central venous catheter should not be repositioned without reason.

1. Wound of the subclavian artery. This is detected by a pulsating stream of scarlet blood entering the syringe. The needle is removed, the puncture site is pressed for 5-8 minutes. Usually, an erroneous puncture of the artery in the future is not accompanied by any complications. However, the formation of a hematoma in the anterior mediastinum is possible.
2. Puncture of the dome of the pleura and the apex of the lung with the development of pneumothorax. An unconditional sign of a lung injury is the appearance of subcutaneous emphysema. The likelihood of complications with pneumothorax is increased with various deformities of the chest and with shortness of breath with deep breathing. In these cases, pneumothorax is the most dangerous. At the same time, damage to the subclavian vein with the development of hemopneumothorax is possible. This usually happens with repeated unsuccessful attempts at puncture and gross manipulations. The cause of hemothorax can also be perforation of the wall of the vein and the parietal pleura with a very rigid conductor for the catheter. The use of such conductors shall be prohibited.. The development of hemothorax may also be associated with damage to the subclavian artery. In such cases, hemothorax is significant. When puncturing the left subclavian vein in case of damage to the thoracic lymphatic duct and pleura, chylothorax may develop. The latter can be manifested by abundant external lymphatic leakage along the catheter wall. There is a complication of hydrothorax as a result of the installation of a catheter into the pleural cavity, followed by the transfusion of various solutions. In this situation, after the catheterization of the subclavian vein, it is necessary to perform a control chest x-ray in order to exclude these complications. 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, with difficult catheterization, and even more so with accidental lung puncture, it is necessary to purposefully exclude the presence of these complications not only immediately after the puncture, but also during the next day (frequent auscultation of the lungs in dynamics, X-ray control, etc.).
3. Excessively deep insertion of the conductor and catheter may damage the walls of the right atrium, as well as the tricuspid valve with severe cardiac disorders, the formation of parietal thrombi, which can serve as a source of embolism. Some authors observed a spherical thrombus that filled the entire cavity of the right ventricle. This is more common with rigid polyethylene guidewires and catheters. Their application should be prohibited. Excessively elastic conductors are recommended to be boiled for a long time before use: this reduces the rigidity of the material. If it is not possible to select a suitable conductor, and the standard conductor is very rigid, some authors recommend performing the following technique - the distal end of the polyethylene conductor is first slightly bent so that an obtuse angle is formed. Such a conductor is often much easier to pass into the lumen of the vein without injuring its walls.
4. Embolism with guidewire and catheter. Embolism with a conductor occurs due to the cutting of the conductor by the edge of the needle tip when the conductor deeply inserted into the needle is quickly pulled towards itself. Catheter embolism is possible when the catheter is accidentally cut and slips into the vein while cutting the long ends of the fixing thread with scissors or a scalpel or when removing the thread fixing the catheter. It is impossible to remove the conductor from the needle. If necessary, remove the needle together with the guidewire.
5. Air embolism. In the subclavian vein and the superior vena cava, pressure can normally be negative. Causes of embolism: 1) suction of air into the vein during breathing through the open pavilions of the needle or catheter (this danger is most likely with severe shortness of breath with deep breaths, with puncture and catheterization of the vein in the patient's sitting position or with the body elevated); 2) unreliable connection of the catheter pavilion with a nozzle for needles of transfusion systems (non-tightness or not noticed their separation during breathing, accompanied by air being sucked into the catheter); 3) accidental tearing of the