yòu xīn dǎo guǎn shù
2 English referenceright catheterization
3 Nameright cardiac catheterization
4 OverviewRight cardiac catheterization was first performed by Fors *** ann in 1929, and right cardiac catheterization was used to measure cardiac output in 1941 by Coumand and Richards. Later, right heart catheterization gradually gained attention, and in 1953 Lategola and Rahn of the University of Rochester first used a flow-directed pulmonary artery catheter with a balloon at the head end in order to occlude certain branches of the pulmonary arteries in their experiments on animals. By 1962, the value of central venous pressure testing in monitoring effective blood volume was demonstrated by Wilson et al, allowing this technique to be widely used in the monitoring of critically ill patients with remarkable clinical results.In the late 1960s, SwanGanz invented the balloon floatation catheter, which led to a significant updating and broadening of hemodynamic monitoring devices and applications.1970 Swan et al. reported the results of 100 critically ill patients monitored with a balloon floating catheter, and concluded that hemodynamic monitoring has important clinical value in pathophysiological diagnosis. Since then, with the continuous updating and improvement of the right heart catheter and the improvement of operation technique, right heart catheterization has been widely used to determine central venous pressure, cardiac output, right ventricular pressure, pulmonary arterial pressure and mixed venous blood oxygen saturation, as well as for atrial and ventricular pacing.
5 IndicationsRight heart catheterization is indicated for:
1. Monitoring hemodynamics.
2. Determination of cardiac output.
3. Right heart and pulmonary arteriography.
4. Endocardial myocardial biopsy.
5. Myocardial electrophysiology.
6. Acute drug trials.
6 ContraindicationsThere are no absolute contraindications to right heart catheterization, but the following points should be noted during implementation:
1. Known bleeding disorders or those who are on anticoagulant therapy, it is best not to carry out the examination, if you do need to check, you should avoid puncturing a vein that is not easy to compress and stop bleeding.
2. If the puncture site is infected, the site should be changed.
7 Preparation 7.1 1. Equipment and items neededTo complete a right heart catheterization, the equipment generally needed includes a cardiac catheter, puncture needles, guide wires, guide tubes, transducers, and physiologic multichannel meters.
(1) cardiac catheter: the catheter's outer diameter is measured in French (F) units (1F = 0.335mm or 0.013 inches), the parameters of various cardiac catheters are shown in Table 1, and the length of the right cardiac catheter in an adult is generally 100cm to 110cm. different catheters are selected according to different diagnostic and therapeutic purposes. The general principles of catheter selection are: on the one hand, the largest possible number of catheters to ensure the accuracy of pressure measurement and the fastest speed in the injection of dye or contrast medium; on the other hand, the smallest possible number of catheters to reduce the incidence of vascular injury, thrombosis and bleeding and other complications. For adult patients, a 7F or 8F catheter is generally preferred for cardiac catheterization or cardiovascular angiography.
①Common right heart catheter: Common right heart catheter includes Coumand catheter, Lehman catheter, GoodaleLubin catheter and balloon floating catheter.Coumand catheter is a reusable multi-purpose catheter with standard wall, end holes, gradual bending of distal end, and impervious to X-rays.It is easy to enter the right heart, and can be used for manometry and blood specimen extraction. The Lehman catheter is a thin-walled variant of the Coumand catheter with the same purpose as the Coumand catheter and is available in sizes from 4F to 9F and in lengths of 50 cm, 80 cm, 100 cm, and 125 cm. The Goodalelubin catheter is characterized by two opposing lateral holes near the end hole. Goodalelubin catheter is characterized by two open side holes near its end holes, and can be reused as a standard catheter for right heart pressure measurement and blood specimen extraction, but it is not suitable for the determination of incarcerated pressure of the pulmonary artery, the size of which is from 4F to 8F, and the lengths of which are 80cm, 100cm, and 125cm. balloon floatation catheter is a kind of multi-lumen right heart catheter with an airbag on its tip, which is used for the determination of pulmonary artery pressure, incarcerated pressure of pulmonary artery, and cardiac output, and there are 5F, 7F, and 7.5F catheters in adult catheters. The adult catheter has 5F, 7F, and 7.5F with a length of 110 cm; the pediatric catheter has 4F and 5F with a length of 60 cm; the balloon floatation catheter may have two to five lumens, a distal thermistor for thermodilution measurement