RU2808912C1 - Method of fixing catheter under skin of anterior chest wall when performing extended block of brachial plexus - Google Patents

Abstract

FIELD: medicine; anesthesiology; intensive care.

SUBSTANCE: invention can be used for fixing a catheter under the skin of the subclavian region during prolonged blockade of the brachial plexus. The catheter is fixed under the skin of the anterior chest wall using a Tuohy guide needle, which is also used to install a catheter to the brachial plexus and a spinal needle with a pencil sharpening of the distal end, the length of the subcutaneous channel is 150 mm, the point where the catheter exits the skin surface is located outside the area of the treated surface skin of the operated limb.

EFFECT: method allows to securely fix the catheter for prolonged blockade of the brachial plexus by enlarging the subcutaneous channel and forming a subcutaneous loop.

1 cl, 14 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to anesthesiology and intensive care. Currently, methods of regional anesthesia, such as blockades of nerve trunks and plexuses, are becoming increasingly popular among anesthesiologists. When performing long-term traumatic surgical interventions on the upper extremities with the need for postoperative pain relief, preference is given to prolonged plexus blockade. A feature of catheter fixation during prolonged blockade by interscalene, axillary and supraclavicular access is a short cutaneous-neural distance (short inner part of the catheter). For more reliable fixation of the catheter, it is carried out subcutaneously. The longer the inside of the catheter, the more secure its fixation will be. When passing the catheter from the supraclavicular region to the subclavian region, the internal part of the catheter is 70 mm - 80 mm. During surgical interventions on the upper third of the shoulder, the treatment area of the surgical field includes the place where the catheter exits from under the skin of the periclavicular region, which creates inconvenience for the operating surgeons and increases the likelihood of catheter dislocation. We propose a method for fixing a catheter for prolonged blockade of the brachial plexus under the skin of the anterior chest wall, where the inner part of the catheter will be 150 mm and the place where the catheter exits from under the skin of the anterior chest wall will be outside the treatment area of the surgical field. The advantages of this method are more reliable fixation due to the increase in the length of the internal part of the catheter, a more convenient place for the catheter to exit onto the skin, which better meets the requirements of asepsis (greater distance from the place where the catheter exits to the skin from the surgical area). In the method we propose, when carrying out an extended block of the brachial plexus, a Tuohy guide needle with an outer diameter of 1.3 mm and a length of 80 mm and a Pencan spinal needle from B/Braun are used to pass the catheter under the skin of the anterior chest wall with the formation of two subcutaneous channels and a subcutaneous loop of the catheter. with an outer diameter of 0.5 mm and a length of 103 mm.

This method of fixing a catheter under the skin of the anterior chest wall is carried out during prolonged blockade of the brachial plexus using a supraclavicular approach for the purpose of anesthesia during operations on the upper limb (shoulder and elbow joint), postoperative analgesia and treatment of acute and chronic pain syndromes. To install the catheter to the brachial plexus and fix the catheter under the skin of the anterior chest wall, use the Perifix ONE kit from B/Braun with a G 18 Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm and a G 20 catheter with an outer diameter of 0.85 mm, with an internal diameter of 0.45 mm and a length of 1000 mm and a Pencan spinal needle from B/Braun with a pencil sharpening of the distal end G 25 with an outer diameter of 0.5 mm and a length of 103 mm.

At the first stage, we install a catheter to the brachial plexus: Under local anesthesia with a solution of lidocaine 5 mg/ml - 5.0 ml, we make a 3 mm skin incision with a pointed scalpel in a place located 10 mm above the upper edge of the clavicle along the anterior axillary line, which corresponds to border of one quarter from the thoracic end of the clavicle and the remaining third quarter of the distance from the thoracic end of the clavicle to the acromial end of the clavicle, after which the wound is expanded with a surgical “mosquito” clamp. Next, a G 18 Tuohy needle is passed through the skin wound under the skin in the subclavian region to the brachial plexus; the advancement and position of the distal end of the needle is controlled using ultrasound navigation. After performing an aspiration test, we pass a G 20 catheter through the lumen of the needle to the brachial plexus at a distance of 15 mm (Fig. 1). Through a catheter, a sodium chloride solution of 9 mg/ml - 5.0 ml is injected into the brachial plexus. We control the distribution of the solution using ultrasonic navigation.

