2 English reference right catheterization
Insertion of right cardiac catheterization in 3 patients
Overview Fors * * * ann performed the right heart catheterization for the first time in 1929. 194 1 year, Coumand and Richards measured cardiac output through the right cardiac catheter. After that, right heart catheterization gradually attracted people's attention. 1953 Ratgora and Rahn of the University of Rochester used a blood flow guiding pulmonary artery catheter with a balloon in the head to block some pulmonary artery branches in animal experiments. By 1962, Wilson and others confirmed the value of central venous pressure detection in monitoring effective blood volume, which made this technology widely used in monitoring critically ill patients and achieved remarkable clinical results. At the end of 1960s, SwanGanz invented balloon floating catheter, which significantly updated and expanded the hemodynamic monitoring equipment and application scope. During 1970, Swan and others reported the results of balloon floating catheter monitoring in 100 critically ill patients, and thought that hemodynamic monitoring had important clinical value in pathophysiological diagnosis. Since then, with the continuous updating and improvement of right heart catheter technology and the improvement of operation technology, right heart catheter has been widely used to measure central venous pressure, cardiac output, right ventricular pressure, pulmonary artery pressure and mixed venous blood oxygen saturation, as well as atrial and ventricular pacing.
5 indications for right cardiac catheterization are as follows:
1. Monitor hemodynamics.
2. Determination of cardiac output.
3. Right heart and pulmonary angiography.
4. Endocardial myocardial biopsy.
5. Myocardial electrophysiological examination.
6. Acute drug trials.
6 contraindications There are no absolute contraindications for right heart catheterization, but the following points should be paid attention to in the implementation process:
1. People who are known to have hemorrhagic diseases or are receiving anticoagulant therapy, it is best not to have an examination. If you really want to do an examination, you should avoid puncturing the vein that is not easy to compress and stop bleeding.
2. If the puncture site is infected, the puncture site should be replaced.
7 Prepare 7. 1. 1. Check the equipment and articles needed for the right cardiac catheter. The commonly needed equipment includes cardiac catheter, puncture needle, guide wire, catheter, transducer and physiological multichannel instrument.
(1) cardiac catheter: the external diameter of the catheter is measured in French (f) units (1f = 0.335 mm or 0.0 13 inch). See table 1 for various cardiac catheter parameters. The length of adult right cardiac catheter is generally 100 cm ~ 65438+. Choose different catheters according to different diagnosis and treatment purposes. The general principles of catheter selection are: on the one hand, use as many catheters as possible to ensure the accuracy and fastest speed of pressure measurement when injecting dye or contrast agent; On the other hand, the minimum number of catheters should be selected as far as possible to reduce the occurrence of complications such as vascular injury, thrombosis and bleeding. For adult patients, cardiac catheter or angiocardiography can generally choose 7F or 8F catheter.
① Common right heart catheters: Common right heart catheters include Coumand catheter, Lehman catheter, GoodaleLubin catheter and balloon floating catheter. Coumand catheter is a reusable multi-purpose catheter, which has the characteristics of standard wall, end hole, gradually curved distal end and opaque X-ray. It can easily enter the right heart and can be used for pressure measurement and blood collection. Generally, the size is 5f ~ 8f, the length is 100cm and the length is 125cm. Lehman catheter is a thin-walled variant of Coumand catheter, and it is used in the same way as Coumand catheter. Its size is 4f ~ 9f, and its length is 50cm, 80cm, 100cm, 125cm. Goodalelubin catheter is characterized by two opposite side holes near its end hole, which can also be reused. It is a standard catheter for measuring right cardiac pressure and blood collection, but it is not suitable for measuring pulmonary artery incarceration pressure. The size is 4f ~ 8f, the length is 80cm, the length is 100cm and the length is 125cm. Balloon floating catheter is a kind of multi-lumen right heart catheter with balloon at the top, which is used to measure pulmonary artery pressure, pulmonary artery incarceration pressure and cardiac output. Adult urinary catheters 5F, 7F, 7.5F, length 1 10 cm. Children's catheters 4F and 5f with a length of 60cm; ; Balloon floating catheter can have 2 ~ 5 lumens, a distal thermistor for measuring cardiac output by thermal dilution method and a ventricular pacing electrode lead; One lumen of the double-lumen catheter is opened at the distal end for measuring pulmonary artery pressure and pulmonary artery incarceration pressure, and the other lumen is communicated with the balloon; The three-lumen catheter has a lumen opening at the distal end for measuring pulmonary artery pressure and pulmonary artery incarceration pressure, a lumen opening at the proximal end for monitoring atrial pressure, and a catheter communicated with the balloon; Three cavities of the four-cavity catheter are the same as those of the three-cavity catheter, and the top of the other cavity is a thermistor, which is connected with a computer through wires and used for measuring cardiac output by thermal dilution method; The five-lumen catheter has another lumen opening at the proximal end, which is used for infusion or administration when measuring cardiac output. Advanced balloon floating catheter can be equipped with optical fiber to continuously monitor the oxygen saturation of mixed venous blood.
