Deep vein puncture is one of the basic skills necessary for physicians, and most of them are internal jugular, subclavian, and femoral vein puncture. How to effectively improve the success rate of deep vein puncture and reduce various complications is the focus of clinicians. Based on my own clinical experience, the author takes the subclavian vein puncture as an example to sort out the key issues during the puncture process and the treatment of complications, hoping to help everyone .
1
Indications for subclavian vein puncture strong>
Subclavian vein (SCV) puncture is often used in the following situations: Those who need a large amount of fluid or blood transfusion in a short period of time and peripheral venipuncture is difficult , Central venous pressure measurement, temporary pacing electrode implantation, permanent pacemaker implantation, etc.
2
subclavian vein anatomy
subclavian The vein is a continuation of the axillary vein from the outer edge of the first rib, with a total length of about 3~4 cm and a width of about 1~2 cm. walking. Image source: LWW Anatomy EssentialsThe SCV tube wall is attached to the proper cervical fascia, the periosteum of the first rib, the scalene anterior muscle, and the subclavian fascia sheath, and its position is constant, and it is not easy to move. The position is conducive to puncture; but at the same time, the tube wall is not easy to retract, and it is easy to enter air and cause air embolism.
3
Subclavian Vein Adjacency
There are subclavian and subclavian muscles in the front and upper part of the subclavian vein, and the subclavian artery in the back. The angular muscle is separated, and the first rib is below; the pleural roof is medial and posterior, and the posterior wall of the subclavian vein is only 5 mm away from the pleura.
4
Puncture Points
< span>01. Preoperative preparation No special instructions, the implantation of permanent pacemaker requires high sterility, pay attention to cleaning the skin dirt, and strictly disinfect. 02. PostureSupine position, pillow between scapulae, head back to the opposite side, the effect is that the neck muscles lift the clavicle to increase the intercostal space The effect is convenient for puncture; For patients with shock or hypovolemia, lower limb elevation can increase the filling degree of SCV and improve the success rate of puncture. 03. Puncture siteConventional puncture site2 to 3 cm below the midpoint of the clavicle, the direction of the puncture needle is aimed at the suprasternal fossa In fact, the area connecting the Adam’s apple to the supraclavicular fossa can be used as the needle insertion direction, and the angle between the needle body and the chest wall skin is less than 10°. The actual puncture position varies with individuals
(1) For obese or well-developed pectoral muscles, the puncture point should be 1 cm lower than the conventional position;
(2) In COPD patients, the puncture should be as close to the lower edge of the clavicle as possible, and in many cases it should be less than 1 cm to avoid the occurrence of pneumothorax; p>
(3) The puncture point of the pacemaker implanted patient should be placed outside the mid-clavicular point and too far inward. Squeeze, resulting in the so-called subclavian vein squeeze syndrome, which may lead to lead breakage in the future; Just in the regular position, the angle between the puncture and the skin should be as small as possible, close to 0°.
5
Puncture Details< /p> After the puncture point is determined, local anesthesia and empty the puncture needle. The needle tip can touch the lower edge of the clavicle first. Press the needle tip down slightly with the thumb to make it pass through the subclavian space. The inner and lower edge of the sternoclavicular is aligned with the suprasternal fossa and slowly advanced, and the bevel of the needle tip faces the direction of the heart, so as to avoid entering the internal jugular vein when the guide wire is delivered. While inserting the needle, gently suction to maintain negative pressure. Do not adjust the direction in the deep tissue after entering the needle. Otherwise, even if the guide wire is successfully inserted, it will be difficult to insert the catheter. The needle should not be inserted too deep, from the skin to the subclavian vein, 4-7 cm for adults and 1-3 cm for children. When no blood can be drawn back, the direction of the needle tip can be adjusted to point between the Adam’s apple and the suprasternal fossa, which can puncture more often. When there is dark red blood, stop advancing, and test its patency repeatedly. Make sure that the puncture needle must be fixed by hand when it is in the venous lumen to avoid displacement and lead to puncture failure. Remove the syringe, block the needle hole with your fingers (to avoid air embolism), insert the guide wire, withdraw the puncture needle, and place the catheter along the guide wire. The air in the sheath is pumped and evacuated, fixed with a needle and thread, and the puncture is completed. Topically covered with sterile gauze after surgery. Notes: Do not release the guide wire if the retraction is not smooth, and do not release the catheter if the end of the guide wire is not exposed. Routine fluoroscopy was performed after operation to observe the position of the catheter and whether there were complications such as pneumothorax.
