Artery puncture. Puncture of the femoral artery Indications: the introduction of medicinal solutions for obliterating diseases of the arteries and purulent-inflammatory processes of soft tissues and bones Antegrade puncture of the femoral artery
I. Indications. Puncture of the radial artery is performed to: 1) determine blood gases or 2) obtain a blood sample if it is impossible to take it from a vein or capillaries.
II. Equipment. Butterfly needles 23 or 25 gauge, 1- or 3-gram syringe, swabs soaked in alcohol and povidone-iodine (povidone-iodine complex), gauze pads 4x4, a sufficient amount of diluted heparin solution 1:1000.
III. Execution technique
A. Flush with a small amount of heparin solution (1:1000 dilution) into the syringe in which the blood sample will be delivered to the laboratory for blood gas determination. A small amount of heparin coating the walls of the syringe is sufficient to prevent blood coagulation. Too much heparin can interfere with results laboratory research. When taking blood to determine biochemical parameters with heparin, the syringe is not washed.
B. The most widely used puncture of the radial artery, which will be described below. Alternative option- puncture of the posterior tibial artery. The femoral arteries are best preserved for emergencies. The brachial arteries should not be punctured due to the lack of collateral circulation in them.
B. Check the condition of the collateral circulation and the patency of the ulnar artery using the Allen test. Press the radial and ulnar arteries on your wrist at the same time, then rub your palm so that it turns white. Reduce pressure on the ulnar artery. If the palm turns pink in less than 10 seconds, there is adequate collateral circulation through the ulnar artery. If the normal color of the palm is not restored within 15 seconds or more or does not appear at all, this means that the collateral circulation is poorly developed and it is better not to puncture the radial artery on this hand. Then it is necessary to check the state of collateral circulation on the other hand.
D. To obtain a blood sample, hold the patient's hand in left hand and straighten it at the wrist. With the index finger of the left hand, palpate the radial artery (Fig. 19). Some help can be provided by marking the puncture site with a fingernail.
E. Wipe the puncture site first with a povidone-iodine swab, then with an alcohol swab.
E. Puncture the skin at an angle of approximately 30° and slowly advance the needle with the bevel upward until blood appears in the connecting tube (see Fig. 19). When taking blood from an artery, it is not necessary to create a strong vacuum in the syringe to fill it.
G. Draw the required amount of blood (the minimum required) into the syringe. The volume of blood taken should not exceed 3-5% of the total circulating blood volume (the volume of circulating blood in a newborn child is approximately 80 ml/kg). Therefore, if 4 ml of blood is taken from a newborn with a body weight of 1 kg, this is 5% of the total circulating blood volume.
3. After removing the needle, to ensure adequate hemostasis, apply a pressure bandage with gauze pad 4x4 to the wrist for at least 5 minutes, but so that there is no complete occlusion of the arteries.
I. Before determining blood gases in the obtained sample, it is necessary to remove air bubbles from it and hermetically close the syringe. Failure to do so may result in errors in the analysis results.
K. The syringe is then placed on ice and immediately sent to the laboratory. On the laboratory form, the time of blood sampling, the temperature of the patient and the level of hemoglobin are noted.
IV. Complications
A. Infection. The risk of infectious complications can be minimized by strictly observing sterility during the procedure. The infection is usually caused by Gram-positive bacteria such as Staphylococcus epidermidis. They should be treated with nafcillin or vancomycin and gentamicin. Each hospital should determine the sensitivity of the pathogen to antibiotics.
B. Hematoma. To reduce the risk of hematoma formation, use the smallest possible gauge of the needle and immediately after its removal, apply a pressure bandage for approximately 5 minutes. Hematomas usually resolve on their own.
B. Arteriospasm, thrombosis and embolism. The risk of these complications can be reduced by using the smallest possible needle gauge. With thrombosis, recanalization of the vessel usually occurs after a certain period of time. Arteriospasm, as a rule, is eliminated on its own.
D. Inaccuracy of the results of determining the lawn of blood. Too much heparin in the syringe can lead to erroneously low pH and PCO2 values. Before drawing blood, remove the heparin solution from the syringe. The presence of air bubbles in the blood sample due to a leaky syringe can result in falsely high PO2 readings and falsely low PCO2 readings.
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percutaneous catheterization femoral artery on Seldinger performed using a special set of tools, consisting of puncture needle, dilator, introducer, metallic conductor soft end and catheter, size 4-5 F ( in French).
Modern angiographic devices are designed in such a way that for puncture it is more convenient to use the right femoral artery. The patient is placed on his back on a special table for angiography and the right leg is brought to a state of maximum pronation.