of cardiac output, and a ventricular pacing electrode lead; the two-lumen catheter has one lumen opening distally for measurement of pulmonary artery pressure and pulmonary artery incarceration pressure and one lumen communicating with an air bag; and the three-lumen catheter has one lumen opening distally for measurement of pulmonary artery pressure and pulmonary artery incarceration pressure. Three-lumen catheter with one lumen opening at the distal end for the determination of pulmonary artery pressure and pulmonary artery inset pressure, one lumen opening at the proximal end for the monitoring of atrial pressure, and one lumen connected to the airbag; four-lumen catheter with the same three lumens as the three-lumen catheter and another lumen tipped with a thermistor connected to the computer by a wire for the determination of cardiac output by thermodilution method; and a five-lumen catheter with one lumen opening proximally for infusion or administration of drugs at the same time for the determination of cardiac output; and a five-lumen catheter with one lumen opening proximally for the determination of cardiac output and the measurement of pulmonary artery pressure. The five-lumen catheter has an additional lumen opening proximal to the catheter, which is used to administer fluids or drugs while cardiac output is measured. More advanced balloon floatation catheters are available with an optical fiber that allows continuous monitoring of mixed venous blood oxygen saturation.
② contrast catheter: can be used for right heart contrast catheter Gemini catheter, NIH catheter, Eppendorf catheter, Grollman pigtail catheter, Berman and Bynumwilson contrast catheter. Gensini catheter tube diameter of 5F ~ 8F, the length of 80cm, 100cm and 125cm. There are two types of NIH catheters, USCI type NIH catheters with diameters from 5F to 8F and lengths of 50cm, 80cm, 100cm, and 125cm; Cook type NIH catheters with diameters of 6.5F, 7.3F, and 8.2F, all with lengths of 110cm; and Eppendorf catheters with diameters of 7F and 8F and lengths of 100cm and 125cm. There are two types of Grollman pigtail catheters, the standard Grollman catheter has a 60° bend and the other type of Grollman catheter has two curvatures, a 60° bend and a reverse bend.The Berman and Bynumwilson contrast catheters, both of which have a balloon at the anterior end, are flow-directed contrast catheters, which allow for simultaneous hemodynamic monitoring and contrast.
③ Catheter sterilization and storage: Most commercially available catheters are single-use products, especially multi-lumen balloon catheters. However, due to the expensive price of catheters, some domestic units are still reused to a limited extent. Therefore, appropriate methods should be used to clean and disinfect the catheter, and to ensure that the catheter is not damaged. Cleaning should generally be carried out in accordance with the following steps: A. Immediately after use, rinse the inner lumen and surface of the catheter with water; B. Using a pressurized rinsing device, rinse with water for 30min ~ 60min; C. Cleaning in the decontamination solution for 30min; D. Pressurized rinsing of the catheter with 100ml of decontamination solution; E. Pressurized rinsing of the catheter with 100ml of distilled water; F. Drying of the catheter. Catheter disinfection is generally used ethylene oxide or formaldehyde gas disinfection for more than 10h, rinsed with sterile liquid before use. The catheter is usually stored by vertical hanging.
(2) puncture needles: the puncture needles used for cardiac catheterization are percutaneous trocar puncture needles, which include three types: single-component needles, double-component needles, and triple-component needles. Single component needles are by far the most commonly used needles for single-wall punctures of arteries and veins, such as percutaneous subclavian, internal jugular, and external jugular vein punctures. Two-component needles are mainly used to puncture well-fixed vessels, where both the anterior and posterior walls are penetrated, the core is withdrawn, and the trocar is slowly withdrawn into the vessel. Three-component needles are rarely used today.
(3) guide wire: guide wire from a straight steel wire core made of finely wound stainless steel wire. Used for cardiac catheterization to make the catheter stretched, easy to pass through the curved blood vessels as well as to assist in percutaneous insertion of catheters or guide tubes. Ideal guide wire required to have the following properties: ① have enough hardness to avoid forward delivery will not circle in the blood vessels; ② have enough flexibility, can make a large bend without being broken, and reduce vascular damage; ③ appropriate smoothness. Due to the special structure of the guide wire, it is not easy to clean thoroughly, are generally recommended as a one-time use of the guide wire, unused wire contamination can also be sterilized using gas sterilization method.