plug from the catheter with simultaneous inspiration. To prevent air embolism during puncture, the needle should be connected to the syringe, and the introduction of the catheter into the vein, disconnecting the syringe from the needle, opening the catheter pavilion should be done during apnea (holding the patient's breath on inspiration) or in the Trendelenburg position. Prevents air embolism by closing the open pavilion of the needle or catheter with a finger. During mechanical ventilation, prevention of air embolism is provided by ventilation of the lungs with increased volumes of air with the creation of positive pressure at the end of exhalation. When carrying out infusion into a venous catheter, constant careful monitoring of the tightness of the connection between the catheter and the transfusion system is necessary.
6. Injury to the brachial plexus and organs of the neck(rarely seen). These injuries occur when the needle is deeply inserted with the wrong direction of injection, with a large number of attempts to puncture the vein in different directions. This is especially dangerous when changing the direction of the needle after it is deeply inserted into the tissue. In this case, the sharp end of the needle injures the tissues like a car windshield wiper. To exclude this complication, after an unsuccessful attempt to puncture the vein, the needle must be completely removed from the tissues, the angle of its introduction in relation to the clavicle of the awards should be changed, and only after that the puncture should be performed. In this case, the point of injection of the needle does not change. If the conductor does not pass through the needle, it is necessary to make sure that the needle is in the vein with a syringe, and again, pulling the needle slightly towards you, try to insert the conductor without violence. The conductor must pass completely freely into the vein.
7. Soft tissue inflammation at the puncture site and intracatheter infection is a rare complication. It is necessary to remove the catheter and more strictly observe the requirements of asepsis and antisepsis when performing a puncture.
8. Phlebothrombosis and thrombophlebitis of the subclavian vein. It is extremely rare, even with prolonged (several months) administration of solutions. The frequency of these complications is reduced if high-quality non-thrombogenic catheters are used. Reduces the frequency of phlebothrombosis regular flushing of the catheter with an anticoagulant, not only after infusions, but also in long breaks between them. With rare transfusions, the catheter is easily clogged with clotted blood. In such cases, it is necessary to decide whether it is advisable to keep the catheter in the subclavian vein. If signs of thrombophlebitis appear, the catheter should be removed, appropriate therapy is prescribed.
9. disposition of the catheter. It consists in the exit of the conductor, and then the catheter from the subclavian vein to the jugular (internal or external). If a disposition of the catheter is suspected, X-ray control is performed.
10. Catheter obstruction. This may be due to blood clotting in the catheter and its thrombosis. If a thrombus is suspected, the catheter should be removed. A gross mistake is to force a thrombus into a vein by “flushing” the catheter by introducing liquid under pressure into it or by cleaning the catheter with a conductor. Obstruction may also be due to the fact that the catheter is bent or rests with its end against the wall of the vein. In these cases, a slight change in the position of the catheter allows you to restore its patency. Catheters installed in the subclavian vein must have a transverse cut at the end. It is unacceptable to use catheters with oblique cuts and with side holes at the distal end. In such cases, there is a zone of the lumen of the catheter without anticoagulants, on which hanging blood clots form. Strict adherence to the rules for caring for the catheter is necessary (see the section "Requirements for caring for the catheter").
11. Paravenous administration of infusion-transfusion media and other medicinal products. The most dangerous is the introduction of irritating liquids (calcium chloride, hyperosmolar solutions, etc.) into the mediastinum. Prevention consists in the obligatory observance of the rules for working with a venous catheter.