Pre-shaven right groin smeared with iodine and then wiped with alcohol and isolated with disposable sterile sheets to prepare a large sterile area for conductor and catheter.
Given the topographic anatomy of the femoral artery, it is necessary to find the inguinal ligament and mentally divide it into three parts. The projection of the passage of the femoral artery is often located on the border of the middle and medial third of the inguinal ligament. Find her palpation, as a rule, is not difficult for its pulsation. It is important to remember that medially from the femoral artery is the femoral vein, and laterally- femoral nerve.
The left hand is palpated on the inner surface lower limb 2 cm below the inguinal ligament, the femoral artery and fixed between the index and middle fingers.
The painfulness of the manipulation requires the patient, who is conscious, to undergo infiltration anesthesia with a solution of novocaine or lidocaine.
After doing local anesthesia skin and subcutaneous tissue with 1% lidocaine solution or 2% novocaine solution, produce puncture femoral artery. Puncture needle entered in the direction ripple, at an angle not exceeding 45 degrees, which reduces the subsequent likelihood of excessive kink catheter.
Tilting the outer end needles to the skin, pierce the anterior wall of the vessel. But more often needle passes both walls at once, and then the tip needles enters the lumen of the vessel only when moving it in the opposite direction.
igloo tilt even more to the thigh, remove from it mandrin and insert a metal conductor, the tip of which is advanced into the lumen of the artery by 10-15 cm in the central direction under pupart ligament. Carefully advancing the tool, it is necessary to assess the presence of resistance. In the correct position needles in the vessel, there should be no resistance.
Further promotion conductor, especially in persons over 50 years of age, it is necessary to carry out only under X-ray control to the level of the twelfth thoracic vertebra (Th-12).
Through the skin with the index finger of the left hand is fixed conductor in the lumen of the artery, and needle are pulled out. Finger pressure prevents removal from the artery conductor and leakage past it under the skin of arterial blood.
To the outer end conductor put on dilator, corresponding in diameter to the input catheter. dilator enter by moving along conductor 2-3 cm into the lumen of the femoral artery.
After removal dilator put on the conductor introducer, which is entered by conductor into the femoral artery.
At the next stage catheterization required at the outer end conductor put on catheter and promoting it distally, enter into introducer and then into the femoral artery.
From the femoral artery catheter (from the Greek kathet?r - a surgical instrument for emptying the cavity) - a tube-shaped instrument intended for insertion medicines and x-ray contrast agents into the natural channels and cavities of the body, blood and lymphatic vessels, as well as to extract their contents for diagnostic or therapeutic purposes. carried out along the vascular bed under X-ray control until aorta, then conductor removed and further advancement of the catheter up to target vessel carried out without it.
It should be remembered that after the end of the procedure, the place puncture must be firmly pressed against the bone base to avoid hematoma.
External iliac artery (arteria iliaca external, femoral artery (arteria temoralis) and their branches. Front view.
1-common iliac artery;
2-internal iliac artery;
3-external iliac artery;
4-lower epigastric artery;
5-femoral vein;
6-external genital arteries;
7-medial circumflex artery femur;
8-femoral artery;
9-subcutaneous nerve;
10-lateral artery, envelope of the femur;
11-deep femoral artery;
12-superficial artery, envelope of the ilium;
13-inguinal ligament;
14-deep artery enveloping the ilium;
15-femoral nerve.
artery puncture and veins - a necessary procedure when conducting diagnostic examination patients with suspected venous and cardiac insufficiency, thrombophlebitis and varicose veins veins. Arterial puncture makes it possible to assess the nature of the blood flow and blood pressure. In addition to diagnostic purposes, arterial puncture is also carried out if rapid blood substitution (blood transfusion) is necessary and when a special drug to stimulate the heart.
Purpose of arterial puncture
Puncture of an artery allows an angiography procedure, thanks to which the doctor is able to make an accurate assessment of the work circulatory system. The procedure is used in the diagnosis of diseases such as atherosclerosis, thrombosis, embolism, aneurysms and vascular injury. Artery puncture is an important step in minimally invasive interventions on blood vessels, as it allows you to perform the necessary procedures under constant visual control.
Thanks to the artery puncture procedure, the procedure for diagnosing many diseases of the heart and internal organs, as well as the process of thrombus formation and subsequent migration of blood clots through the arteries. An indication for arterial puncture is also the need for clinical research arterial blood and the need for constant monitoring of blood pressure, for which, after a puncture, a special catheter is inserted into the artery. Arterial puncture is not performed in case of fractures of the ribs and clavicle, with inflammatory processes and exacerbation of a number chronic diseases.