② Contrast catheter: There are Gemini catheter, NIH catheter, Eppendorf catheter, Grollman pigtail catheter, Berman and Bynumwilson contrast catheter which can be used for right heart imaging. Gensini catheter has a diameter of 5f ~ 8f and a length of 80cm, 100cm and 125cm, respectively. There are two types of NIH catheters. USCI NIH catheter has a diameter of 5f ~ 8f and a length of 50cm, 80cm, 100cm and125cm. . The diameter of Cook NIH catheter is 6.5F, 7.3F and 8.2F, and the length is 1 10cm. The diameter of Eppendorf catheter is 7F and 8F, and the length is 100cm and 125cm. There are two kinds of Grollman pigtail catheters, the standard Grollman catheter has a 60 bend, and the other Grollman catheter has two bends, namely a 60 bend and a reverse bend. Berman and Bynumwilson contrast catheters have balloons at the front ends, which belong to blood flow-oriented contrast catheters and can be used for hemodynamic monitoring and comparison at the same time.
③ Disinfection and preservation of catheters: At present, catheters on the market are mostly disposable products, especially multi-lumen balloon catheters. However, due to the high price of catheters, some domestic units still reuse them to a limited extent. Therefore, the catheter should be cleaned and disinfected by appropriate methods, and the catheter should not be damaged. Cleaning should generally be carried out according to the following steps: a. Clean the catheter lumen and surface washing with clean water immediately after use; B, adopting a pressurized washing device and washing with clean water for 30-60 minutes; C, cleaning in a decontamination solution for 30 minutes; ; D, pressurizing and flushing the catheter with 100ml decontamination solution; E. pressurize the catheter with 100ml distilled water; Dry the catheter. Generally, the catheter is disinfected with ethylene oxide or formaldehyde gas 10h or more, and washed with sterile liquid before use. Usually, the catheter is stored by vertical suspension.
(2) Puncture needle: The puncture needle used in cardiac catheterization is a percutaneous puncture needle, which includes three types: single-group minute hand, double-group minute hand and three-group minute hand. Single-component needle is the most commonly used puncture needle at present, which is used for single-wall puncture of arteries and veins, such as percutaneous subclavian, internal and external jugular vein puncture. The double-group minute hand is mainly used to puncture and fix the blood vessel, with both front and rear walls penetrating, exiting the needle core, and slowly withdrawing the trocar into the blood vessel. Three sets of minute hands are rarely used at present.
(3) Guide steel wire: The guide steel wire is made of stainless steel wire finely wound on the inner core of straight steel wire. When used for cardiac catheterization, the catheter is extended to facilitate percutaneous insertion of catheter or guide tube through curved blood vessels. The ideal guide wire requires the following properties: ① it has enough hardness to avoid loop formation in blood vessels when it is sent forward; (2) It has enough flexibility, can be greatly bent without breaking, and reduces vascular injury; ③ Proper smoothness. Due to the special structure of the guide wire, it is not easy to clean it thoroughly. It is generally recommended to guide the steel wire to be used once, and the unused steel wire can also be disinfected by gas disinfection when it is polluted.
