hello

2.  — carrying out infusion and drug therapy,
parenteral nutrition;
 — venous pressure measurements;
 — injection of a dye to measure cardiac output
using the dye dilution method;
 — carrying out transvenous
electrocardiostimulation . There is a distinction
between catheterization of peripheral and central
veins, and in the absence of special indications,
preference is given to peripheral veins, due to the
significantly lower risk associated with this
procedure

3.  for intravenous administration of medications;
 — carrying out infusion-transfusion therapy
and/or parenteral nutrition.
 There are no contraindications to
catheterization of peripheral veins. If there are
inflammatory or purulent processes in the area
of the intended puncture, vein catheterization
is performed in the unchanged area.

4. Dufaux -type needle into the vein and passing the
catheter through it to any depth, after which the
needle is removed (the maximum diameter of the
catheter depends on the internal diameter);
2) insertion of a catheter placed on a needle with a
protruding end (the maximum length of the catheter is
determined by the length of the needle);
Seldinger method , in which the vein is punctured
with a needle, a conductor (fishing line) is inserted
into the lumen of the vein through the needle to the
required depth, the needle is removed and a catheter
is inserted in its place along the fishing line. It is
necessary to carefully control the depth of insertion of
the fishing line and catheter, and avoid introducing it
too deeply.

5.  Any saphenous vein can be used. Most often, catheterization of the veins
of the elbow, hands, and feet is used. Simultaneous catheterization of
several saphenous veins is allowed. Under aseptic conditions,
venipuncture is performed using a special cannula made of modern
synthetic material (for example, polyurethane), placed on a needle, which
is used as a stylet. After identifying the vein, the catheter is advanced
deep into its lumen and fixed to the skin with adhesive material (adhesive
tape), and the needle is removed. The only complication of catheterization
of peripheral veins (besides the formation of hematomas) is the
development of phlebitis and thrombophlebitis, which occur more often
the longer the catheter has been in operation. If complications develop,
the use of the vein is stopped and the catheter is removed. It is advisable
to apply a pressure bandage with heparin- based ointment. The average
period of use of a polyurethane catheter with an anti-clotting coating with
daily change of surrounding wipes with disinfectant material and rinsing
with a heparin solution (at a dilution of 1:100 - 1.0 ml) after use of the
catheter is 3-7 days.

6. Catheters for peripheral veins with an
additional injection port.
16G HELM (1.7x45)
18G HELM (1.3x45)
20G HELM (1.0x33)
22G HELM (0.9x25)
24G HELM (0.6x19)

7. Size Specification:
Size, G Size, mm Liquid flow
rate
(ml/min)
Main areas of use Color
code
16 1.7 x 51 >150 Rapid transfusion of whole blood or its
components.
18 1.3 x 44 >75 Surgery or patients requiring infusion
of blood components or large volumes
of fluid.
20 1.1 x 32 >54 Patients requiring up to 2-3 liters.
fluids per day or long-term
administration of medications.
22 0.8 x 25 >25 Patients requiring long-term
administration of medications, cancer
patients, children and adults with
small veins.
24 0.7 x 20 >15 Mainly for children.

9.  the need for dynamic control of the central
venous pressure;
 the need for long-term administration of
introtropic and vasopressor drugs;
 parenteral nutrition and infusion therapy using
hyperosmolar solutions;
 conducting transvenous pacemaker;
 inaccessibility of peripheral veins or
discrepancy in total diameter; installed
peripheral catheters and the planned rate and
volume of infusion therapy.

10.  - inflammatory and other damage at the site of
the intended puncture;
 - superior vena cava syndrome and Paget-
Schrötter disease (traumatic thrombosis of the
subclavian vein);
 - coarctation of the aorta (relative
contraindication). If it is possible to catheterize
several peripheral veins, central venous
catheterization should be abandoned.

11. Strictly speaking, the term “catheterization
of the central vein ” means catheterization
of the superior (usually) or inferior vena cava ,
since the veins that are directly used to access
these areas of the vascular bed (subclavian,
internal jugular or femoral) are not central in
the full sense this word. The tip of the catheter
when catheterizing a central vein should be in
either the superior or inferior vena cava.

