CEWNIKOWANIE ŻYŁY SZYJNEJ WEWNĘTRZNEJ POD KONTROLĄ ULTRASONOGRAFII

Olena O. Karlova1, Vyacheslav V. Kaminsky 2, Olena V. Kuzminska3

1 P.L. Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine

2 City Сenter of Reproductive Medicine, Kyiv, Ukraine

3 O.O. Bogomolets National medical university, Kyiv, Ukraine

Abstract

Introduction: The use of ultrasound assistance of major vessels simplifies and facilitates vascular catheterization under conditions that significantly complicate gaining vascular access and reduces the risk of complications.

The aim of the work is technical improvement of catheterization of major vessels, in particular, of the jugular vein, under guidance of ultrasound.

Materials and Methods: The result of catheterization of the internal jugular vein in 126 patients of intensive care unit, was analyzed. In 75 patients Seldinger’s catheterization was used, taking into account anatomical markings, in 51 patients a method using ultrasound navigation was applied.

Results: The advantages of catheterization of the main vessels under the guidance of ultrasound are established, in particular, control over the procedure and reduction of the time of its carrying out, the possibility of catheterization at the first attempt and the absence of complications associated with the procedure.

Conclusions: The greatest effectiveness of internal jugular vein catheterization under the guidance of ultrasound assistency has been proved, which reduces the time of the procedure by 23.1%, reduces the number of attempts of catheterization, enables to monitor the progress of the procedure and prevent complications by using ultrasound navigation in 100% of the cases.

Wiad Lek 2017, 70, 6 cz. I, 1047-1050

INTRODUCTION

One of the topical issues of modern anesthetics is well-timed diagnosis and provision of appropriate care to patients [2, 12].

The use of sonographic assistance in the intensive care, obstetric-gynecological hospitals improves the quality of urgent operations and treatment.

Advances in ultrasound diagnosis at the present-day stage significantly extend the use of methods in the intensive care unit [3, 4]. In particular, the use of ultrasound assistance of major vessels simplifies and facilitates vascular catheterization under conditions that significantly complicate gaining vascular access and reduces the risk of complications. Conditions complicating catheterization include: peculiar properties of body build, hypovolemia disorder, collapse, intravenous drug abuse, congenital deformation of blood vessels, cardiac arrest.

Modern development of anesthesia ultrasound assistance implementation in practice began in 2003 in the United States. Performing in clinical setting over 5 million of central venous catheterization showed decrease in the incidence of mechanical complications to 5% – 19% [6, 7, 14].

Use of ultrasound before or during catheterization enables to accelerate performance of the procedure at the first attempt and prevent the development of complications associated with the procedure. From printed sources we know that over 15% of patients undergoing catheterization have complications [1, 10, 11]. Mechanical complications occur in 5-19% of cases [8, 13, 15], infectious – in 5-26% [9], thrombotic – in 2-26% [8].

Sufficient number of procedures and proven positive result of decrease in the incidence of complications after the procedure became the foundation in 2011 for the Center for Disease Control (Center of Disease Control, CDC) for reasoned use of ultrasound navigation in the process of installation of central venous catheters to reduce the number of attempts of cannulation and mechanical complications.

THE AIM

The aim of the work is technical improvement of catheterization of major vessels, in particular, of the jugular vein, under guidance of ultrasound.

MATERIALS AND METHODS

The study is based on the results of the procedures during the period from 2015 to 2016 and 126 catheterizations were analyzed. The object of the study were individuals, females, mean age 38.8 ± 1.02, who were treated in the intensive care unit of the Kyiv City Center for Reproductive Medicine. All patients were examined in the following scope: general clinical methods, laboratory and instrumental methods (ECG, ultrasound of major vessels) [4, 5].

The subjects of the study were divided into two groups. The first group included 75 patients who were provided catheterization of internal jugular vein by Seldinger technique, guided by anatomical markings. The second group included 51 patients, catheterization in which was performed under the guidance of ultrasound using «Mindray» scanner with a linear probe of 7.5 MHz. Catheterization of the jugular vein was made using dynamic ultrasound assistence.

The choice of surgical accesses to catheterization was made due to individual characteristics of the patients taking into account peculiar properties of body build, presence of the signs of hypovolemia disorder and collapse, congenital deformation of blood vessels or deformations associated with intravenous drug abuse, cardiac arrest.

For internal jugular vein catheterization, the standard Seldinger method was used, using static and dynamic ultrasound techniques. Ultrasound examination of the vein was made in two projections (on the short and long axis).

Static imaging studies were conducted immediately prior to the catheterization and sterilizing operative field, dynamic assistance during catheterization. The survey used cross sections in a two-dimensional image on the long (long axis (LAX)) (image 1) and on the short axis (short axis (SAX)) (image 2).

For collection and processing of study results, a database was created in Microsoft Excel 2007 format. Calculation was performed using the software Statistica for Windows 6.0 (Statsoft Inc., USA).

RESULTS AND DISCUSSION

The main evaluation criteria that were taken into account in the course of the study were based on the timing of catheterization of patients of the studied groups, determining the number of attempts of catheterization and frequency of complications when performing the procedures, shown in Table I.

As the results of the study have shown, the time of catheterization in group I exceeded the same parameter in group II of patients by 1.3 times and amounted to 13.09 ± 0.41 min., to 10 ± 0.27 min. in the second group (p<0.01).

Number of catheterization attempts in the I group of patients: the procedure at the first attempt in 77.3 ± 4.8 % (58 patients), at the third attempt – in 22.6 ± 4.8%.

Positive results of vascular catheterization at the first attempt were reported in all patients of the II group. Complications in the course of the procedure were 4.1 ± 2.2 % in the I group. Instead, dynamic observation of the procedure in patients in the II group enabled to determine positive results without causing complications.