(4) Catheter and sensor: Catheter consists of a conical expansion tube and a slightly shorter sleeve. At present, most guide tubes are equipped with hemostatic valves at the end of the cannula to reduce the incidence of bleeding, thrombosis and air embolism during intubation. Side arm tubes can be used for infusion, medication and pressure measurement. The use of catheters provides great convenience for replacing catheters and placing multiple catheters.
The sensor can convert the pressure signal into an electrical signal. The ideal sensor has the advantages of accurate pressure measurement (the reading error is within 1mmHg), good linearity (the measured value is accurate in the measured pressure range), stable temperature (generally, the measured pressure error is less than 2.5mmHg in the temperature range of 15℃ ~ 30℃), seismic insulation and convenient use.
(5) Physiological multichannel instrument: it is mainly used to record various changes of pressure, oxygen saturation, electrocardiogram, respiration and temperature. Generally, four physiological recorders or eight physiological recorders are selected.
7.2 2. Preparation before examination (1) Preoperative examination: A detailed understanding of medical history, physical examination and other examination results is helpful to avoid complications. For patients who use aspirin and other drugs, they should stop using 10 days before operation. The following routine examinations should be completed before operation: blood routine, platelet count, bleeding time, coagulation time, prothrombin time and partial prothrombin time. For patients with abnormal coagulation function or arrhythmia, corresponding treatment should be given, and examination can only be considered after the condition is controlled.
(2) Obtain consent: The patient should be informed of the purpose and necessity of right heart catheterization before the examination, so as to eliminate the worries of the patient and actively cooperate with the examination. When necessary, explain the operation process and some possible situations to the patient, obtain the consent of the patient and his family and sign the operation consent form.
(3) Preparation of examination room: The examination of the right cardiac catheter must be carried out under aseptic conditions. The examination room is generally an operating room or a strictly disinfected ward, and should be equipped with corresponding rescue facilities. And prepare the following supplies: local products; Surgical sheets, cloth towels and towel clips; Small square yarn; 5ml and 10ml syringes; Sterile heparin saline and its container; Lidocaine; One-component or two-component puncture needle; Guide steel wire, expansion tube, conduit, sensor, liquid pipeline and joint; Surgical blades and handles; Hemostatic forceps; Dentate tweezers; Needle holder, leather sewing needle, silk thread; Cardiac catheter; Monitoring equipment; Dirt container; Blood transfusion support; Specimen bottle; Cardiopulmonary resuscitation equipment.
Right cardiac catheterization can be performed under fluoroscopic or non-fluoroscopic conditions. In general, the right cardiac catheterization through femoral vein and the choice of pacemaker placement must be made under fluoroscopy. For balloon floating catheter placed through elbow vein, subclavian vein or internal jugular vein, the position of catheter tip can be determined by the waveform change on the display without fluoroscopy assistance.
(4) Operator staffing: including a physician with rich experience in vascular intervention technology and an assistant to assist in the operation.
(5) Equipment preparation
① Connect pressure gauge, sensor and monitor:
A connect the sensor wire to the pressure monitor, ground the pressure monitor, and then turn on the power switch of the monitor.
B inject heparin into a pressurized infusion bag filled with normal saline at a dose of 1 ~ 2u/ml.
C. Drop a few drops of liquid on the diaphragm of the aseptic sensor and connect the sensor head end. Note that there should be no bubble residue at the joint of the two parts.
D. Connect the pipeline system and infusion bag as shown in figure 1, and close the exhaust cover of the three-way switch.
② Zero adjustment of sensor and monitor: both the sensor and monitor should be zeroed before measurement, and zeroed every 4 hours during monitoring. The method is as follows, as shown in Figure 2.
A. Place the sensor in the horizontal position of the patient's right atrium and turn on the ventilation switch of the sensor.
B. Press the monitor zero control button to obtain the zero point, adjust the scan curve of the monitor and determine the zero point.