At the second stage, we place a catheter in the first subcutaneous canal: We pass the Tuohy needle from the skin wound at the site of access to the brachial plexus under the skin of the subclavian region in the caudal direction at a distance of 70 mm to a point located along the midclavicular line at the level of the second intercostal space, having previously carried out local anesthesia of the skin lidocaine solution 5 mg/ml - 5.0 ml (Fig. 2). At the site where the distal end of the Tuohy needle exits, we make a 3 mm skin incision. Then we expand the wound with a surgical mosquito-type clamp and through the distal end of the Tuohy needle we pass a spinal needle Pencan G 25 - 103 mm towards the proximal end of the needle (Fig. 3, 4). After that, the Tuohy needle is removed from the first subcutaneous canal and the proximal end of the catheter is fixed at the distal end of the spinal needle (we pass the distal end of the spinal needle into the lumen of the proximal end of the catheter at a distance of 3 mm) located in the first subcutaneous canal of the subclavian and supraclavicular region. Then the spinal needle with the catheter fixed on it is removed from the first subcutaneous canal (Fig. 5, 6).

At the third stage, we place a catheter in the second subcutaneous channel: We pass the Tuohy needle from a skin wound located in the subclavian region under the skin of the anterior chest wall towards a point on the sternum located along the sternal line at the level of the second intercostal space at a distance of 70 mm, having previously carried out a local skin anesthesia with a solution of lidocaine 5 mg/ml - 5.0 ml (Fig. 7). Next, through the distal end of the Tuohy needle we pass a spinal needle Pencan G 25 - 103 mm towards the proximal end of the needle (Fig. 8). After that, the Tuohy needle is removed from the second subcutaneous canal, with the distal end of the spinal needle located in the wound of the subclavian region, and the proximal end in the wound in the anterior chest wall along the sternal line. Next, we fix the proximal end of the catheter at the distal end of the spinal needle (we pass the distal end of the spinal needle into the lumen of the proximal end of the catheter at a distance of 3 mm) (Fig. 9). After that, the spinal needle with the catheter fixed on it is removed from the second subcutaneous canal.

At the fourth stage, we place the catheter in the small subcutaneous canal, forming a subcutaneous loop of the catheter: From a point located 10 mm lateral to the catheter exit from the second subcutaneous canal of the anterior chest wall, we pass the Tuohy needle in the caudal direction to a distance of 10 mm under the skin of the anterior chest wall (Fig. 10). Next, we pass a spinal needle Pencan G 25 - 103 mm through the lumen of the Tuohy needle from the distal end towards the proximal end (Fig. 11). After that, the Tuohy needle is removed from the small subcutaneous canal, while the spinal needle is located under the skin of the anterior chest wall. Next, we fix the proximal end of the catheter to the distal end of the spinal needle (we pass the distal end of the spinal needle into the lumen of the proximal end of the catheter at a distance of 3 mm). After which we remove the spinal needle with the catheter fixed on it from the small subcutaneous canal (Fig. 12). Then the proximal end of the catheter is passed between the surface of the skin and the cutaneous portion of the catheter located between the exit of the catheter to the surface of the skin from the second subcutaneous channel and the entrance of the catheter into the small subcutaneous channel, thus forming a subcutaneous loop of the catheter (Fig. 13).

Then the proximal end of the catheter was cut off with a surgical scalpel and connected through a connector to an antibacterial filter (Fig. 14). As a result, the catheter installed to the brachial plexus from the supraclavicular approach was passed under the skin of the anterior chest wall at a distance of 150 mm from the access site to the brachial plexus.

In FIG. Figure 1 shows the catheter being passed to the brachial plexus.

In FIG. Figure 2 shows a Tuohy needle passed under the skin of the subclavian region in a caudal direction.

In FIG. Figure 3 shows the expansion of the wound with a surgical mosquito forceps.

In FIG. Figure 4 shows the passage of a spinal needle through the lumen of the Tuohy needle from its distal end towards the proximal end.

In FIG. Figure 5 shows the fixation of the proximal end of the catheter on the distal end of the spinal needle at a distance of 3 mm.

In FIG. Figure 6 shows the removal of a spinal needle with a catheter fixed on it from the first subcutaneous canal.

In FIG. Figure 7 shows the formation of a second subcutaneous canal using a Tuohy guide needle, which is passed from a skin wound located in the subclavian region under the skin of the anterior chest wall towards a point on the sternum located along the sternal line at the level of the second intercostal space at a distance of 70 mm

In FIG. Figure 8 shows the passage of a spinal needle through the lumen of the Tuohy needle from its distal end towards the proximal end.