(4) guide tube and transducer: guide tube consists of a progressively thinner dilatation tube and a slightly shorter casing, most of the current guide tube at the end of the casing with a hemostatic flap to reduce bleeding during intubation, reduce the incidence of thrombus and air embolism, and the side-arm tubes can be used for infusion of fluids, medications, and manometry. The use of guide tubes facilitates catheter exchange and placement of multiple catheters.
Transducers convert pressure signals into electrical signals. The more ideal transducer with accurate pressure measurement (reading error within 1mmHg), good linear characteristics (in the measured pressure range of accurate values), temperature stability (generally required in the 15 ℃ ~ 30 ℃ rhyming temperature range of pressure measurement error is less than 2.5mmHg), seismic and insulating, as well as ease of use and other advantages.
(5) physiological multi-channel instrument: mainly used to record a variety of pressure, oxygen saturation, electrocardiogram, respiration, as well as temperature and other changes. Generally choose four-channel physiological recorder or eight-channel physiological recorder.
7.2 2. Preparation before examination(1) Preoperative examination: detailed understanding of the medical history, physical examination and the results of other tests, help to avoid complications. For patients using aspirin and other drugs, they should stop using them for more than 10 days before surgery. The following routine tests should be completed preoperatively; blood count, platelet count, bleeding time, clotting time, prothrombinogen time and partial thromboplastin time. For those with coagulation abnormalities or arrhythmias, appropriate treatment should be given, and the examination should be considered only after the condition is under control.
(2) Obtaining consent: Before the examination, the patient should be allowed to understand the purpose and necessity of right heart catheterization, and eliminate the patient's concerns in order to actively cooperate with the examination. If necessary, explain to the patient the operation process and some of its possible situations, obtain the consent of the patient and his family and sign the consent form.
(3) the preparation of the examination room: right heart catheterization must be carried out under sterile conditions, the examination room is usually an operating room or a strictly sterilized sick room, should be equipped with appropriate rescue facilities. And prepare the following supplies: topical *** products; surgical sheets, cloth towels, towel clamps; small square gauze; 5ml and 10ml syringes; sterile heparin saline and its container; lidocaine; single or double component puncture needles; guide wires, dilatation tubes, guiding tubes, transducers, fluid tubes and connectors; surgical blades, knife handles; haemostatic forceps; toothed forceps; needle holders, suture needles and filaments; cardiac catheterization; monitoring equipment; Dirt containers; infusion holders; specimen bottles; equipment for cardiopulmonary resuscitation.
Right heart catheterization can be performed under fluoroscopic or non-fluoroscopic conditions. Generally, right heart catheterization through the femoral vein and the selection of a pacemaker must be performed under fluoroscopy; whereas, for the placement of a balloon floatation catheter through the elbow vein, the subclavian vein, or the internal jugular vein, the catheter's tip can be positioned without fluoroscopic assistance, and changes in waveforms on the monitor can be used to determine the catheter's tip position.
(4) Operator staffing: including a physician with extensive experience in vascular intervention technology and an assistant to assist in the operation.
(5) Equipment preparation
①Connect the pressure measuring tube, transducer and monitor:
A. Connect the transducer wire to the pressure monitor, ground the latter, and then turn on the monitor power switch.
B. Infuse heparin at a dose of 1 to 2 U/ml into a pressurized infusion bag containing saline.
C. Put a few drops of liquid on the sterile transducer diaphragm and connect the head end of the transducer, taking care that there should be no air bubbles left at the connection of the two parts.
D. Connect the piping system to the infusion bag as shown in Figure 1, and close the vent cap of the three-way switch.
② Transducer monitor apoplexy: the transducer and monitor should be zeroed before measurement and zeroed every 4h during monitoring as follows, see Figure 2.
A. Place the transducer at the level of the patient's right atrium and turn on the ventilation switch of the transducer.
B. Press the monitor zero control button to obtain the zero point, adjust the scanning curve of the monitor to determine the zero point.