Puncture technique
Often artery puncture carried out in the elbow area. Before performing an artery puncture, the doctor must make sure that the ulnar artery functions normally and provides blood circulation, for this the doctor performs a procedure for squeezing the radial and ulnar arteries, as a result of which the patient's hand turns pale. With a load on the arm (compression and relaxation of the hand), a change in color is noted skin from deathly pale to grey. After removing the pressure bandage normal color the skin is restored in a few seconds, which indicates normal arterial circulation.
The artery puncture procedure is carried out under the influence of local anesthesia and the treatment of the puncture site with antiseptic and antibacterial drugs. For convenience, a roller is placed under the patient's arm, the artery is fixed with fingers and a needle is inserted, while the angle of inclination of the needle is 45-50⁰. Inserting the needle at a right angle minimizes damage to the artery, but not everyone can perform this procedure. Experienced medical workers easily determine the approach to the artery by pulsation, which is transmitted through the needle, which avoids such negative consequences as injury to both walls of the artery and the formation of hematomas. The appearance of scarlet blood testifies to the puncture of the artery.
In the case of a puncture of the femoral artery, the procedure is similar to the puncture of the cubital vein, the only difference is the size of the needle used. For the convenience of puncturing the femoral artery, the needle is placed on the syringe. After carrying out the necessary diagnostic and therapeutic manipulations, the needle is removed from the artery. If necessary, it remains in the artery and a special catheter is connected to it, through which further procedures are performed.
Complication of a puncture
The main consequence of arterial puncture is a double puncture, hematoma formation and nerve ending injury. In case of chronic diseases of cardio-vascular system, a complex and serious consequence of a puncture can be the formation of blood clots. In rare cases, complications such as allergic reaction and bleeding at the puncture site. Observance of rest, as well as strict adherence to and implementation of all doctor's recommendations, will help to avoid the negative consequences of arterial puncture. After the puncture of the femoral artery, the patient is advised to rest in bed and wear a pressure bandage, which is usually removed the next day after the procedure. In our clinic, you can get qualified assistance for all types of diseases of the cardiovascular system, undergo necessary examination and treatment.
As with venous access, arterial access used for various purposes:
for intra-arterial blood transfusion;
during arterial catheterization.
For intra-arterial infusion use the vessels closest to the heart. Intra-arterial blood transfusion is technically more difficult than intravenous. In addition, complications are possible in the form of damage and thrombosis of the arterial trunks. For this reason, currently this method practically not applied.
Indications:
clinical death due to massive unreplenished blood loss;
terminal state with shocks of any etiology (BP is 60 mm Hg and below);
no access to veins.
Advantages. This access allows you to transfuse a sufficient amount of transfusion medium into the vascular bed in the shortest possible time. direct blood supply to cerebral vessels coronary vessels. Reflex stimulation of cardiac activity. In addition, it should be noted that the diameter of the needles at arterial access much less than in venous
Arterial puncture
The need for this manipulation occurs when:
obtaining arterial blood samples;
direct registration of arterial pressure;
the introduction of contrast agents in cases of certain examination methods.
The most commonly used puncture of the radial and femoral arteries.
Puncture of the radial artery
It is used most often, since in this case, even with a violation of blood circulation in the radial artery, the blood supply to the hand usually does not change. Before puncture, it is necessary to make sure that the ulnar artery and its anastomoses with the palmar arch are functioning normally - Allen's test for the adequacy of collateral circulation: they pinch the ulnar and radial arteries with their fingers so that the blood flows out of the veins from the hand and it turns pale. The patient is asked to squeeze and unclench his hand several times. In this case, the palm acquires a deathly pale hue. The ulnar artery is released, and with sufficient collateral circulation, despite the clamped radial artery, normal skin color is restored after 5-10 seconds. If the color of the hand does not return to its original color during this time, the Allen test is considered negative, which indicates occlusion of the radial artery.
Anatomy. The radial and ulnar arteries are branches of the brachial artery and supply blood to the hand through the superficial and deep palmar arch. The radial artery is located along the lateral edge of the forearm, palpated on the wrist at the distal end radius. Here it is covered only by fascia and skin.
Puncture progress. The hand is unbent at the wrist joint, placed on a roller, and the pulsation of the arteries is determined. The skin and subcutaneous tissue are infiltrated with an anesthetic solution, since arterial puncture is a painful procedure for the patient. Anesthesia also eliminates arterial spasm. The vessel is fixed between the index and middle fingers, the needle is inserted in the proximal direction at an angle of 45° to the horizontal plane. With a slow approach to the artery, there is a feeling of transmission pulsation. The needle is advanced until blood appears. A more experienced physician can puncture the artery at a right angle, which minimizes trauma to the artery. The presence of the needle in the artery is indicated by the entry of scarlet pulsating blood into the syringe.