Clinical case

The results of the procedure are represented in the form of a clinical case. Patient N. aged 32 admitted to the intensive care unit with a diagnosis of pregnancy 37 weeks, preeclampsia, and systemic inflammatory response syndrome. During the last 5 years uses injectable drugs. The presence of scarring in the projection of catheterization of peripheral veins complicates the catheterization to the great extent (Image 3).

Jugular vein catheterization was performed applying the standard Seldinger method under the guidance of ultrasonic navigation.

It should be noted that the static methods of ultrasound examination to perform manipulations enabled to determine distinguishing characteristic of superficial lateral location of the jugular vein, which often causes the development of perforation complications located near the common carotid artery in the course of catheterization using anatomical markings.

As the results of the study have shown a decrease of time for the procedure to an average of 9.2 ± 1.8 min.

It should be noted that in the setting of ultrasonic assistance and dynamic observation of the procedure the risk of incidence of complications decreases to the great extent which include perforation of the vein and adjacent vessels, thrombosed catheter and vein, infection, air embolism and thrombembolia, arrhythmias (a sign that the end of the catheter is in the right atrium or ventricle), hematoma, pneumothorax, hemothorax, hydrothorax, chylothorax, perforation of the heart, cardiac tamponade, damage to neighboring nerves and arteries, thrombosis.

In the course of the procedure, the monitoring of it and locating puncture needle as well as the catheter is carried out (Image 4).

CONCLUSION

The greatest effectiveness of internal jugular vein catheterization under the guidance of ultrasound assistency has been proved, which reduces the time of the procedure by 23.1%, reduces the number of attempts of catheterization, enables to monitor the progress of the procedure and prevent complications by using ultrasound navigation in 100% of the cases.

REFERENCES

1. Arnow P.M., Quimosing E.M., Beach M. Consequences of intravascular catheter sepsis, Clin. Infect. Dis. 1993; 16: 778-84.

2. Bodenham A., «Can you justify not using ultrasound guidance for central venous access?» Critical Care; 10, pp. 175- ‐6, 2006.

3. Bykov M.V. Ultrasonic studies in providing infusion therapy in intensive care units. -Tver: OOO “Publishing House “Triada”, 2011. – 36 p.

4. Clinical recommendations for the catheterization of vessels under ultrasound guidance [Text]: guidelines / FSBEI HVE Military Medical Academy named after S. M. Kirov.-2015.-36.p

5. Lelyuk, V.G. Ultrasound angiology/ Lelyuk V.G., Lelyuk S.E. – Moscow: Realnoye vremia, 1999. – 288 p.

6. Lobato E., Sulek C., Moody R., Morey T., «Cross- ‐sectional area of the right and left internal jugular veins,» J CardiothoracVascAnesth, № 13, pp. 136- ‐8, 2009.

7. McGee D., Gould M., «Preventing complications of central venous catheterization,» N Engl J Med,т. 348, pp. 1123- ‐33, 2003.

8. Merrer J., DeJonghe B., Golliot F. etal. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial, JAMA 2001; 286: 700-7.

9. Raad I., Darouiche R., Dupuis J. et al. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: a randomized, double-blindtrial, Ann. Intern. Med. 1997; 127: 267-74.

10. Richards M.J., Edwards J.R., Culver D.H., Gaynes R.P. Nosocomial infections in medical intensive care units in the United States, Crit. CareMed. 1999; 27: 887-92.

11. Pittet D., Tarara D., Wenzel R.P. Nosocomial bloodstream infection in critically ill patients: excess length of stay, extra costs, and attributable mortality, JAMA 1994; 271: 1598-601.

12. Rothschild J., «Ultrasound guidance of central vein catheterization. In: Making healthcare safer: a critical analysis of patient safety practices» AHRQ Publication No 01- ‐E058. Rockville, MD: Agency for Healthcare Research and Quality, pp. 245- ‐53, 2001.

13. Sznajder J.I., Zveibil F.R., Bitterman H., Weiner P., Bursztein S. Central vein catheterization: failure and complication rates by three percutaneous approaches, Arch. Intern. Med. 1986; 146: 259-61.

14. Troianos C., Jobes D., Ellison N., «Ultrasound- ‐guided cannulation of the internal jugular vein. Aprospective, randomized study,» AnesthAnalg, т. 72, pp. 823- ‐6, 1991.

15. Veenstra D.L., Saint S., Saha S., Lumley T., Sullivan S.D. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: meta-analysis, JAMA 1999; 281: 261-7.

ADDRESS FOR CORRESPONDENCE

Olena O. Karlova

P.L. Shupyk National Medical Academy of Postgraduate Education

9 Dorogozhycka st., 04112, Kyiv, Ukraine

tel: 38(044)205-49-46

e-mail: office@nmapo.edu.ua

Received: 10.06.2017

Accepted: 12.11.2017

Table I. The main evaluation criteria of catheterization of patients of the studied groups

Parameters

І group

ІІ group

75

51

Time of catheterization, min

13.09±0.41*

10.0 ±0.27

Number of attempts of catheterization

(from the 1st attempt), %

77.3±4.8*

0

Number of attempts of catheterization

(from the 3rd attempt), %

22.6±4.8*

0

Complications in the course of the procedures, %

4.1±2.2*

0

Notes:* – under р<0.01 compared with those in healthy subjects;

Image 1. Catheterization of the vessel in longitudinal section (long axis (LAX)). Longitudinal location of the sensor in relation to the vessel.

Image 2. Catheterization of the vessel in transsection (short axis (SAX) .

Image.3. The presence of scarring in vascular projection in drug dependent
patients.

Image 4. Position of the guidewire in the lumen of the internal jugular vein.