Edema of the hand after extraction of the subclavian catheter
Oncological patients often havepuncture and catheterize the central and peripheral veins for chemotherapy, parenteral nutrition, or blood sampling for research. In many patients, after repeated repetition of these procedures, veins on the hands due to loss of patency become unfit for further use. In such cases, the use of the "catheter port" (MPC) system may be effective.
Physiological consequences. Because the blood flow rate in the central veins than in peripheral, they reduced the risk of developing chemical inflammation by administration of nutrient solutions, and chemotherapy.
A warning. The patient should be located in the position of Trendelenburg. This increases central venous pressure and reduces the risk of air embolism of the venous system.
Do not leave the catheter guide in the atrium, as its presence can cause arrhythmia.
The catheter inserted through the needle can not be removed through it. A needle cut can damage the catheter and even cut off its part, which will turn into a foreign body in the venous system.
To prevent gas embolism, all syringes or catheters connected to the central venous system must be filled with heparinized isotonic sodium chloride solution.
The patient is positioned in theTrendelenburg, at an angle of 15 °, which increases central venous pressure and thus reduces the likelihood of air embolism. The accessibility of the subclavian vein increases, if you expand your shoulders further, placing a rolled towel under the thoracic spine, between the shoulder blades. The head is turned in the opposite direction.
These techniques improve access to the subclavian vein. The skin of the upper half of the thorax and neck is treated as for a surgical operation. Follow the rules of asepsis. The 14-gauge needle, 5 cm in length, connected to a 10 ml syringe filled with 2-3 ml of heparinized isotonic sodium chloride solution, is injected through the skin, and its cut must be turned downwards. The best place for puncture is just below the middle of the lower edge of the clavicle. The needle should be moved towards the tip of the finger, slightly pressing into the supragranular recess. This progression occurs under the lower edge of the clavicle in a horizontal plane, toward the anterior surface of the trachea, at the level of the supragranular cavity. The needle and syringe are located parallel to the surface of the operating table, closer to the anterior wall of the subclavian vein, in the direction of its longitudinal axis. Confirmation of getting into a vein is a massive inflow of blood into the syringe with easy reverse movement of the piston. The syringe is disconnected from the cannula of the needle, and its opening is immediately covered with a finger.
A flexible conductor is inserted through the needle into the upper vena cava (VPV). When the conductor is securely installed in the SVC, the needle is removed.
The conductor entering through the skin underclavicle. Choose the best place for MPC: about 8 cm below the collarbone and between the ribs. Make a 4 cm long incision, and form a pocket deeper than the subcutaneous fat, on the surface of the thoracic fascia. In the formed pocket, a thorough hemostasis must be performed.
It shows the PDC inserted into the pocket with an attached catheter. The MPC is fixed to the thoracic fascia by the holes along the edges with a nylon thread 3/0.
Before connecting to the venous system, the MAC and the catheter are completely filled with heparinized isotonic sodium chloride solution.
An incision length of 1 cm is performed next to the conductor,below the clavicle. A narrow long clip is held under the skin from the side of the small incision to the large subcutaneous pocket. They catch the catheter from the MPC and stretch it under the skin to the conductor, standing in the subclavian vein.
The MPC position is marked in the lower right corner. The cut of the skin above the MPC is sewn with a thin suture or staples. On the conductor through the incision of 1 cm in the subclavian vein introduced expander. Note that the catheter is coming out from under the skin next to the expander.
The conductor is removed through the expander. The aperture of the expander is covered with a finger so that air does not get into the vein through it. The length of the catheter from the MPC is measured to the subclavian vein and further along the vein to the ERW. The surplus catheter is cut off with sharp scissors.
The catheter is guided through the expander into the subclavian vein and then, finally, into the ERW.
The envelope of the expander is arranged in such a way thattears when removed from the subclavian vein. To do this, fingers hold its edges. The assistant moves the catheter further into ERW. The extender is extracted by dividing it in half and is removed completely.
To monitor the position of the catheter, theradiography. If the catheter is in the right atrium, it should be removed 4-5 cm through the skin incision. After the final placement of the catheter in the desired position, the cut of the skin is closed with a thin suture or staples. The MPC system is washed by injection through a membrane of 10 ml of heparinized isotonic sodium chloride solution.