C. Press the monitor calibration button to adjust the scan line to the proper position.
D. Turn off the transducer vent switch.
8 METHODS 8.1 1. Patient's ***Patient's *** Generally take the supine position to fully expose the puncture site. For ease of operation, a soft cushion can be used for local support. The patient's *** should remain relatively unchanged during the procedure.
8.2 2. Determination of the puncture siteAccording to the experience and habits of the operator, as well as different purposes of the examination to choose a different puncture site. Pulmonary artery cannulation can be performed in the internal jugular vein, subclavian vein, noble vein or femoral vein, etc. See Figure 3. The advantages and disadvantages of different cannulation routes are shown in Table 2.
8.3 3. Operator PreparationWear a mask and a cap, routinely wash your hands with a surgical brush and antiseptic solution, put on a gown, routinely sterilize the skin at the puncture point, wear sterile gloves, and lay out a sterile cavity towel or surgical towel.
8.4 4. AnesthesiaFor right heart catheterization, local anesthesia is used. Local anesthetics are most often chosen lidocaine, which produces a rapid effect, the general dose of 1% lidocaine 5 ml to 20 ml, the maximum dose of 300 mg (without epinephrine) and 500 mg (with epinephrine). Procaine may also be used at a maximum dose of 1 mg/kg (without epinephrine). For local anesthesia, the skin is punctured with a syringe in an oblique upward direction, and an appropriate amount of local anesthetic (0.5 ml) is injected to form a small dermal mound. The needle is gradually introduced in the predetermined direction of puncture, and the local anesthetic is injected slowly and in multiple directions, and the syringe should be withdrawn back to make sure that the needle is not in the blood vessel before each injection; each time the direction is changed, the needle should be retreated to the subcutaneous area before the injection is made. After anesthesia is completed, venous localization is usually performed by drawing back blood from the syringe before withdrawing the syringe, and then the syringe is withdrawn, leaving the needle in the vessel, and bleeding can be prevented by pressing down on the end of the needle with the thumb. For formal puncture, the catheterization needle can then be fed along this route. Using this method to localize the vein reduces the risk of accidental penetration of the puncture needle into the artery.
8.5 5. Procedure 8.5.1 (1) The basic procedure for venous cannulationSee Figure 4.
① Use a sharp blade to make a small incision in the skin (2mm to 3mm in length); use vascular forceps to bluntly separate the subcutaneous tissues in the direction of the blood vessels.
①Puncture the vessel with a thin-walled puncture needle while maintaining retraction, with an angle of approach of 30° to 40°; with good retraction, reduce the angle of approach and then slightly advance the needle in the direction of the vessel and ensure that the needle is located in the vessel.
③ Insert the soft end of the guide wire of the appropriate size, and make it extend the tip of the needle into the blood vessel for 15 cm to 20 cm.
④ Fix the guide wire with the thumb and forefinger of one hand to prevent it from moving, and place the remaining three fingers on the top of the puncture point to apply pressure, and pull out the puncture needle with the other hand; use sterile wet gauze to wipe the guide wire clean.
⑤ From the end of the guide wire into the guide tube, note that before the guide tube into the skin, should be exposed to the guide tube tail guide wire length should be maintained at more than 10cm.
⑥ close to the skin of the guide tube and guide wire held together, in a small degree of rotation to push the tip of the guide tube through the skin into the blood vessels, and continue along the direction of the blood vessels into the guide tube, note that you should always keep a section of the guide wire in the guide tube outside the tail.
(7) Withdraw the guide wire, aspirate and flush the guide tube to remove the clot and ensure that the guide tube is intravascular.
8.5.2 (2) Pulmonary artery cannulation① Insert the catheter into the vein through the guidewire and gently feed it forward. If you choose the internal jugular vein, subclavian vein or elbow vein puncture intubation, in anticipation of the front end of the catheter to reach the superior vena cava when the balloon partially inflated, you can find that the pressure curve changes with breathing, then make the patient cough, a large pressure fluctuations can be verified that the catheter has been entered into the thoracic cavity.
② When the catheter arrives at the right atrium, the balloon will be filled to 0.8ml ~ 1.0ml, the right atrial pressure wave should be observed, there is an a-wave, a v-wave, and fashionable visible c-wave.
