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Kanylace tepny se využívá především k přímé monitoraci arteriálního krevního tlaku (TK). Lze kanylovat různé tepny. Přednost se dává distálním tepnám zásobujících region s kolaterálním, alternativním cévním vybavením: a. radialis, a. tibialis, a. dorsalis pedis. Použití větších tepen je metodou volby tam, kde předpokládáme významnou poruchu periferní vaskulární rezistence a zavedení kanyly v distálních oblastech je problematické.
POSTUP:
1. Dezinfekce místa vpichu a detekce pulzu

Nejprve je nutná pečlivá desinfekce místa vpichu a následná přesná<br /><br /><br />
detekce pulzu k určení místa vpichu

Nejprve je nutná pečlivá dezinfekce místa vpichu a následná přesná detekce pulzu k určení místa vpichu
2. Punkce a vyhledání tepny

Metodou Through and through projdeme skrz tepnu a následně se<br /><br /><br />
pomalu vracíme až detekujeme v zadní části kanyly krev

Metodou Through and through projdeme skrz tepnu a následně se pomalu vracíme až detekujeme v zadní části kanyly krev
3. Vlastní zavedení kanyly a fixace náplastí

Po detekci krve zasunujeme plastovou kanylu pres kovovou jehlu.<br /><br /><br />
Nasledně ji fixujeme náplastí, abychom předešli náhodnému povytažení

Po detekci krve zasunujeme plastovou kanylu pres kovovou jehlu. Nasledně ji fixujeme náplastí, abychom předešli náhodnému povytažení

Indikace:
– hemodynamicky nestabilní pacient: šokové stavy, hypertenzní krize, hypotenze
– nitrolební hypertenze
– nutnost podávání vazoaktivních látek: katecholaminy, nitroprusid sodný
– ventilačně nestabilní pacient (nutnost opakovaného a častého vyšetření krevních plynů)
– nutnost opakovaných krevních odběrů
– pravidelné odběry krevních vzorků
– angiografické vyšetření
– hemofiltrace/hemoperfuze
– měření cardiac output

Přímé měření krevního tlaku
Měření arteriálního tlaku je nezbytnou součástí sledování každého akutního stavu. Střední arteriální tlak (MAP) závisí na srdečním výdeji(CO) a systémovém odporu (SVR): MAP = CO × SVR. Rovnice sama ukazuje na hranice v měření arteriálního krevního tlaku. Krevní tlak (TK) neinformuje o proudění krve. Může být proto normální i při stoupajícím periferním odporu a současně se snižujícím srdečním výdeji, a tedy i při sníženém prokrvení orgánů. MAP tedy považujeme jen za hrubý indikátor prokrvení orgánů, zvláště když mnohé orgány mají autoregulaci, tj. jejich prokrvení je v širokém rozmezí perfuzních tlaků udržováno prostřednictvím změn cévního odporu konstantní. Arteriální TK měříme přímo nebo nepřímo.
Nepřímé metody – jsou jednoduché a neinvazivní.
Přímé metody – jsou invazivní, vyžadují vybavení a používají se jen v rámci speciálního nebo komplexního monitorování.
Rozdíly mezi nepřímým a přímým měřením krevního tlaku jsou zřejmé především u šoku, hypertenze, hypotermie a obezity.

Výhody přímého měření
– nepřetržité sledování
– trvalá přesnost měření
– rychlé rozeznání oběhových poruch
– přímé sledování hemodynamických účinků poruch srdečního rytmu
– nepřímé hodnocení kontraktility myokardu z rychlosti vzestupu arteriální tlakové křivky
– odhad tepového objemu ze systolické části tlakové křivky
– přístup do arterie k odběru krevních vzorků: ABR (Astrup) a další laboratoř

Praktické poznámky
– pokud se nedaří a místo kanylace je totálně rozpíchané, pomůže někdy napolohování končetiny do jiné polohy, ve které bude pulzace lépe hmatná
– pokud se nedaří a místo kanylace je totálně rozpíchané, pak místo, kde arterii trefíme, leží obvykle jinde, než střed našich marných pokusů.
– pokud arterii náhodně trefíme, ale nepodaří se zakanylovat, je třeba počítat s tím, že mohou vymizet její pulzace (jak z důvodu výronu krve, tak při vazokonstrikci cévy)
– dobrou variantou se zdá tento postup: u dětí, kde lze již použít Terumo kanylu 22 G – vést vpichy na oblast arterie pomalu, nevytahovat hned jehlu, zkoušet couvat a mírně měnit sklon vpichu. Zdá se, že takto by se při úspěšném propíchnutí arterie, měla objevit v konusu kapiláry skoro 100 % světlá kapka krve. Je třeba však po 3–4 „rejdech“ raději kanylu   propláchnout a vyklepat z ní vodu, protože existuje reálná možnost, že dojde k ucpání jehly.
– pokud chceme následně zavést delší arteriální katetr, je lépe vodič katetru zavádět až do zcela zasunuté kanyly. Zatím se zdá, že při kanylaci je úspěšnost zasunutí vlastní kanyly do arterie vyšší než zavedení vodiče skrze kanylu. Při zasouvání vlastní kanyly platí: v oblasti zápěstí Teruma zavádět bez proplachu, v oblasti a. brachialis a a. dorsalis pedis raději s proplachem (ostatní místa nejsou zatím probádána).
– u novorozenců počítat s velmi periferním uložením arterií. Proto je důležitá velká opatrnost při vytahování kanyly, protože lumen arterie se často nachází těsně pod povrchem, kde už zpravidla průběh arterie nepředpokládáme a při vytahování kanyly často vyjedeme z pod kůže ven.

ANESTEZIOLOGIE A URGENTNÍ MEDICÍNA

(vf)

Už to přestává být srandou, když zjistíte, že jste další na řadě :)

Už to přestává být srandou, když zjistíte, že jste další na řadě 🙂
(zdroj – text : http://www.wikiskripta.eu/index.php/Kanylace_tepny )

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