Катетеризация бедренной вены у детей. Безопасный сосудистый доступ

Abstract

Objective. To identify risk factors of injuries to femoral vasculature of femoral vessel injuries, optimize the process of cannulation, reduce the risk of injury to femoral artery and its branches. Patients and methods. A screening sonography of the femoral puncture area was carried out in 466 patients. Of those, 240 patients had the bilateral sonography of the recommended optimal point for femoral vein access. The sonography of major vessels in the femoral vein access areas was performed using the ultrasound scanners Phillips HD 11 ХЕ, SonoSite М-turbo. Mindrey M7, M9, Samsung HM 70, and others; linear multi-frequency transducers with the working frequency range of 7 to 18 mHz, of 40mm and 20mm aperture. Sonography was perfromed from the level of inguinal ligament downwards, in the plane orthogonal to the major vessels in B mode and later with color Doppler mapping (CDM) of venous and arterial vessels. Results. Ultrasound findings of 240 patients were analyzed and anatomic variants of the femoral vascular bundle were identified: 29% patients had high origin of the deep femoral artery on one of the sides; 17.9% had high origin of the deep femoral artery combined with high origin of the medial circumflex femoral artery immediately behind the femoral vein; 5% had high origin of the medial circumflex femoral artery immediately from the femoral artery behind the femoral vein; in 2%, the femoral vein was located between the deep femoral artery and femoral artery 2 cm inferiorly to the inguinal fold. Sonography demonstrated that the femoral vein is easily compressible during venipuncture, and the distance between the anterior and posterior walls of the compressed femoral vein gets less than the access needle diameter. Special techniques were suggested to avoid perforation of the posterior femoral vein wall during access. It was clearly demonstrated that utilization of these techniques combined with ultrasound-assisted placement of a peripheral venous catheter on a trocar needle during femoral vein access has decreased injuries of the femoral artery and its branches from 10% to 1.3% of cases. A proprietary technology of safe stepwise cannulation of femoral veins is described. Conclusion. Ultrasound examination facilitates detection of vascular anatomy nuances and choice of the safer approach to femoral vein access. Measures preventing inadvertent puncture of the posterior wall, such as increased blood filling of the femoral vein, utilization of peripheral venous catheters for initial access, and a stepwise vein catheterization, have made it possible to achieve high percentage of successful cannulations and reduce complications. Key words: intensive care in children, ultrasound examination, venous access, femoral vein cannulation