In FIG. Figure 9 shows the fixation of the proximal end of the catheter on the distal end of the spinal needle at a distance of 3 mm.

In FIG. Figure 10 shows a Tuohy needle being passed under the skin of the anterior chest wall at a distance of 10 mm from a point located 10 mm lateral to the catheter exit from the second subcutaneous canal.

In FIG. 11 shows the passage of a spinal needle through the lumen of a Tuohy needle from the distal end towards the proximal end.

In FIG. 12 shows the fixation of the proximal end of the catheter on the distal end of the spinal needle at a distance of 3 mm.

In FIG. Figure 13 shows the removal of a spinal needle with a catheter fixed on it from the small subcutaneous canal.

In FIG. 14 shows the formed subcutaneous loop of the catheter and the position of the catheter with an antibacterial filter attached to it, which is secured to the skin with a retainer.

A clinical example is given as an implementation of the invention.

Patient I., 53 years old. Diagnosis: Main: fracture of the upper third of the left humerus with displacement of fragments. Related: Stage 2 hypertension. Arterial hypertension 2 degrees. Risk of grade 2 cardiovascular complications. Physical status according to ASA class 2. An operation was performed: “Osteosynthesis of a fracture of the upper end of the left humerus with displacement of fragments with a titanium plate.” Anesthesia manual: “Extended block of the brachial plexus using a supraclavicular approach with fixation of the catheter under the skin of the anterior chest wall.” In the supine position under aseptic conditions, under local anesthesia with a solution of lidocaine 5 mg/ml - 5.0 ml, a 3 mm skin incision was made with a pointed scalpel in a place located 10 mm above the upper edge of the clavicle along the anterior axillary line, after which the wound was expanded with a mosquito-type surgical clamp. Next, a G 18 Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm was passed through the skin wound under the skin in the subclavian region to the brachial plexus; the advancement and position of the distal end of the needle was controlled using ultrasound navigation. After performing an aspiration test, a G 20 catheter was passed through the lumen of the needle to the brachial plexus at a distance of 15 mm from the distal end of the needle. A sodium chloride solution of 9 mg/ml - 5.0 ml was injected through the catheter into the brachial plexus. The solution distribution was controlled using ultrasonic navigation. Next, a Tuohy needle from the skin wound at the site of access to the brachial plexus was passed under the skin of the subclavian region in the caudal direction at a distance of 70 mm to a point located along the midclavicular line at the level of the second intercostal space, having previously carried out local anesthesia of the skin with a solution of lidocaine 5 mg/ml - 5 .0 ml. A 3 mm skin incision was made at the site where the distal end of the Tuohy needle exited. The wound was then widened with a surgical mosquito forceps and a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm was passed through the distal end of the Tuohy needle towards the proximal end of the needle. After which the Tuohy needle was removed from the first subcutaneous canal and the proximal end of the catheter was fixed to the distal end of the spinal needle located in the first subcutaneous canal of the subclavian and supraclavicular region. Then the spinal needle with the catheter fixed on it was removed from the first subcutaneous canal. Then a Tuohy needle was passed from a skin wound located in the subclavian region under the skin of the anterior chest wall towards a point on the sternum located along the sternal line at the level of the second intercostal space at a distance of 70 mm, having previously carried out local anesthesia of the skin with a solution of lidocaine 5 mg/ml - 5.0 ml. Next, a Pencan G 25 spinal needle with an outer diameter of 0.5 mm and a length of 103 mm was passed through the distal end of the Tuohy needle towards the proximal end of the needle. After which the Tuohy needle was removed from the second subcutaneous canal, with the distal end of the spinal needle located in the wound of the subclavian region, and the proximal end of the needle in the wound in the area of the anterior chest wall along the sternal line. Next, the proximal end of the catheter was fixed to the distal end of the spinal needle. After which the spinal needle with the catheter fixed on it was removed from the second subcutaneous canal. Then, from a point located 10 mm lateral to the catheter exit from the second subcutaneous channel of the anterior chest wall, a Tuohy needle was passed in the caudal direction to a distance of 10 mm under the skin of the anterior chest wall. Next, a Pencan G 25 spinal needle with an outer diameter of 0.5 mm and a length of 103 mm was passed through the lumen of the Tuohy needle from the distal end towards the proximal end. After which the Tuohy needle was removed from the small subcutaneous canal, while the spinal needle was located under the skin of the anterior chest wall. Next, the proximal end of the catheter was fixed to the distal end of the spinal needle. After which the spinal needle with the catheter fixed on it was removed from the small subcutaneous canal. Then the proximal end of the catheter was passed between the surface of the skin and the cutaneous portion of the catheter located between the exit of the catheter to the surface of the skin from the second subcutaneous channel and the entrance of the catheter into the small subcutaneous channel, thus forming a subcutaneous loop of the catheter. Then the proximal end of the catheter was cut off with a surgical scalpel and connected through a connector to an antibacterial filter. A fixation sticker is applied to the catheter. Postoperative pain relief was carried out in the trauma department for 3 days with a solution of ropivacaine 2 mg/ml at a dose of 3 mg/hour. The patient reported a pain level on the visual analog pain scale from 0 cm to 2 cm (mild pain) for the entire period of the extended brachial plexus block. Treatment of the location of the cutaneous fixing loop of the catheter in the area of the anterior chest wall with an antiseptic solution and changing of aseptic stickers was carried out once a day. The catheter was removed after 3 days; the catheter site showed no signs of aseptic inflammation. No catheter dislocation was noted.

