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V předchozím článku jsme probrali periferní žilní systém. nyní si řekneme něco málo o centrálních žilních přístupech.

 Centrální žílyJaké jsou indikace ke kanylaci centrální žíly?:
– nutnost velmi rychle a masivní objemové náhrady
– parenterální výživa
– nemožnost zajistit vstup do krevního řečiště cestou kanylace periferních žil
– měření centrálního venózního tlaku a zavedení katetru pro měření tlaku v plicnici
– infuzní podání katecholaminů
– potřeba hemodialýzy, hemoperfúze, kontinuálních eliminačních metod
– zavedení dočasné kardiostimulace

Jaké máme místa vstupu?:
– v. jugularis int.
– v. subclavia
– v. brachiocephalica
– v. femoralis

Kanylace centrální žíly sebou nese i komplikace, podívejme se tedy na nejčastější komplikace:
– pneumothorax (častější při kanylaxi v. subclavia než při kanylaci v. jugularis int.)
– krvácení
– trombóza (častější při vícedenní kanylai v. femoralis u dospělých)
– infekty a katétrové sepse (nižší frekvence jsou u přístupu podklíčkovou žilou než vnitřní jugulárkou)

 

 

 

 

 

Centrální katetr 1
Centrální žilní katetr zavedený levou v. subclavia, který je nesprávně hluboko. Hrot zasahuje až do dolní duté žíly . Přílišná delka katetru zvyšuje riziko trombotických a septických komplikací.

Subclavialní katetr
Subklaviální katetr, který je rozlomený na čtyři kusy a embolizovaný do plicního řečiště. V tomto případě bylo na vině použití starého materiálu.

Hluboce zavedený katetr
Nesprávná poloha hluboko zavedeného centr. katetru z periferie (v tomto případě z pravé kubity). Katetr vjel do pravostranné v. jugularis int. a stočil se do smyčky.

Kanylace centrální žíly periferním přístupem:
Při této metodě se jedná o zavedení dlouhého plastového katetru z periferní žíly na horní končetině, zpravidla z kubity nebo z předloktí v povodí v. basilica, s uložením hrotu katetru až do dolní duté žíly. Tyto kanylace jsou při zachování striktně sterilního způsobu ošetřování spojeny s nižší frekvencí katetrových infektů a sepsí. Lze je udržovat desítky (výjimečně až stovky) dní. Jsou spojeny s nižším rizikem iatrogenního poranění (krvácení, PNO,…) a přitom si zachovávají příznivé vlastnosti centrálních žilních katetrů – možnost podávání koncentrovaných roztoků, katecholaminů, příp. měření centrálního venózního tlaku.

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