Puncture of the femoral artery
Anatomy. The femoral artery is a continuation of the trunk of the external iliac artery. The artery crosses the middle of the line drawn from the anterior superior iliac spine to the pubic joint. Medial to the artery lies the femoral vein, both vessels pass together in the Scarpov triangle.
Puncture progress. The femoral vein is punctured at the pupart ligament (inguinal). Use a large needle with a diameter of 1.2 mm.
For comfort manipulation the needle is placed on the syringe. Middle and index fingers left hand probe the pulsation of the vessel wall. The needle is inserted between the fingers with a cut down to avoid puncture of the opposite wall and directed at a slight angle to the skin. As soon as the needle penetrates the lumen of the artery, blood under strong pressure enters the syringe. After that, the syringe is disconnected and further necessary measures (transfusion, catheterization) are started.
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1. Indications:
a. Inability to catheterize the subclavian or internal jugular veins to measure CVP or administer inotropic agents.
b. Hemodialysis.
2. Contraindications:
a. Surgery in the groin in history (relative contraindication).
b. The patient should remain in bed while the catheter is in the vein.
3. Anesthesia:
1% lidocaine.
4. Equipment:
a. Antiseptic for skin treatment.
b. Sterile gloves and wipes.
c. Needle 25 gauge.
d. Syringes 5 ml (2).
e. Suitable catheters and dilator
f. System for transfusion (filled).
g. Catheterization needle 18 gauge (5 cm long).
h. 0.035 J-shaped conductor.
i. Sterile bandages
j. Safety razor
K. Scalpel
l. Suture material (silk 2-0).
5. Position:
Lying on your back.
6. Technique:
a. Shave, treat your skin antiseptic solution and cover the left or right inguinal region with sterile material.
b. Palpate the pulse on the femoral artery at a point in the center of an imaginary segment between the superior anterior iliac spine and the symphysis pubis. The femoral vein runs parallel and medial to the artery (Fig. 2.10).
Rice. 2.10
c. Inject the anesthetic through a 25 gauge needle into the skin and subcutaneous tissue 1 cm medial and 1 cm distal to the point described above.
d. Palpate the pulse on the femoral artery and gently move it laterally.
e. Attach an 18-gauge puncture needle to a 5 ml syringe, pierce the anesthetized skin, and while aspirating, advance the needle cranially at a 45° angle to the skin surface parallel to the pulsating artery. There is less risk with a medial approach to the vein than with a lateral one (Figures 2.11 and 2.12).
Rice. 2.11
Rice. 2.12
f. If a deoxygenated blood does not appear in the syringe after inserting the needle to a depth of 5 cm, slowly remove the needle while constantly aspirating. If there is still no blood, change the direction of the needle through the same puncture hole cranially and 1-3 cm laterally towards the artery.
G. If there is still no backflow, recheck the landmarks and try again at a point 0.5 cm medial to the pulse as described in (e). If this attempt fails, stop the procedure.
h. If the syringe appeared arterial blood, remove the needle and place your hand on the site as described below.
i. If injected into a vein, disconnect the syringe and press the opening of the needle cannula with your finger to prevent air embolism.
J. Pass the J-guide through the needle towards the heart, keeping it in the same position. The conductor must pass with minimal resistance.
j. If resistance is encountered, withdraw the guidewire, ensure that the needle is in the vein by aspirating blood into the syringe.
1. Once the guidewire has passed, withdraw the needle while constantly monitoring the position of the guidewire.
m. Expand the puncture hole with a sterile scalpel.
n. Insert the dilator along the guidewire by 3-4 cm, pushing subcutaneous tissues and holding the conductor. It is not recommended to insert the dilator deeper, as it can damage the femoral vein.
A. Remove the dilator and insert a central venous catheter 15 cm over the wire.
R. Remove the guidewire, aspirate blood through all ports of the catheter to confirm its intravenous position, and infuse sterile isotonic saline. Secure the catheter to the skin with silk sutures. Apply a sterile dressing to the skin.
q. The patient should remain in bed until the catheter is removed.
7. Complications and their elimination:
a. Femoral artery puncture / hematoma
. Remove the needle.
. Press with your hand for 15-25 minutes, then apply a pressure bandage for another 30 minutes.
. Bed rest for at least 4 hours.
. Control the pulse in the lower limb.
Chen G., Sola H.E., Lillemo K.D.