C. Press the display calibration button to adjust the scanning line to a proper position.
D. turn off the ventilation switch of the sensor.
Method 8. 1. 1. Patients * * * Patients * * generally take the supine position to fully expose the puncture site. For the convenience of operation, cushions can be used for local support. During the operation, the patient's * * * should remain relatively unchanged.
8.2 2. Determination of puncture site Choose different puncture sites according to the operator's experience and habits and different inspection purposes. Pulmonary artery intubation can choose internal jugular vein, subclavian vein, basilic vein or femoral vein, as shown in Figure 3. The advantages and disadvantages of different intubation routes are shown in Table 2.
8.3 3. Operators should wear masks and hats, wash their hands with surgical brushes and disinfectant, put on surgical gowns, disinfect the skin at puncture points, wear sterile gloves and spread sterile hole towels or surgical towels.
8.4 4. Right cardiac catheterization was performed with anesthesia and local anesthesia. Lidocaine is the most commonly used local anesthetic with rapid action. The general dose is 5 ml ~ 20 ml of 1% lidocaine, and the maximum dose is 300mg (without adrenaline) and 500mg (with adrenaline). Procaine can also be used, the maximum dose is 1mg/kg (without adrenaline). During local anesthesia, use a syringe to obliquely puncture the skin, inject a proper amount of local anesthetic (0.5ml) to form a small pitch, gradually insert the needle along the predetermined puncture direction, and slowly inject local anesthetic in multiple directions. Before each injection, the syringe should be withdrawn to ensure that the needle is not in the blood vessel. Every time you change direction, you must first retreat the needle to the skin and then insert the needle. After anesthesia, before withdrawing the syringe, locate the vein by sucking blood back from the syringe, then withdraw the syringe, keep the needle in the blood vessel, and press the needle tail with your thumb to prevent bleeding. During the formal puncture, the catheter puncture needle can be sent out along this route. Locating vein in this way can reduce the risk of puncture needle mistakenly penetrating artery.
8.5 5. Operation flow 8.5. 1 (1) The basic operation steps of intravenous intubation are shown in Figure 4.
① Make a small skin incision with a sharp blade (2 mm ~ 3 mm in length); Bluntly separate subcutaneous tissue along the vascular direction with vascular forceps.
② Puncture the blood vessel with a thin-walled puncture needle with an insertion angle of 30 ~ 40; In the case of good blood return, reduce the needle insertion angle, and then slightly insert the needle along the direction of the blood vessel to ensure that the needle is located in the blood vessel.
③ Insert the soft end of the guide wire with appropriate size, so that it extends out of the needle tip and enters the blood vessel 15 cm ~ 20 cm.
(4) Fix the guide wire with the thumb and forefinger of one hand to prevent it from moving, put the other three fingers above the puncture point to pressurize, and pull out the puncture needle with the other hand; Wipe the guide wire with sterile wet gauze.
⑤ Insert the catheter from the tail of the guide wire. Pay attention to keep the length of the guide wire exposed from the tail of the catheter above 10cm before the catheter enters the skin.
⑥ Hold the catheter close to the skin together with the guide wire, and rotate slightly to push the tip of the catheter through the skin and into the blood vessel, and continue to feed the catheter along the blood vessel direction. Pay attention to always keep a guide wire outside the tail of the catheter.
⑦ Remove the guide wire, aspirate and flush the catheter to remove the blood clot and ensure that the catheter is in the blood vessel.
8.5.2 (2) Pulmonary artery intubation ① Insert the catheter into the vein through the catheter and gently move forward. If the catheter is punctured in internal jugular vein, subclavian vein or elbow vein, the balloon will be partially filled when the front end of the catheter reaches the superior vena cava, and it can be found that the pressure curve changes with breathing. At this time, the patient coughs and the pressure fluctuates greatly, which can confirm that the catheter has entered the chest cavity.
② When the catheter reaches the right atrium, the balloon is inflated to 0.8 ml ~ 1.0 ml, and the right atrial pressure wave should be observed, including an A wave, a V wave and a fashionable C wave.
