What should I do if I need a venous indwelling needle when I meet a critically ill patient with bad blood vessels in emergency work? Ask the master for advice!

Rapid establishment of venous access in emergency is one of the necessary skills to deal with critically ill patients. Under normal circumstances, the peripheral veins of critically ill patients are collapsed, and emergency medical staff are required to quickly establish venous passages for rapid fluid infusion and blood transfusion. At present, there are several clinical methods to choose from.

Section 1 central venous catheter insertion

Central vein refers to the great vein near atrium, including superior vena cava and inferior vena cava. Catheterization of central vein refers to the operation technique of implanting puncture catheter into blood vessel through a larger peripheral vein, so that the catheter opening is located at or near the central vein. Commonly used puncture blood vessels are: internal jugular vein, subclavian vein and femoral vein.

Scope of application:

Rapid intravenous infusion, especially a large number of hypotonic, hypertonic or irritating solutions;

Maintain venous access for a long time; Central venous pressure monitoring;

Hemodialysis or hemofiltration;

Solve the difficulty of peripheral vein puncture;

Multiple venous blood samples are needed.

Taboo:

Severe coagulation dysfunction; The puncture vein channel is damaged or blocked; There is infection at the puncture site.

Puncture method

1. Prepare sterile gloves, iodine, alcohol and other local disinfection products, sterile hole towels, tweezers, normal saline, 2% lidocaine, anesthetic syringes with long needles, central venous catheter puncture suits, suture kits and other items.

2. If the posture allows, the patient usually lies on his back. When performing internal jugular vein puncture or subclavian vein puncture, you can put a small pillow under the patient's shoulder, turn the patient's head to the opposite side of puncture, and the arm on the puncture side is close to the body side. During femoral vein puncture, the patient's lower limbs slightly flexed and abduct.

3. Needle insertion point and direction

A the recommended puncture point for internal jugular vein puncture is the midpoint of the medial edge of sternocleidomastoid bone, which is equivalent to the chest.

Vertex of sternocleidomastoid triangle. Puncture parallel to the medial edge of the mastoid clavicle, with the needle tip aligned with the nipple. The needle axis forms an angle of 45 with the front.

There are many subclavian vein puncture methods. The author thinks that the puncture point with high success rate is located in the patient.

Below the midpoint of the clavicle 1- 1.5cm, the puncture direction is aimed at the Adam's apple, and the angle with the skin is the smallest angle that can pass through the clavicle. The depth of needle insertion is subject to smooth blood return, generally 3-5cm.

C. Femoral vein Femoral vein puncture needs to be performed at the position of 0.5- 1cm below the inguinal ligament after touching the femoral artery, and the needle is inserted at the head end at a 45-degree angle with the skin, parallel to the artery.

Pipeline placement method

1. At the selected puncture point, prepare for disinfection, towel laying/local anesthesia first. During anesthesia, use it for a long time.

Needle. Insert the needle carefully, suck it back after each needle advance, and if there is no blood return, push in a small amount of anesthetic. Local swelling after a large number of injections affects the success rate of puncture. After blood is seen in transfusion, the needle should be stopped immediately to judge the patency of transfusion and determine the size of blood vessels and the position of needle. When it is determined that the needle has entered the larger blood vessel and the needle is in a good position, the direction, angle and depth of needle entry should be remembered. Then pull out the anesthesia needle.

2. Take out the empty needle for puncture, and inhale 1 ml of normal saline according to the angle, direction and depth of anesthesia needle.

Needle. Stop when you see blood coming back. If you can't see the blood coming back, go in and out carefully. If there is still no blood return, the puncture needle should be pulled out and repositioned with an anesthetic needle. Then repeat the above work.

3. After the puncture needle sees the returned blood, in most cases, it can be confirmed whether the puncture tip is in the vein by observing the color of the blood (arterial blood is bright red and venous blood is dark red). In some cases (such as hypoxemia and anemia), arteries and veins cannot be distinguished by color. At this point, you can separate the syringe from the needle, observe the bleeding situation, judge the blood vessel pressure, and determine whether it is an artery or a vein.