6
Complications and Management
01. Wrong guide wire into the internal jugular vein span>Complaint of neck pain and ear pain when the guide wire was delivered. Countermeasures:Adjust the bevel of the needle tip to the direction of the heart; the hook of the shaping wire also faces the direction of the heart; Lateral displacement, avoiding the opening of the internal jugular vein when the guide wire is fed into the blood vessel, so that the guide wire can enter the uppervena cava. 02. Accidental penetration of the subclavian artery< /span>It is a common complication. It is very important to judge the mispuncture of the subclavian artery. It is generally not difficult to judge the mispuncture according to the color and pressure of the returned blood. As long as a catheter is not placed, needle injury is generally not serious. Countermeasures: Immediately pull out the puncture needle and press the artery locally for more than 5 minutes without bleeding. 03. PneumothoraxWhen the gas is withdrawn during puncture, it is necessary to think of puncturing the apex of the lung , and routine fluoroscopy is also required after surgery to detect pneumothorax complications in time. Due to the thin needle, pneumothorax is basically not serious.For patients with lung compression < 30%, the main observation is to perform closed thoracic drainage if they cannot be absorbed;
Thoracentesis should be performed for patients with lung compression of 30% to 50%, and closed chest drainage should be performed if it cannot be effectively relieved;
For patients with lung compression> 50%, direct closed thoracic drainage is performed, and the chest X-ray shows no signs of pneumothorax to be cured.
Pneumothorax is often seen in COPD patients, and women and those with an angle between the clavicle and sternum < 60° are prone to complications of pneumothorax. Those with poor cardiopulmonary function and obvious emphysema may die soon due to poor compensatory ability once pneumothorax occurs. The risk of surgery must be assessed before puncture. span>The subclavian vein should not be the first choice for puncture in such patients. 04. Difficulty in feeding the guide wire1) The needle tip is in the true lumen of the vessel< /span>In most cases, the direction of the needle tip is the problem, and the direction of the needle tip can be rotated smoothly; in a few cases, it can enter a branch or other blood vessel; If a section is fed If resistance is encountered in the future, the blood vessel may be tortuous or enter a side branch. If necessary, the vascular condition can be understood by puncture needle angiography, and then the direction of the guide wire is adjusted. 2) The needle tip is not in the blood vessel This situation is also very common. It may be that the needle tip is not fixed firmly, and no blood can be returned when the needle is withdrawn. Then send the needle tip forward or back, as long as the blood returns smoothly, the puncture needle is fixed, and the guide wire can be fed. 3) The needle tip enters the false lumen (under the intima) at this time, it can only be punctured by hand, but not by force. 05. Arrhythmiascaused by the introduction of a guidewire or catheter too deep into the myocardium, most commonly ventricular arrhythmias and sinus Tachycardia. The ECG monitoring should be closely observed or the patient’s feelings should be asked during puncture. Once arrhythmia is found, the operation should be stopped and the guide wire or catheter should be withdrawn a little to disappear. Most do not need to be terminated with drugs span>.
Summary
Before subclavian venipuncture Evaluate the condition, choose the route according to the cardiopulmonary function, choose the puncture point according to the physical condition, move gently, do not use violence when encountering resistance, understand the shape of the guide wire and catheter through fluoroscopy, and understand the blood vessel condition by angiography if necessary.
Catheter indwelling for multiple days is recommended before extubationroutine ultrasonography Whether the blood vessel has thrombosis, so as to avoid pulmonary embolism during extubation. In addition, multiple puncture failures are not required. In clinical practice, more puncture operations will naturally be smoother.
Planning: lySubmission: [email protected]
< span>Source of title map: Zhanku Hailuo