Claims (1)

A method of fixing a catheter under the skin of the anterior chest wall when performing an extended block of the brachial plexus, which consists in the fact that after installing the catheter to the brachial plexus, the first subcutaneous channel is formed as a result of inserting a Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm from the skin wound into at the point of access to the brachial plexus under the skin of the subclavian region in a caudal direction at a distance of 70 mm to a point located along the midclavicular line at the level of the second intercostal space, and then at the exit point of the distal end of a Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm, an incision is made skin 3 mm, the wound is expanded with a surgical mosquito forceps and a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm is passed through the distal end of a Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm towards the proximal end. needle, after which a Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm is removed from the first subcutaneous canal and the proximal end of the catheter is fixed to the distal end of a spinal Pencan needle with an outer diameter of 0.5 mm and a length of 103 mm located in the first subcutaneous canal subclavian and supraclavicular areas, then a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm with a catheter fixed on it is removed from the first subcutaneous canal and the catheter is passed into the second subcutaneous canal, formed by inserting a Tuohy needle with an outer diameter of 1.3 mm and 80 mm long from a skin wound located in the subclavian region along the midclavicular line in the second intercostal space at the exit of the catheter from the first subcutaneous canal, under the skin of the anterior chest wall in the direction of the sternum to a point located along the sternal line at the level of the second intercostal space at a distance 70 mm, then through the distal end of a Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm, a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm is passed towards the proximal end of the needle, after which a Tuohy needle with an outer diameter of 1 .3 mm and 80 mm long is removed from the second subcutaneous canal, while the distal end of the Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm is located in the wound of the subclavian region at the site where the catheter exits the first subcutaneous canal, and the proximal end is in the wound in the area of the anterior chest wall along the sternal line at the level of the second intercostal space, after which the proximal end of the catheter is fixed on the distal end of a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm, then a Pencan spinal needle with an outer diameter of 0.5 mm and a length A 103 mm catheter with a catheter fixed on it is removed from the second subcutaneous canal, after which the catheter is passed into the small subcutaneous canal and a subcutaneous loop of the catheter is formed, namely, from a point located 10 mm lateral to the exit of the catheter from the second subcutaneous canal of the anterior chest wall, a Tuohy needle is inserted with an outer diameter of 1.3 mm and a length of 80 mm in the caudal direction to a distance of 10 mm under the skin of the anterior chest wall, then a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm is passed through the lumen of a Tuohy needle with an outer diameter of 1, 3 mm and 80 mm long from the distal end towards the proximal end, and then a Tuohy needle with an outer diameter of 1.3 mm and a length of 80 mm is withdrawn from the small saphenous canal, while a Pencan spinal needle with an outer diameter of 0.5 mm and 103 mm long is located under the skin of the anterior chest wall, then the proximal end of the catheter is fixed to the distal end of a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm, after which a Pencan spinal needle with an outer diameter of 0.5 mm and a length of 103 mm with the catheter fixed on it, it is removed from the small subcutaneous canal and the proximal end of the catheter is passed between the surface of the skin and the cutaneous portion of the catheter located between the exit of the catheter to the surface of the skin from the second subcutaneous canal and the entrance of the catheter into the small subcutaneous canal, thus forming a subcutaneous loop of the catheter.