4. After confirming that the needle tip is in the vein, a metal guide wire should be implanted. First, retract the J-shaped tip into a straight line, then insert the tip of the bracket into the tail end of the blue needle, gently push the guide wire with your thumb, observe the scale, and feel whether the entrance is smooth, so that the guide wire can smoothly enter 30cm (that is, the three black lines on the guide wire reach the small hole at the tail end of the blue needle).

5. Gently pull out the puncture needle. At the beginning of withdrawal, the needle tip has not left the skin. In order to prevent the needle from pulling out the guide wire, the thumb should gently press the guide wire. After the needle tip leaves the skin, hold the skin end of the guide wire with the other hand and completely withdraw the puncture needle from the guide wire.

6. Use skin expander to expand skin and subcutaneous tissue. When the catheter to be inserted is thick (e.g. above 7E), it is necessary to cut the skin at the puncture point with a blade, and then expand the skin and subcutaneous tissue with a dilator to prevent excessive resistance when placing the catheter. The method is to put the dilator into the puncture point along the guide wire, screw it into the skin and subcutaneous tissue to expand the future catheter route, and then return the dilator after expansion.

7. Take out the catheter from the packaging box, moisten the lumen with normal saline, then rotate it along the guide wire and send it to the patient's vein. Before the catheter enters the skin, the guide wire must be withdrawn to the exposed position of the catheter end. Pinch the guide wire with your fingers and send the catheter into the body to prevent the guide wire and catheter from entering the blood vessel at the same time. The internal jugular vein catheter was delivered to the depth of 14- 15cm, the subclavian vein catheter was delivered to the depth of 15- 16cm, and the femoral vein catheter was delivered to the depth of 25-30cm. Then pull out the guide wire. After pulling out the guide wire, immediately seal the catheter mouth with fingers, liver cover or infusion tube to prevent gas from entering the body or bleeding.

8. After the catheter is inserted, connect the end of the extension tube with a syringe and perform suction. The blood should flow back smoothly, which proves that the catheter tip is static.

In the blood vessels. Then, heparin saline is injected into the lumen that will not be used immediately to prevent blood coagulation from blocking the tube.

9. Suture and fix the catheter on the skin, and close the puncture point with disposable dressing.

Puncture the second elbow vein for central venous catheter insertion.

Central venous catheterization via elbow vein (PICC) is a kind of deep venous catheterization, in which the catheter is inserted through elbow vein with a guide needle, so that its top is located in the superior vena cava. Because its puncture point is in elbow vein, it is more intuitive and the success rate of puncture is higher than that of other deep vein catheterization.

Scope of application and contraindications: concentric vein catheterization.

Preparation before puncture

1 catheter selection PICC is an extremely soft and highly elastic silicone catheter, which is not affected by acid and alkali drugs, has good histocompatibility and does not irritate the blood vessel wall. Generally, the conduit specifications are 1.9 Fr, 2.8 Fr, 3 Fr, 4 Fr, 5 Fr. Select the appropriate model according to the patient's infusion requirements and local vascular conditions.

2 Your vein is the first choice for puncture, because your vein is straight and thick, and there are few venous valves. When the arm is perpendicular to the trunk, it is the straightest and most direct way, followed by the median elbow vein, cephalic vein and puncture point. If the position is low and the blood vessels are thin, it will easily lead to the obstruction of blood return or the friction between the catheter and the blood vessel wall, which will easily damage lymph or nervous system.

Preparation of articles: PICC puncture kit (including detachable trocar, catheter, hole towel, therapeutic towel, 5 ml syringe, skin disinfectant, dressing, 3M transparent patch, tourniquet, paper ruler, gauze and tweezers), gloves, heparin cap, heparin diluent, normal saline and 20ml syringe.

Test tube placement step

A, measure the length of the catheter, the upper arm abduction 90 degrees, determine the puncture point, from the puncture point to the ipsilateral sternal stalk and then vertically downward to the length of the third intercostal space.

B, strict aseptic operation principle: the elbow joint is covered with a therapeutic towel, and the puncture site is disinfected with 0.5% iodophor for 3 times, with the range of 10cm.