12. The origin is the jugular foramen of the skull (continuing from the sigmoid
sinus) and goes towards the chest.
The carotid artery and vagus nerve pass together in the carotid vagina.
Before occupying first a lateral and then an anterolateral position relative to the
internal carotid artery, the internal jugular vein is located behind the artery.
The vein has the ability to expand significantly, adapting to increased blood
flow, mainly due to the compliance of its lateral wall.
The lower part of the vein is located behind the attachment of the sternal and
clavicular heads of the sternocleidomastoid muscle to the corresponding
formations and is tightly pressed to the posterior surface of the muscle by the
fascia.
Behind the vein are the prevertebral plate of the cervical fascia, the prevertebral
muscles and the transverse processes of the cervical vertebrae.
 Below , at the base of the neck, are the subclavian artery and its branches, the
phrenic and vagus nerves and the dome of the pleura.
The thoracic duct flows into the confluence of the internal jugular and
subclavian veins on the left, and the right lymphatic duct flows into the right.

14.  1. The head is turned in the direction opposite to the punctured
vein, the neck is slightly extended .
 2. Provide aseptic conditions on the skin area, the boundaries of
which are the collarbone, lower jaw and midline of the neck
(lateral portion of the sternocleidomastoid muscle).
 3. Find a point located in the middle of the distance between the
mastoid process of the temporal bone and the place of attachment
of the sternal portion of the sternocleidomastoid muscle.
 4. The internal jugular vein can be punctured from this point
 - more medial myshchy or
 - its lateral (points) - at the apex of the triangle formed by the two
heads of the sternocleidomastoid muscle .
 5. The patient is placed in the Tredelenburg position (preferably, but
not required).
 6. The carotid artery is identified by palpation and local anesthesia
is performed with a 2% lidocaine solution .

15.  7. The main needle for puncture of the internal jugular vein is passed
lateral to the artery along its course at an angle of 30° to the skin with
constant aspiration until the vein is identified (usually to a depth of 2-5
cm). Venous blood should flow into the syringe easily, without visible
effort.
 8. The syringe is disconnected and a conductor is passed through the
lumen of the needle 4-5 cm beyond the end of the needle ( Seldinger
method ). The guidewire should “slip” freely into the lumen of the vein.
The needle is removed along the guidewire.
 9. The main catheter is passed along the guide (if necessary, first using a
dilator - a stiffer catheter with a pointed end; or an introducer - for
passing a multilumen catheter) . The guidewire is removed, the blood is
aspirated again (control of the catheter position), the catheter is fixed to
the skin with ligatures and washed with a weakly heparinized solution.
 10. It is possible to catheterize the internal jugular vein using a catheter
placed on a stylet. In this case, after identifying the vein, the catheter is
passed deep into its lumen, and the stylet needle is removed.
 11. Modern methods allow catheterization of central veins under visual
control using ultrasound.

16.  12. If there is any doubt about the location of the catheter, an
ultrasound or X-ray contrast examination is performed.
 13. Catheter care:
 - daily change of sterile wipes with treatment of the skin at the
catheter site;
 - daily rinsing with heparin solution after completion of infusion-
transfusion therapy.
 14. It is unacceptable to flush a thrombosed catheter or try to push
the thrombus inside with a stylet or guidewire. If thrombosis is
suspected, the catheter is removed.
 15. Repeated puncture at the site of the “old” catheter is
undesirable; it is recommended to use the contralateral side.
 16. Under normal conditions, catheterization is attempted on the
right side (there is no risk of damage to the thoracic lymphatic
duct). If there is an injury in the chest area, unilateral
inflammatory or other pathological process in the lungs, a vein on
the affected side is used for catheterization

17. Set for catheterization of central veins
"MEDISET", 1 piece
Ready-to-use set of materials for central venous
catheterization.
1 Foliodrape for instrument table / 75 x 90 cm
1 Valatex hand towel
1 plastic clip
5 round non-woven swabs /plum size
1 Foliodrape /75 x 90 cm with 10 cm opening
1 black 22G needle for local anesthesia
1 18G needle
1 syringe / 10 ml
1 syringe / 20 ml
1 disposable scalpel
1 plastic graduated tray
1 steel surgical tweezers
1 scissors
1 metal clamp (for artery) 6
Medicomp non-woven cloths / 7.5 x 7.5 cm 2
Sterilux gauze pads /5 x 5 cm
1 fixing adhesive bandage Hydrofilm / 6 x 9 cm .

18. The photo shows the main landmarks used to select the puncture point - the sternocleidomastoid muscle, its sternal and
clavicular legs, the external jugular vein, the clavicle and the jugular notch. The most commonly used puncture points are
shown - 1 - anterior access; 2 - central access; 3 - rear access; 4 - supraclavicular access. Various variations are possible, for
example, puncture at a point lying between points 2 and 4; some manuals call it the central lower access, etc. You can find at
least three more puncture points mentioned in the manuals. Remember, if you were able to clearly feel the pulsation of the
carotid artery on the side of the puncture and even manage to move it with your finger in the medial direction, this does not
guarantee successful puncture of the vein, but will save you from puncture of the carotid artery in almost 100% of cases.
Remember how the IJV passes in relation to the carotid artery after exiting the cranial cavity. In the upper third behind the
artery, in the middle third laterally , in the lower third it passes anteriorly, connecting with the ipsilateral subclavian vein
approximately at the level of the anterior segment of the first rib.

