It is quite difficult to imagine modern intensive care without the procedure for catheterization of the cervical veins. The subclavian vein is most commonly used for catheter insertion. This procedure can be performed both below and above the clavicle. The place of introduction of the catheter is determined by a specialist.
This method of vein catheterization has several advantages: the introduction of a catheter is quite simple and comfortable for the patient. To perform this procedure, a central venous catheter is used, which is a long flexible tube.
Clinical anatomy
The subclavian vein collects blood from the upper limb. At the level of the lower edge of the first rib continues axillary vein. At this point, it bends around the first rib from above, and then runs along the front edge of the scalene muscle behind the clavicle. It is placed in the pre-ladder space. This space is a frontal triangular gap, which is formed by a furrow of a vein. It is surrounded by scalene muscle, sternum-thyroid, sternum-hyoid muscle and clavicular-mastoid muscle tissue. The subclavian vein is located at the very bottom of this gap.
It passes through two points, while the lower one is located 2.5 centimeters inward from the coracoid process of the scapula, and the upper one is three centimeters below the sternum edge of the end of the clavicle. In children under five years of age and newborns, it passes in the middle of the clavicle. The projection shifts with age to the middle third of the clavicle.
The vein is located slightly obliquely relative to the central line of the body. When moving the arms or neck, the topography of the subclavian vein does not change. This is due to the fact that its walls are very closely connected with the first rib, subclavian muscles, clavicular-thoracic fascia and clavicular periosteum.
Indications for CPV
The subclavian vein (photo below) has a rather large diameter, as a result of which its catheterization becomes most convenient.
The catheterization procedure of this vein is shown in the case of:
- The upcoming complex surgical intervention with a possible loss of blood.
- The need for intensive care.
- Introductions of a cardiac pacemaker.
- The need to measure central pressure in the veins.
- Parenteral Nutrition
- The need for sensing of cardiac cavities.
- Open heart surgery.
- The need for X-ray contrast studies.
Catheterization Technique
CPV should be carried out exclusively by a specialist and only in a room specially equipped for such a procedure. The room must be sterile. For the procedure, a resuscitation unit, an operating room or an ordinary dressing room, is suitable. In the process of preparing the patient for CPV, it must be laid on the operating table, while the head end of the table should be lowered by 15 degrees. This should be done in order to exclude the development of air embolism.
Puncture methods
Puncture of the subclavian vein can be performed in two ways: supraclavicular access and subclavian. In this case, a puncture can be done from either side. This vein is characterized by good blood flow, which, in turn, reduces the risk of thrombosis. There is more than one access point for catheterization. Specialists give the most preference to the so-called Abaniak point. It is located on the border of the inner and middle third of the clavicle. The success rate of catheterization at this point reaches 99%.
Contraindications to CPV
CPV, like any other medical procedure, has several contraindications. If the procedure is unsuccessful or impossible for any reason, then jugular or internal and external femoral veins are used for catheterization .
Puncture of the subclavian vein is contraindicated in the presence of:
- Blood coagulation and hypocoagulation disorders.
- Syndrome of the superior vena cava.
- Paget-Schröter Syndrome.
- Local inflammatory process at the proposed site of catheterization.
- Bilateral pneumothorax.
- Emphysema or severe respiratory failure.
- Injuries to the clavicle.
It should be understood that all the contraindications listed above are quite relative. In case of the vital need for CPV, urgent access to veins, the procedure can be carried out without taking into account contraindications.
Possible complications after the procedure
Most often, catheterization of the subclavian vein does not entail serious complications. Any change in the process of catheterization can be determined by the bright red pulsating blood. Experts believe that the main reason for complications is that the catheter or guidewire was improperly located in the vein.
Such a mistake can provoke the development of such unpleasant consequences as:
- Hydrothorax and fiber infusion.
- Perforation of the venous wall.
- Subclavian vein thrombosis.
- The formation of nodes and twisting of the catheter.
- Vein catheter migration.
- Heart rhythm disturbance.
In this case, adjustment of the catheter position is required. After the port amendment, consultants with extensive experience are required. If necessary, the catheter is removed completely. In order to avoid the deterioration of the patient's condition, it is necessary to immediately respond to the manifestations of symptoms of complications, especially thrombosis.
Prevention of Complications
In order to prevent the development of air embolism, strict adherence to the tightness of the system is required. After the procedure is completed, all patients who have undergone it are prescribed radiography. It eliminates the formation of pneumothorax. Such a complication is not excluded if the catheter has been in the neck for a long time. In addition, vein thrombosis, the development of air embolism, multiple infectious complications, for example, sepsis and suppuration, and catheter thrombosis can occur.
To prevent this from happening, all manipulations should be carried out only by a highly qualified specialist.
We examined the anatomy of the subclavian vein, as well as the procedure for its puncture.