③ When the electrocardiogram is closely monitored and there is no ventricular arrhythmia, the catheter is gently sent into the right ventricle, and the right ventricular pressure waveform can be seen, which is a waveform with large amplitude, high systolic pressure waveform and low diastolic pressure waveform.
④ Continue to push the catheter until the pulmonary artery pressure waveform is observed, which is a high-level pressure waveform with small amplitude, high systolic pressure waveform and high diastolic pressure waveform. If the catheter length has reached 15cm, there is still no pulmonary artery pressure waveform. It may be that the catheter is circling in the right ventricle, so the catheter should be slowly retreated to the right atrium and then pushed into the pulmonary artery. Different veins are selected for puncture, and the length of the catheter that needs to enter the blood vessel to send the catheter into the pulmonary artery is different, as shown in Table 3.
⑤ If it is necessary to measure pulmonary artery incarceration pressure, the catheter can be sent forward while keeping the balloon inflated until the balloon is embedded in the medium-sized pulmonary artery and cannot move forward, so as to obtain pulmonary artery incarceration pressure. After the measurement, loosen the inflatable syringe and let the balloon deflate automatically, and the waveform can be restored to pulmonary artery pressure waveform.
⑥ Check the position of the catheter front end and the direction of the catheter in the heart with fluoroscopy or chest X-ray to reduce the * * * effect of the catheter on the ventricular wall.
⑦ After sucking out and flushing the proximal lumen of the catheter, connect it to the continuous flushing system, and use the three-way piston steering sensor for steering when measuring the pressure.
⑧ Suture the catheter and guide tube on the skin near the puncture point. After local disinfection, it was covered with sterile dressing and fixed with adhesive tape.
8.5.3 (3) Monitoring of pressure ① Right atrial pressure: When the catheter reaches the right atrium, the pressure wave in the right atrium can be seen, which consists of an A wave and a V wave, and a C wave can be seen in fashion, as shown in Figure 5A. Its average pressure is about 0.27 ~ 0.80 kPa (2 ~ 6 mm Hg). There is no A wave in patients with atrial fibrillation, but there is a high A wave when atrioventricular separation occurs.
② Right ventricular pressure: When the catheter further enters the right ventricle, the pressure suddenly rises and a right ventricular pressure wave appears, as shown in Figure 5B. When the ventricle contracts, its pressure is equal to the pulmonary artery systolic pressure, which is about 2.67 ~ 4.0 kPa (20 ~ 30 mmHg), but the diastolic pressure drops to 0 ~ 0.67 kPa (0 ~ 5 mmHg).
③ Pulmonary artery pressure: If the catheter is sent forward, pulmonary artery pressure wave can be recorded, as shown in figure 1 15C. The systolic blood pressure is high, which is similar to the right systolic blood pressure, about 2.67 ~ 4.0 kPa (20 ~ 30 mmHg). The diastolic blood pressure is still at a high level, which cannot be recovered to zero, and it is about1.07 ~1.60 kpa (8 ~12 mmhg). Common heartbeat waveform; Generally, it is necessary to measure its average pressure, which is about1.33 ~ 2.67 kpa (10 ~ 20mmhg).
④ Pulmonary artery incarceration pressure: keep the balloon inflated, and then send it into the catheter, and a pulmonary artery incarceration pressure waveform appears, which represents the pressure formed in the opposite direction of the left atrium, including an A wave and a V wave, and sometimes a C wave can be seen, as shown in Figure 5D. Its average pressure is about 0.53 ~ 1.60 kPa (4 ~ 12 mm Hg). Under normal circumstances, pulmonary artery incarceration pressure is close to pulmonary artery end diastolic pressure, so it is not necessary to measure pulmonary artery incarceration pressure to reduce the occurrence of complications. However, for patients with pulmonary hypertension, pulmonary embolism, severe hypoxemia or heart rate exceeding 120 beats/min, there is a big difference between pulmonary artery end diastolic pressure and pulmonary artery incarceration pressure, so pulmonary artery incarceration pressure must be measured.