③ Under close monitoring of the electrocardiogram without ventricular arrhythmia, the catheter is gently sent to the right ventricle, and the right ventricular pressure waveform is visible as a waveform with a large amplitude, a higher systolic pressure waveform and a lower diastolic pressure waveform.
④Continue to feed the catheter forward until a pulmonary artery pressure waveform is observed, which is a higher level and lower amplitude waveform with a higher systolic and diastolic pressure waveform. If the length of the catheter has reached 15 cm, and there is still no pulmonary artery pressure waveform, the catheter may be circling the right ventricle, and the catheter should be slowly retreated to the right atrium, and then the catheter should be sent forward to the pulmonary artery. The length of the catheter required to enter the pulmonary artery is inconsistent with the selection of different veins to be punctured, as shown in Table 3.
⑤ For the determination of pulmonary artery incarcerated pressure, the catheter can be fed forward while the balloon is kept inflated to the point that the balloon is embedded in the medium-sized pulmonary artery and cannot be further advanced, which is the time when the pulmonary artery incarcerated pressure can be obtained. After measurement, release the inflatable syringe and allow the balloon to deflate automatically, and the waveform will revert to a pulmonary artery pressure waveform.
⑥ Check the position of the catheter tip and the course of the catheter within the heart with fluoroscopy or chest radiographs to minimize catheter *** on the ventricular wall.
⑦ After suctioning and flushing the proximal lumen of the catheter, connect it to a continuous flushing system and steer it with a three-way piston steering transducer when determining the pressure.
⑧ The catheter and guide tube were sutured to the skin near the puncture point. After local disinfection, cover with a sterile dressing and secure it with adhesive tape.
8.5.3 (3) Monitoring of pressure①Right atrial pressure: when the catheter arrives at the right atrium, the pressure wave of the right atrium can be seen, consisting of an a-wave, a v-wave, and there is a fashion to see a c-wave, see Fig. 5A. The average pressure is about 0.27 to 0.80 kPa (2 to 6 mmHg). There is no a-wave in patients with atrial fibrillation, while a tall a-wave is seen in atrial separation.
② Right ventricular pressure: When the catheter enters further into the right ventricle, the pressure suddenly rises, and a right ventricular pressure wave appears, see Figure 5B. During ventricular systole, the pressure is equal to the pulmonary artery systolic pressure, which is about 2.67 to 4.0 kPa (20 to 30 mmHg), but the diastolic pressure falls to the same level of 0 to 0.67 kPa (0 to 5 mmHg).
③ Pulmonary artery pressure: continue to feed the catheter forward, then the pulmonary artery pressure wave can be recorded, see Figure 115C. systolic pressure is higher, similar to the right systolic pressure, about 2.67-4.0kPa (20-30mmHg); diastolic pressure is still maintained at a high level, and can not be restored to zero, about 1.07-1.60kPa (8-12mmHg); often visible Re-beat waveform; in general, all need to measure its average pressure, about 1.33 ~ 2.67kPa (10 ~ 20mmHg).
④Pulmonary artery embedded pressure: keep the balloon inflated, and further feed the catheter, there is a pulmonary artery embedded pressure waveform, representing the pressure formed by the reversal of the left atrium, including an a-wave and a v-wave, and sometimes c-wave can be seen, see Fig. 5D. Its average pressure is about 0.53～1.60kPa (4～12mmHg). Under normal circumstances, the pulmonary artery inset pressure is similar to the pulmonary artery end-diastolic pressure, and it can be unnecessary to determine the pulmonary artery inset pressure to reduce the occurrence of complications; however, for those with pulmonary hypertension, pulmonary embolism, severe hypoxemia, or a heart rate of more than 120 beats/min, the difference between the pulmonary artery end-diastolic pressure and the pulmonary artery inset pressure is large, and it is necessary to determine the pulmonary artery inset pressure.
8.5.4 (4) Determination of cardiac outputThe use of temperature as an indicator to determine cardiac output according to the principle of indicator dilution was first reported by Fegler in 1954. For the measurement, a thermodilution catheter, a temperature-sensitive resistor, and a cardiac output computer are required. Room temperature or ice temperature liquid can be used as an indicator for determination, the method is basically the same, the domestic more ice temperature measurement method, according to the change in the temperature of the indicator, the computer calculates the cardiac output through the following formula.