Algorithm for the management of patients with catheter-associated bloodstream infections (CAIC)

AMP - antimicrobials

Algorithm for managing patients with bacteremia or fungemia.

AMP - antimicrobials

"Antibacterial lock" - the introduction of small volumes of a solution of antibiotics in high concentration into the lumen of the CVC of the catterer, followed by exposure for several hours (for example, 8-12 hours at night when the CVC is not used). As a "lock" can be used: Vancomycin at a concentration of 1-5 mg / ml; Gentamimin or Amikocin at a concentration of 1-2 mg / ml; Ciprofoloxacin at a concentration of 1-2 mg / ml. Antibiotics are dissolved in 2-5 ml of isotonic NaCl with the addition of Heparin ED. Before subsequent use, the Antibacterial Castle CVC is removed.

Features of puncture and catheterization of the subclavian vein in children

1. Puncture and catheterization must be performed under conditions of perfect anesthesia, ensuring the absence of motor reactions in the child.
2. During the puncture and catheterization of the subclavian vein, the child's body must be given the Trendelenburg position with a high roller under the shoulder blades; the head leans back and turns in the direction opposite to the punctured one.
3. Change of aseptic dressing and treatment of the skin around the injection site should be done daily and after each procedure.
4. In children under 1 year of age, it is more expedient to puncture the subclavian vein from the subclavian access at the level of the middle third of the clavicle (Wilson's point), and at an older age, closer to the border between the inner and middle thirds of the clavicle (Aubanyac's point).
5. The puncture needle should not have a diameter of more than 1-1.5 mm, and a length of more than 4-7 cm.
6. Puncture and catheterization should be performed as atraumatically as possible. When performing a puncture, a syringe with a solution (0.25% novocaine solution) must be put on the needle to prevent air embolism.
7. In newborns and children of the first years of life, blood often appears in the syringe during the slow removal of the needle (with simultaneous aspiration), since the puncture needle, especially not sharpened, easily pierces the anterior and posterior walls of the vein due to the elasticity of the child's tissues. In this case, the tip of the needle may be in the lumen of the vein only when it is removed.
8. Conductors for catheters should not be rigid, they must be inserted into the vein very carefully.
9. With a deep introduction of the catheter, it can easily get into the right parts of the heart, into the internal jugular vein, both on the side of the puncture and on the opposite side. If there is any suspicion of an incorrect position of the catheter in the vein, an X-ray control should be carried out (2-3 ml of a radiopaque substance is injected into the catheter and a picture is taken in the anterior-posterior projection). The following depth of catheter insertion is recommended as optimal:

• premature newborns - 1.5-2.0 cm;
• full-term newborns - 2.0-2.5 cm;
• infants - 2.0-3.0 cm;
• children aged 1-7 years - 2.5-4.0 cm;
• children aged 7-14 years - 3.5-6.0 cm.

Features of puncture and catheterization of the subclavian vein in the elderly

In elderly people, after puncture of the subclavian vein and passage of a conductor through it, the introduction of a catheter through it often encounters significant difficulties. This is due to age-related changes in tissues: low elasticity, reduced skin turgor and sagging of deeper tissues. At the same time, the probability of success of the catheter is increased when it is wetting(physiological solution, novocaine solution), as a result of which the friction of the catheter decreases. Some authors recommend cutting the distal end of the catheter at an acute angle to eliminate resistance.

Bladder catheterization is a procedure to drain the bladder. Catheterization is performed if it is necessary to solve the following tasks:

Urine sampling directly from the bladder, which allows you to obtain accurate data for performing various types of urinalysis.

The introduction of drugs directly into the bladder, its emptying in case of congestion and blockage of the urinary canal, as well as washing the urethra and bladder, removing sand.

Simplifies the care of immobilized patients.

The catheter can be installed in patients of both sexes and any age category, both during operations and for a longer period.

Types of catheters used in the procedure

All devices differ in size, material from which they are made, type of device and location in the body. The size of the catheter tube varies depending on the gender of the patient, so for women the length of the tube is about 14 centimeters, for men 25 centimeters. They can be made of rubber, silicone or latex, plastic, metal. According to the type of location in the human body are:

• Internal, completely located in the body of the patient.
• External, partly located in the body, and the other part is brought out.

Allocate urethral and suprapubic catheter. The first is inserted through the urethra, the second is installed through a tissue incision above the pubis.

In addition, there are single-channel, two-channel and three-channel catheters, disposable and installed for a long time. The most widespread Foley catheter which is set for both men and women.

How is the installation of a bladder catheter in men

The catheterization procedure for men is performed by experienced medical personnel using special equipment. It features a rigid, curved end that allows you to push the penis tissue apart and overcome pressure on the prostate urethra.

Before performing catheterization, the healthcare professional should prepare the necessary instruments and supplies. The patient lies on his back, while the medical worker stands to his right. Before performing the procedure, the specialist treats the hands, then the penis is treated with an antiseptic solution, which is wrapped with a sterile napkin below the head.

An anesthetic ointment may be used. For example, Lidocaine 2% gel allows not only to anesthetize the procedure, but also to reduce friction when the device passes through the urethra. If anesthesia is not performed, then a few drops of sterile glycerin are dripped into the open opening of the urethra, or the tip of the device is lubricated with a lubricant.