8.5.4 (4) The determination of cardiac output was first reported by Fegler in 1954, with temperature as the indicator and based on the indicator dilution principle. Thermal dilution catheter, thermistor and cardiac output computer are needed for measurement. You can use a liquid at room temperature or ice temperature as an indicator, and the method is basically the same. Ice temperature measurement method is mostly used in China. According to the change of indicator temperature, the computer calculates the cardiac output through the following formula.
Where Vi is indicator capacity, (TBTi) is the difference between blood temperature and indicator temperature, K 1 is the ratio of specific heat and specific gravity of indicator to blood, K2 is the coefficient of temperature change of liquid in catheter, catheter dead space, injection speed and conversion unit, and TB(t)dt is the blood temperature integral changing with time.
The steps of measuring cardiac output with ice temperature as an index are as follows:
① Put 5m indicator liquid and temperature probe into ice bath for more than 5 minutes.
② Perform computer self-check before monitoring, and press the "self-check" button of the computer. When the word "Ready" appears, press the "Start" button, the display will show "0.00", and then the word "OK" will be displayed in 15s, indicating that the computer is working normally. Generally, you only need to check yourself once a day.
③ Press the "indicated temperature" and "blood temperature" buttons respectively to measure the indicated temperature and blood temperature.
④ Input the correct calculation constant into the computer, and the value of this constant can be found on the catheter package.
⑤ Suck 10ml indicator liquid and press the "cardiac output" button.
⑥ When the word "Ready" appears on the display screen, connect the syringe to the proximal lumen of the catheter.
⑦ Press the "Start" button, immediately inject the indicating liquid into the syringe evenly and quickly within 4s, observe the shape of the simulated curve, and judge whether the injection meets the requirements, as shown in Figure 6.
⑧ Repeat steps ⑦ ~ ⑦ to measure cardiac output again.
Generally, it must be measured at least three times to calculate its average value. If there is a big difference between the three measured values, the number of measurements should be increased to obtain a more accurate average.
8.5.5 (5) The normal values of pulmonary circulation indexes detected by right cardiac catheterization are shown in Table 4.
8.5.6 (6) Collection of samples Blood samples were collected from pulmonary artery to determine the oxygen saturation of mixed venous blood. For patients with suspected left-to-right shunt, blood samples of pulmonary artery and right atrium can be collected to observe the difference between them, which has diagnostic value. In order to ensure safe sampling and obtain qualified specimens, blood collection should be carried out according to the following steps.
① Use an empty needle to extract about 5ml of blood from the catheter and discard it, and then use another empty needle to extract blood samples.
② Blood sampling should be done slowly to reduce the chance of hemolysis. When collecting blood gas analysis samples, the needle should be emptied with heparin. After obtaining enough blood samples, the air in the needle should be exhausted, sealed and stored, and immediately sent for inspection or stored in an ice bath for a short time.
(3) Immediately after sampling, the catheter should be washed quickly to remove the blood in the tee and catheter, so as to ensure the patency of the catheter.
8.5.7 (7) After monitoring the removal of pulmonary artery catheter, remove the pulmonary artery catheter according to the following steps. First, explain the extubation process and possible feelings to patients; Then, according to the position of venipuncture, let the patient take the lying position or supine position (puncture of internal jugular vein and subclavian vein); Under the condition that no abnormal electrocardiogram is detected, the gas in the airbag is sucked by a syringe for active exhaust; Take off the dressing, cut the suture, and quickly retreat the catheter to the front position of the catheter, so that the patient can pause breathing and pull out the catheter together; Immediately press the puncture site, disinfect it locally with disinfectant and cover it with dressing. If the catheter is retained for a long time, the skin puncture point should be closed with oil gauze to prevent air embolism.
9 Complications Right heart catheterization is safe and the incidence of complications is low. However, in the process of pulmonary artery intubation and long-term monitoring, serious complications sometimes occur, even leading to the death of patients. The complications that should be paid attention to in right cardiac catheterization are as follows.