19. Venous puncture from the posterior approach (or lateral) is carried out from the puncture point located
at the intersection of the external jugular vein and the lateral edge of the sternocleidomastoid muscle; if
the external jugular vein is not pronounced, you can focus on the upper edge of the thyroid cartilage.
The needle is passed under the muscle in the direction of the jugular notch, and a vacuum is maintained
in the syringe. The vein is punctured at a depth of 2 to 5 cm. If it was not possible to puncture the vein in
the chosen direction, you can change the angle of attack both in a more cranial direction and in a caudal
direction. Safety considerations require caution; When repeating puncture attempts, try to control the
position of the carotid artery, use the exploratory puncture technique with a needle of a smaller caliber.

20. In this example, the direction of the needle has been changed to a more caudal direction,
however, the needle is still directed under the sternocleidomastoid muscle. After obtaining
blood in the syringe, evaluate its color (if the volume of solution in the syringe is large or if
there are local anesthetics in the solution, the blood may appear scarlet due to dilution or
interaction with the local anesthetic). Try to inject the blood back, assessing the resistance -
thereby you will return a few milliliters of warm blood to the patient and you can suspect
arterial puncture if there is significant resistance.

21. Carefully remove the syringe from the needle. To ensure that the hand holding the
puncture needle does not tremble while you place the syringe on the table and take the J-
shaped guide, try to lean your hand on the patient. The conductor must be brought into
working position in advance and placed within reach, so that you do not have to bend
dramatically in an attempt to get it, in which case you will probably find that the needle
has come out of the vein, because You have lost control of the needle.

22. The conductor should not encounter significant resistance when inserted; sometimes you can feel the characteristic
friction of the corrugated surface of the conductor against the edge of the needle cut if it comes out 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 slide further. When bringing the conductor back, it can get caught by the braid on the edge of the
cut and, at best, “come apart”; in the worst case, the conductor will be cut off and you will get problems that are
incommensurate with the convenience of checking the position of the needle without removing it, but by removing
the conductor. Thus, if there is resistance, remove the needle with the guide and try again, already knowing where
the vein passes. If the repeated attempt ends in the same way, you can turn the guidewire over and try to insert it
into the needle with the straight end. If unsuccessful, change the puncture point. After successfully passing the
guidewire to a distance of no more than 20 cm (to avoid provoking atrial arrhythmias), remove the needle while
holding the guidewire.

23. In this example, a double puncture of the internal jugular vein is performed, since for almost any
operation with artificial circulation we install an introducer and an additional catheter. The
internal jugular vein is used due to the fact that it is easily accessible for puncture, compression
hemostasis and for a number of other reasons. The subclavian vein is practically not punctured
from the subclavian approach, because the catheter is often pinched between the rib and clavicle
when the sternum is retracted. In connection with the installation of two catheters, we leave the
first guide in place to prevent cutting or damage to the catheter by the needle during puncture
and use it as an additional guide indicating the position of the vein.

24. The puncture point from the central access is classic, i.e. the angle formed by the sternal and
clavicular legs of the sternocleidomastoid muscle. The needle is passed at an angle of 30-40
degrees in the direction of the ipsilateral nipple. If there is no vein in this direction, you can
try to slightly change the direction to the medial or lateral side. Remember that the vein is
usually located at a depth of 1-3 cm; in delicate patients it can lie almost under the skin.

25. After carefully disconnecting the needle, control its position by placing the syringe on the
table and taking the guidewire. Insert the conductor into the vein no more than 20 cm,
following the rules described above.

26. While holding the guidewire, remove the needle. Now we have a nice picture - two
strings sticking out of a person’s neck. You can begin sequential insertion of the catheter
and sheath .

27. To install the introducer, it is necessary to insert a dilator into its lumen; if the side outlet is
integrated into the introducer body , a three-way tap should be put on it so as not to lose blood after
removing the dilator . All these manipulations are carried out in advance on the manipulation table.
Before introducing the introducer-dilator system , it is necessary to cut the skin and underlying
tissue with a scalpel at the point of entry into the skin of the conductor, in the direction of its further
passage. The depth of the dissection depends on the distance at which you entered the vein; if this
happened directly under the skin, you should only cut the skin with a scalpel at a length sufficient
to insert the introducer . Make every effort not to cut the vein.