Where Vi is the indicator capacity, (TBTi) is the difference between the blood temperature and the indicator temperature, K1 is the ratio of the indicator to the specific heat of blood and specific gravity, K2 is the coefficient for the change in temperature of the liquid in the catheter, the catheter dead space, the speed of the injection, and the conversion unit, and TB (t) dt is the integral of the blood temperature over time.
The steps for determining cardiac output with ice temperature as an indicator are as follows:
① Place the indicator liquid and temperature probe in an ice bath for more than 5min.
② computer self-test before monitoring, press the computer "self-test" button, when the word "ready", press the "start" button, the monitor reads "0.00". "0.00", and then display "OK" in 15s, indicating that the computer is working properly. Generally only need to self-test once a day.
③ Press the "Indicator Temperature" and "Blood Temperature" buttons to determine the indicator and blood temperature.
④ Enter the correct calculation constants into the computer, the values of which can be found on the catheter package.
⑤ Aspirate 10 ml of indicator fluid and press the Cardiac Output button.
(6) When "ready" appears on the display, connect the syringe to the proximal lumen of the catheter.
⑦ Press the "Start" button, immediately within 4s uniform and rapid injection of the liquid in the syringe instructions, observe the simulation curve shape, to determine whether the injection requirements, see Figure 6.
⑧ Repeat steps ⑤ to ⑦, and then determine the cardiac output.
Generally, at least three measurements should be made to calculate the average value, and if the difference between the three measurements is large, the number of measurements should be increased to obtain a more accurate average value.
8.5.5 (5) Normal values of pulmonary circulation indices by right heart catheterizationSee Table 4.
8.5.6 (6) Collection of specimensBlood specimens are collected from the pulmonary artery for determination of mixed venous blood oxygen saturation. For patients suspected of having a left-to-right shunt, blood specimens from the pulmonary artery and right atrium can be collected to observe the difference between the two, which is of diagnostic value. To ensure safe sampling and obtain qualified specimens, blood should be taken according to the following steps.
① First, use an empty needle to withdraw about 5 ml of blood from the catheter and discard it, and then use another empty needle to withdraw the blood specimen.
② The blood should be drawn slowly during sampling to reduce the chance of hemolysis. In the collection of blood gas analysis specimens, heparinized empty needles should be used and after obtaining enough blood specimens, the air in the needle is exhausted, sealed and stored, and immediately sent for examination or stored in an ice bath for a short period of time for examination.
③ Immediately after sampling, the catheter should be flushed quickly to remove blood from the tee and catheter to ensure that the catheter is clear.
8.5.7 (7) Removal of the pulmonary artery catheterAfter monitoring, remove the pulmonary artery catheter according to the following steps. First, explain to the patient the extraction process and possible sensations; then, according to the site of venous puncture, let the patient take the prone position or the supine position with the head stretched out (internal jugular vein and subclavian vein puncture); in the case of monitoring the absence of abnormal electrocardiograms, use a syringe to suction the gas in the air sac for active exhaustion; after removing the dressings and cutting the sutures, quickly back the catheter to the position of the front end of the guiding tube, let the patient pause for a moment to pause for breath, and remove the catheter and the guiding tube together. catheter and guide tube together; immediately press the puncture site, local disinfection treatment with antiseptic solution, and dressing coverage. If the catheter is left in place for a longer period of time, the skin puncture site should be sealed with oil gauze to prevent air embolism.
9 ComplicationsRight heart catheterization is relatively safe and has a low complication rate. However, more serious complications may occur during pulmonary artery intubation and prolonged monitoring, and may even lead to death. The complications that should be prevented during right heart catheterization are listed below.
9.1 1. Complications of venous puncture and cannulationDuring venous puncture and cannulation, the more common complications are: local hematoma, thrombosis, phlebitis, accidental penetration of the artery, accidental injury to the nerve, infection, air embolism, pneumothorax, and hemothorax. Among them, air embolism and pneumothorax are more serious and can jeopardize the patient's life. However, puncture in strict accordance with the operating procedures can significantly reduce the occurrence of complications.