9. 1. 1. Complications of venous puncture and intubation In the process of venous puncture and intubation, the common complications are: local hematoma, thrombosis, phlebitis, accidental arterial puncture, nerve injury, infection, air embolism, pneumothorax and hemothorax. Among them, air embolism and pneumothorax are more serious, which can endanger the life of patients. However, puncture in strict accordance with the operating procedures can significantly reduce the occurrence of complications.
(1) Pneumothorax: Pneumothorax was found in patients who received subclavian vein puncture and internal jugular vein puncture, which was caused by the puncture needle injuring the pleura at the lung apex, and the incidence rate was about 1% ~ 10%. For patients with chronic obstructive pulmonary disease, it is easy to be injured accidentally because of the elevation and expansion of the lung apex. When pneumothorax occurs, patients may have obvious chest pain, and then they may have clinical manifestations of dyspnea, which is related to the speed and volume of gas entering pleural cavity. Once pneumothorax caused by puncture is found, it should be treated according to its clinical manifestations and pneumothorax volume. The specific methods include thoracic puncture and water-sealed bottle drainage. See chapter 16 for details. Measures to prevent pneumothorax include: patients with chronic obstructive pulmonary disease should choose other puncture sites as far as possible, or avoid puncture points not too far from the outside, puncture not too deep, and minimize puncture times. If the puncture times have reached three times, the other side should be selected for puncture.
(2) Air embolism: Air embolism is extremely rare, but its mortality rate is as high as 50%, which is caused by air entering the blood circulation through an open venous pipeline during surgery, and it is common in patients undergoing internal jugular vein and subclavian vein puncture. Gas can enter the vein through the following ways: ① when puncturing, it enters through a puncture needle or cannula; (2) After placing the tube, the conduit or connecting tube is not well sealed and leaks; ③ After extubation, enter through subcutaneous tunnel. Extensive 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 supine position, given high concentration oxygen inhalation and auxiliary ventilation, or hyperbaric oxygen therapy, and can be pumped through the pulmonary artery catheter. Cardiopulmonary resuscitation should be performed when cardiac arrest occurs. Preventive measures for air embolism include operating in strict accordance with the operating procedures, paying attention to pressing the tail end of the puncture needle and catheter or using a cannula with an air valve, carefully checking and connecting all connectors, and paying attention to the replenishment of liquid in the infusion bottle.
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9.2 2. Complications of hemodynamic monitoring In the process of hemodynamic monitoring, there may be some complications, especially arrhythmia, thrombosis, pulmonary infarction, pulmonary artery rupture and infection.
(1) Arrhythmia: Arrhythmia is the most common complication, especially ventricular premature beats and non-persistent ventricular tachycardia. When the catheter enters the heart cavity, arrhythmia will appear in the myocardium. Usually the attack time is short, and the catheter disappears quickly after entering the pulmonary artery. Generally, no special treatment is required. However, in rare cases, ventricular fibrillation will occur and electrical defibrillation is needed immediately.
(2) Thrombosis: After the catheter enters the blood vessel, endothelial cells, platelets and fibrin aggregate to form thrombus, which can cause the platelet count to decrease. Thrombosis can block pulmonary artery branches and cause pulmonary infarction. Continuous flushing of pipeline with heparinized normal saline can reduce the formation of thrombus.
(3) Pulmonary infarction: Pulmonary infarction can be caused by catheter incarceration for too long or thromboembolism. The patient has obvious chest pain, dyspnea, cough, hemoptysis and severe hypotension. Measures such as minimizing catheter incarceration time and preventing thrombosis can reduce the occurrence of pulmonary infarction.
(4) Pulmonary artery rupture: After the catheter enters the pulmonary artery, it may be caused by excessive feeding of the catheter tip, excessive inflation of the balloon, or eccentric inflation of the balloon, which forcibly washes and blocks the catheter. Pulmonary hypertension, the elderly or patients with heart disease are more likely to have this complication. Once it happens, it often leads to the patient's rapid death. The rupture of pulmonary artery can be prevented by continuously observing the pressure at the end hole of the catheter, ensuring that the catheter is located in a larger pulmonary artery, reducing the times of balloon inflation, slowly inflating the balloon, and emptying the balloon before irrigation.