28. The introducer-dilator system is introduced through the guidewire . Try to hold the
catheter with your fingers closer to the skin to avoid bending the guide and causing
additional trauma to the tissue, or even the vein. There is no need to insert a rigid
dilator with the introducer until it stops; after the distal end of the introducer enters the
vein, it will easily slide further without the dilator , and by removing the latter you will
save yourself from the risk of tearing the vein. Remember that both the guidewire and
the dilator must be removed at the same time , after which the introducer is sealed with
a hemostatic valve.

29. Removing the dilator and guidewire

30. The position of the introducer is verified by aspiration of venous blood. The introducer is
washed with sodium chloride solution. Fixed to the skin with a ligature. We recommend making
a loop around the introducer itself and placing a second loop on the side arm to secure it axially.
The second guidewire is used to insert an additional catheter, but this is mentioned in other
sections.

31. The subclavian vein is located in the lower part of the subclavian triangle.
It is a continuation of the axillary vein and starts from the lower border of the 1st rib.
First, the vein goes around the first rib from above, then deviates inward , down and
slightly anteriorly at the place of attachment of the anterior scalene muscle to the first
rib and enters the chest cavity, where behind the sternoclavicular joint it connects with
the internal jugular vein.
From here, as a brachiocephalic vein, it turns into the mediastinum, where, connecting
with the vein of the same name on the opposite side, it forms the superior vena cava.
In front, along its entire length, the vein is separated from the skin by the collarbone.
The subclavian vein reaches its highest point just at the level of the middle of the
clavicle, where it rises to the level of the upper border of the clavicle.
The lateral part of the vein is located anterior and inferior to the subclavian artery, and
both of them cross the upper surface of the first rib.
Medially , the vein is separated from the artery lying posterior to it by the fibers of the
anterior scalene muscle.
Behind the artery is the dome of the pleura. The dome of the pleura rises above the
sternal end of the clavicle.
The subclavian vein crosses the phrenic nerve in front, the thoracic duct passes above
the apex of the lung on the left, which then enters the angle formed by the confluence of
the internal jugular and subclavian veins - Pirogov's angle.

33. Subclavian and supraclavicular approaches are used for puncture and
catheterization.
Position: the patient is placed on a hard horizontal surface, a small cushion
of folded clothing is placed between the shoulder blades, the head is
slightly thrown back and turned as far as possible in the direction opposite
to the puncture site, the arm on the puncture side is lowered slightly and
pulled down (toward the lower limb), and also rotated outward .
When choosing a puncture site, the presence of damage to the chest is
important: the puncture begins on the side of the damage, and only if there
is massive crushing of the soft tissue in the clavicle area or when it is
fractured, the puncture is performed on the opposite side.
Landmarks : clavicle, jugular notch, pectoralis major muscle,
sternocleidomastoid muscle.

34. The collarbone is mentally divided into 3 parts.
The puncture sites are located 1-1.5 cm below the
collarbone at the points:
1. Below the middle of the collarbone ( Wilson's point ).
2. At the border of the inner and middle third of the
clavicle ( Aubaniac point ).
3. 2 cm away from the edge of the sternum and 1 cm
below the edge of the clavicle ( Giles point ).
Subclavian access

35. Puncture from all points is performed towards the same landmarks.
The most common point is Obanyaka .
To find it, you can use the following technique : the index finger is placed in
the jugular notch, the middle finger is placed at the top of the angle formed
by the outer leg of the sternocleidomastoid muscle and the clavicle, and the
thumb slides along the lower edge of the clavicle (towards the index finger)
until it will fall into the subclavian fossa. Thus, a triangle is formed, at the
vertices of which the operator’s fingers are located.
insertion point is located at the site of the thumb, the needle is directed to
the index finger.

36. Technique: the skin and subcutaneous fat are punctured vertically with
a needle to a depth of 0.5-1 cm, then the needle is directed at an angle of 25°-
45° to the collarbone and 20°-25° to the frontal plane in the direction of one of
the landmarks:
1. On the upper edge of the sternoclavicular joint from the puncture side;
2. On the jugular notch of the sternum (by placing a finger in it);
3. Lateral to the sternoclavicular joint from the side of the puncture.
The needle is directed slowly and smoothly, strictly to the landmark, passes
between the first rib and the collarbone, at this moment the angle of the needle
in relation to the frontal plane is reduced as much as possible (the needle is
kept parallel to the plane on which the patient lies). A vacuum is created in the
syringe all the time (during insertion and removal of the needle) by the piston.
The maximum depth of insertion of the needle is strictly individual, but
should not exceed 8 cm. You should try to feel all the tissues traversed by the
needle. If the maximum depth is reached and no blood appears in the syringe,
then the needle is removed smoothly to the subcutaneous tissue (under the
control of aspiration - since it is possible that the vein was passed through “at
the entrance”) and only then directed to a new landmark. Changes in needle
direction are made only in the subcutaneous tissue. Manipulating the needle
deep into the tissue is strictly unacceptable! In case of failure, the needle is
redirected slightly above the jugular notch, and in case of repeated failure, an