(1) Pneumothorax: Pneumothorax is seen in patients undergoing subclavian and internal jugular vein puncture, and is caused by the puncture needle damaging the pleura in the apical region of the lung, with an incidence of about 1% to 10%. In patients with pre-existing chronic obstructive pulmonary disease (COPD), the elevated and distended apices of the lungs make them highly susceptible to inadvertent injury. When pneumothorax occurs, the patient may experience significant chest pain, which may be followed by the clinical manifestation of dyspnea, the latter of which is related to the speed and volume of gas entering the pleural cavity. Once a puncture resulting in pneumothorax is detected, it should be treated depending on its clinical manifestations and the amount of gas accumulated in the pleural cavity, and the specific methods include chest puncture and aspiration as well as the use of water-seal bottle drainage, etc., as described in Chapter XVI. Measures to prevent the occurrence of pneumothorax include, for patients with chronic obstructive pulmonary disease, try to choose other puncture sites, or in the operation should be avoided puncture point should not be too lateral, the needle should not be too deep, and minimize the number of times of puncture, etc., if the number of times of puncture has reached 3 times, but still unsuccessful patients should choose the other side of the puncture.
(2) Air embolism: Air embolism is extremely rare, but has a mortality rate of up to 50%. It is caused by air entering the circulation through the open venous line during the procedure, and is commonly seen in patients undergoing internal jugular vein and subclavian vein puncture. Gas can enter the vein through the following pathways: (1) during puncture, through the puncture needle or cannula; (2) after placement, the catheter or connecting tube is not sealed properly, and air leaks into it; (3) after extraction, it enters through the subcutaneous tunnel. Larger-scale air embolism can cause severe acute respiratory distress syndrome, severe hypotension, syncope, hypoxemia, and even severe arrhythmia and cardiac arrest. Once air embolism occurs, the patient should be immediately placed in the left side of the head down supine position, given high concentration of oxygen and assisted ventilation, or hyperbaric oxygen therapy, and can be pumped through the pulmonary artery catheter, cardiopulmonary resuscitation when cardiac arrest occurs. Preventive measures for air embolism, including strictly in accordance with the operating procedures, care should be taken to hold down the end of the puncture needle and catheter or use a cannula with an anti-air flap, all the connectors should be carefully inspected and connected, and attention should be paid to replenishment of fluids in the infusion bottle.
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9.2 2. Complications of hemodynamic monitoringDuring hemodynamic monitoring, a number of complications can occur, with arrhythmias, thrombosis, pulmonary infarction, pulmonary artery rupture, and infection being more common.
(1) Arrhythmia: Arrhythmia is the most common complication, with premature ventricular beats and non-sustained ventricular tachycardia being the most common. When the catheter enters the cardiac chambers, the arrhythmia is caused by myocardial ***. The episodes are usually brief and disappear rapidly after the catheter enters the pulmonary artery. No special treatment is usually required. However, in rare cases, ventricular fibrillation can occur, requiring immediate electrical defibrillation.
(2) thrombosis: after the catheter enters the blood vessel, *** endothelial cells and lead to platelet and fibrin aggregation, the formation of thrombus, and can cause a decrease in platelet count. After the thrombus is dislodged, it can block the branch of pulmonary artery and pulmonary infarction occurs. Continuous flushing of the tubes with heparinized saline can reduce the formation of thrombus.
(3) Pulmonary infarction: pulmonary infarction can be caused by prolonged catheterization or thrombus embolism. Patients present with obvious chest pain, dyspnea, cough, hemoptysis, severe hypotension and other manifestations. Minimizing catheter embedded time and preventing thrombosis can reduce the occurrence of pulmonary infarction.
(4) Pulmonary artery rupture: After the catheter enters the pulmonary artery, it can be ruptured due to the tip of the catheter being fed too much, or the balloon being overinflated, or the balloon being inflated eccentrically, as well as the forceful flushing of the embedded catheter. This complication is more likely to occur in people with pulmonary hypertension, the elderly, or those with existing heart disease. Once it occurs, it often leads to rapid death of the patient. Pulmonary artery rupture can be prevented by continuously observing catheter end-hole pressures, ensuring that the catheter is located in a larger pulmonary artery, reducing the number of times the balloon is inflated, inflating the balloon slowly, and deflating the balloon first when performing irrigation.