C, the operator wear sterile gloves, the needle angle is 20, just above the blood vessel, reduce the angle after blood transfusion and then enter 1 ~ 2 mm, loosen the tourniquet, slowly push the outer sleeve forward, press the blood vessel at the catheter tip 1cm, draw out the metal guide needle, and send the PICC catheter to the predetermined length with tweezers (be careful when sending the catheter, don't use force to prevent resistance. Pull out the outer sleeve, break and remove the outer sleeve, pull out the guide wire, draw blood for transfusion, and rinse the catheter with 20ml diluted heparin solution to observe whether it is unblocked. Connect the heparin cap and the fixed catheter to the infusion set.

Venotomy of the third section

Great saphenous vein in front of medial malleolus is usually used. In addition, the trunk of great saphenous vein, cephalic vein of upper limb, median elbow vein and superficial wrist vein along the lower inguinal segment can also be used.

Scope of application:

As an alternative route of peripheral vein infusion, all liquids that can be infused through peripheral vein can be infused through this route;

Take venous blood many times;

Rapid fluid replacement for anti-shock.

Contraindications: concentric venous catheterization.

Bloodletting bag: blade, knife handle, gauze, mosquito vascular clamp, triangular needle, silk thread, needle holder and small pointed scissors.

Method steps:

1, routine skin disinfection, laying sterile towels and local anesthesia;

2. Incision: make a transverse incision with a length of about 0.8cm above the anterior edge of the medial malleolus tip along the vertical direction of the vein;

3. Use mosquito vascular forceps to separate subcutaneous tissue, find the vein, and close to the vein for blunt separation. The free vein is about1cm;

4. Pick up the vein with a vascular clamp and pass two silk threads from below, one for ligating the distal end of the vein and the other for standby. Prepare the infusion set, check whether the plastic tube or silicone tube for intravenous intubation is suitable, rinse the plastic tube with a little injection, rinse the disinfectant and exhaust the air;

5. Lift the ligature, and obliquely cut a small mouth near the heart vein wall with small sharp scissors, accounting for about one third of the vein circumference. Be careful not to cut too much, resulting in vein rupture;

6. Accurately insert plastic tube or silicone tube from vein incision, about 5-6cm. Be careful not to insert vein dissection;

7. Immediately after insertion, tie the vein and catheter together with spare silk thread, and pay attention to the tightness. Too loose may cause the catheter to fall off and leak, and too tight may compress the pipeline.

8. Suture the skin, fix the tube on the skin suture, and then fix it with auxiliary materials and adhesive tape.

The fourth quarter bone marrow cavity puncture infusion

The hollow and non-collapsed venous plexus in bone can play a role similar to central vein administration, and drugs and liquids administered by vein can also be administered by infusion through bone marrow cavity. However, intramedullary perfusion also has its complications, such as fat embolism and osteomyelitis. If emergency venous access cannot be established, bone marrow infusion can be performed. At the same time of bone marrow infusion, venous access should be actively established. Once the venous access is successfully established, bone marrow infusion should be stopped, the puncture needle should be pulled out and the puncture point should be bandaged.

indicate

Unconventional infusion channel, which only replaces venous access in emergency.

Contraindications

1. There is infection at the puncture site.

2. The puncture site is suspected or has a fracture;

3. Skeletal sclerosis or osteogenesis imperfecta is suspected or existed.

operational approach

Site selection: distal femur, proximal tibia, humerus, sternum (suitable for older children and adult patients), iliac crest and greater trochanter of femur.

Instrument preparation

Bone marrow puncture needle, saline syringe, lidocaine, heparin saline injection (5-50U/mL), anticoagulant irrigation catheter, dressing, fixed splint and common intravenous infusion catheter.

operation sequence/order

Take the tibia as an example to introduce the puncture method, and other parts can also be analogized according to this principle.

1, local disinfection preparation, needle inserted into the flat bone surface of the middle and lower tubercle of tibia.

2. When the needle is inserted, the needle tip is slightly close to the tibia to avoid the bone growth plate at the bone end.

3. When inserting the needle, rotate back and forth and push forward until you feel disappointed. Withdraw bone marrow blood with a syringe (a few can't).

4. Inject 5- 10ml normal saline into the medullary cavity with a syringe, and rinse and remove the clots and bone fragments in the medullary needle.

5. After connecting the common infusion strip, infusion and drug infusion can be started.

6, fixed.