37. Considered safer, but less common.
needle insertion point ( Joff's point ) is located at the apex of the
angle (or at a distance of up to 1 cm from it along the bisector)
between the upper edge of the clavicle and the place of
attachment of the lateral leg of the sternocleidomastoid muscle to
it .
After puncturing the skin, the needle is directed at an angle of
40°-45° in relation to the collarbone and 10°-20° in relation to the
anterior surface of the lateral triangle of the neck. The direction
of needle movement approximately corresponds to the bisector
of the angle formed by the clavicle and the sternocleidomastoid
muscle. The vein is located at a depth of 2-4 cm from the surface
of the skin.
Supraclavicular approach

38.  The room where CPV is performed must be in a sterile operating room:
dressing room, intensive care unit or operating room.
 In preparation for CPV, the patient is placed on the operating table with
the head lowered by 15° to prevent air embolism.
 The head is turned in the direction opposite to the one being punctured,
the arms are extended along the body. Under sterile conditions, a
hundred is covered with the above instruments. The doctor washes his
hands as before a normal operation and puts on gloves.
 The surgical field is treated twice with a 2% iodine solution, covered with
a sterile diaper and treated again with 70° alcohol.
 Local anesthesia is administered (for patients in an unconscious and
deranged state, CPV is performed under anesthesia).
 Using a catheterization needle with a syringe containing novocaine (it is
necessary that they separate freely), a puncture of the skin is made from a
selected point in the PVI projection. The needle is first washed with
novocaine, the tissues are additionally anesthetized, then a vacuum is
created by pulling the piston.

39. Entry into the PV can be defined as a failure followed by the appearance of
blood in the syringe.
The needle must be moved only in one chosen direction and its changes are
possible only when the end of the needle is brought into the subcutaneous space.
After entering the PV, the needle is inserted even deeper into the vein by 2 - 3
mm under the control of blood flow.
Then the syringe is removed, the entrance to the needle is closed with a finger.
The conductor is inserted through the needle at a distance of 15 cm.
The needle, with precautions not to pull out the guide, is removed, and a
catheter is passed along it with a rotational movement to a depth of 8 cm (its end
should be in the superior vena cava, where there is good blood flow and less
thrombosis occurs).
If it is difficult to pass the catheter through the tissue, it is necessary to use a
bougie; you can use a metal conductor-string with a flexible and rounded end.
After removing the guidewire, the location of the catheter in the vein is
monitored by the flow of blood into the syringe. Then the catheter is washed and
the infusion system is connected, or closed with a rubber sterile plug without
defects to create a “ heparin lock” (10 ml of heparin solution is injected through
the plug, which is prepared at the rate of 1 unit of heparin in 1 ml of physiological
sodium chloride solution).

40. The catheter is sutured to the skin with silk ligatures using double knots:
the first set of knots is tied on the skin, the second is fixed to the catheter
here, the third is on the cannula after stitching its ears.
For very long infusions , it is possible to pass the catheter through the
subcutaneous tunnel to the axillary area with its further fixation to the skin.
It is preferable to puncture the PV on the right to avoid possible damage to
the thoracic duct, which is located on the left.

41. Incorrect position of the guidewire and catheter .
This leads to:
- heart rhythm disturbances;
- perforation of the wall of the vein, heart;
- migration through veins;
- paravasal administration of fluid (hydrothorax, infusion into the fiber);
- twisting of the catheter and formation of a knot on it.
In these cases, correction of the position of the catheter, assistance from
consultants, and possibly removal of it are required to avoid worsening the
patient's condition.
Puncture of the subclavian artery usually does not lead to serious
consequences if it is promptly identified by pulsating bright red blood.
To avoid air embolism, it is necessary to maintain the tightness of the
system. After catheterization, a chest X-ray is usually ordered to rule out
possible pneumothorax.
If the catheter is left in the PV for a long time, the following complications
may occur:
• vein thrombosis .
• catheter thrombosis ,
• thrombo- and air embolism, infectious complications (5 - 40%), such as
suppuration, sepsis, etc.