Then, wearing sterile gloves, holding the penis with one hand and tilting it to the stomach, with the other hand, using sterile instruments, the rounded end curved upwards is inserted to a depth of five centimeters. Further, the tube of the device is intercepted higher, and, pushing the penis, the medical worker slowly inserts the tube another five centimeters.

The appearance of urine from the other end of the device indicates that it has reached the bladder. If the device is equipped with a cuff to secure it in the bladder, it is pushed a little further, and the cuff is filled with sterile water to open, and the free end is lowered into the urine collection container.

How is the installation of a bladder catheter in women

The procedure for catheterization in women is different. First, the doctor cleans his hands and puts on rubber gloves. The patient takes a supine position with the legs bent to the side at the knee joints. The health worker stands in front of the patient.

First, a thorough hygienic treatment of the perineal organs is carried out. Then, changing gloves and placing the necessary sterile instruments and materials, preparations are made for the procedure. With one hand, the health worker spreads the large and small labia, while they are treated with an antiseptic solution, the direction of movement is from the navel to the back. The vagina and anus are covered with a sterile napkin.

Having prepared the necessary tools and opened a disposable bag with a catheter, the medical worker treats his hands with an antiseptic and changes gloves to sterile ones. The catheter is lubricated with a solution of glycerin or a lubricant and, holding it with tweezers, is smoothly inserted into the urethra to a depth of ten centimeters. The appearance of urine indicates that it has reached the bladder.

If the device contains a bladder cuff, it is inflated with a sterile water solution. The free end of the system is placed in the urinal. Further, the necessary procedures are carried out, for example, washing the bladder or administering drugs, and if necessary, the catheter is removed. If it is installed for a long time, then the urinal is attached to the patient's thigh, it is necessary to ensure that the tube leading to the urinal is not bent, as this will stop the outflow of urine.

What are the contraindications for the procedure

The catheterization procedure is strictly contraindicated if there are suspicions of a violation of the integrity and injury of the urethra. Symptoms of damage to the urethra can be hematomas, blood in the canal or in the scrotum. In addition, contraindications to the procedure are:

• Acute form of prostatitis.
• Infectious inflammatory diseases of the genitourinary system.
• Bladder injury.
• Penile injury.

Rules for the care of the bladder catheter

Basic rule for catheter care cleanliness. It should be regularly washed, and once a day, treat the device with soapy water. When carrying out hygiene procedures, you should follow the basic rules:

Movements should be made from the navel to the back.

If the patient cannot move, washing is carried out with cotton swabs, while the swab is carried out from top to bottom, changing each time. It is forbidden to carry out the procedure with one swab, this can bring the intestinal flora and cause inflammation.

Regularly inspect the area of ​​penetration of the catheter, for the presence of urine leakage.

If the device is installed for a long time, it is necessary to replace the tube once a week.

In addition, it is necessary to monitor the correct fixing of the urinal, it should not touch the floor, when lying down, the urinal should not be placed above the level of the patient's body. Remember to empty your urinal regularly. Compliance with proper care of the catheter allows you to avoid possible complications.

How to remove the catheter yourself

Removal of the catheter, as well as its installation, is carried out by medical personnel, however, there are cases when it is necessary to independently remove it. For this you should:

Wash your hands well with soap, do this twice, pat them dry with disposable tissues or a clean towel.

Empty the urinal.

Take a comfortable position, lying on your back. It is worth relaxing, this will allow you to easily remove the device without discomfort.

Carry out the treatment of the genital organs with water or saline.

Wearing rubber gloves, treat the junction of the drainage tube and the catheter with an alcohol raster.

Empty the bottle. Usually the device has two branches, one is used to drain urine, the other can be used to empty the balloon that holds the catheter inside the bladder. To do this, use a syringe that is placed in the valve of the cylinder and all the liquid is drawn out of it.

Slowly remove the catheter from the urethra. Extraction should not cause strong discomfort. If they are present, the liquid from the balloon may not have been completely removed.

Inspect the removed catheter for damage.

Monitor the state of the body in the next two days after removal. If you have a fever, blood in the urine, signs of inflammation or no urination, you should immediately consult a doctor.