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Mdico utiliza os dedos indicador e mdio da mo no-dominante para sentir o pulso carotdeo 4. Avana a agulha de puno, lateralmente a este pulso, sobre o vrtice superior do tringulo, em direo ao mamilo ipsilateral, em um ngulo de 20 a 30 graus acima do plano da pele OBS: A VJI, na maioria das vezes, se encontra prxima o bastante da pele para ser puncionada com uma agulha hipodrmica simples.
Passa sob a clavcula e cruza a borda superior da primeira costela, para se juntar VJI, formando a veia briaquioceflica Procedimento. Paciente colocado em posio de Trendelenburg, com um coxim baixo entre as escpulas para afastar os ombros 3.
Mdico punciona a pele 2 a 3 cm distais do ponto mdio da clavcula 4. Avana a agulha na direo da frcula esternal, at que sua ponta atinja o ponto de transio entre os teros mdio e proximal da clavcula 5.
Avana a agulha, sob aspirao, imediatamente abaixo da clavcula, encostando na superfcie inferior da mesma. OBS: Caso no penetre sangue na seringa, a agulha deve ser retirada lentamente, mantendose a aspirao nesse momento, mtas vezes, ocorre identificao da veia e, em seguida, dar um direcionamento mais ceflico a ela.
A complicaes infecciosas e trombticas importncia da veia safena como potencial substituta arterial. Por outro lado, pode ser muito til em uma emergncia, para iniciar infuso rpida de solues cristaloides em situao de traumatismo dos MMSS ou como acesso temporrio em crianas.
Deve-se EVITAR disseco venosa perifrica em portadores de insuficincia renal crnica, j q eles necessitam de fstulas arteriovenosas para hemodilise, e as veias mais utilizadas para esse fim so as ceflicas e as baslicas Caso o acesso seja indispensvel e a puno central no seja possvel, devem ser examinadas as jugulares externas para cateterismo de VCS por tcnica de Seldinger se at estas estiverem indisponveis, a soluo utilizar mesmo as braquiais para o acesso provisrio Cateteres instalados em posio central em renais crnicos, seja por disseco direta seja por puno, devem, preferencialmente, usar a via jugular, j que a trombose da subclvia impossibilitaria a confeco de uma fstula arteriovenosa no membro afetado.
Disseces diretas de veias centrais, como subclvias, VJI ou femorais, so reservadas a situaes em que:. O cateter tem calibre superior ao das veias perifricas ex: cateteres de hemodilise So realizados procedimentos para implantes de cateteres centrais de longa permanncia, quando necessria a confeco de tneis subcutneos.
Nesses locais, disseco, isolamento e introduo do cateter podem ser feitos sem ligadura venosa distal, j que o calibre grande da veia permite a confeco de uma bolsa no ponto de interseo, com fio cirrgico vascular. Braquiais, formando a V. Axilar Acesso cirrgico para cateterismo da V. Baslica deve ser feito em seu segmento mais superficial, ou seja, perto do epicndilo medial do mero: inciso transversa ou longitudinal distncia de dois dedos proximais desse acidente sseo, podendo a veia ser identificada abaixo de um filete oriundo do nervo cutneo medial do brao.
Braquial profunda e est geralmente duplicada, seguindo contida em um feixe subfascial, junto com a A. Braquial e o N. Facilmente utilizadas para punes perifricas por isso, frequentemente apresentamse obstrudas no brao, qdo solicitado acesso cirrgico Geralmente encontram-se prvias em sua poro proximal, no sulco deltopeitoral, onde feita uma inciso longitudinal, com afastamento dos mm Acessos nesse segmento so mais comuns para instalao de marca-passos cardacos e cateteres de longa permanncia.
Pode ser isolada com rapidez, porm, acessos prximos prega inguinal apresentam maior ndice de infeco e trombose venosa, se comparados aos MMSS Inciso paralela prega inguinal e abaixo dela, a dois dedos mediais do pulso femoral veia femoral localiza. Safena ou V. Facial deve-se tomar cuidado com o ramo submandibular do nervo facial, neste caso.
Cabo de bisturi n 3 Lmina n 15 Tesoura Metzenbaum delicada Tesoura reta para fio. Pinas hemostticas tipo Halstead Porta-agulha Afastadores tipo Farabeuf ou afastador autoesttico Pinas de disseco e dente-de-rato. Escolha do cateter, de acordo com o calibre venoso 4.
Medida at a VCS, da seguinte maneira: com o membro superior em 9 graus com o trax, seguir uma linha reta do ponto da inciso at a cabea da clavcula direita e descer por trs espaos intercostais 5. Contra-abertura da inciso 6. Passagem do cateter pela contra-abertura com ligadura do reparo sobre a veia e o cateter 8. Insuficincia respiratria aguda por hematoma cervical Enfisema subcutneo Leso de plexo braquial Leso do ducto torcico esquerda Embolia gasosa Perfurao cardaca.
Imediatas Ligadura arterial inadvertida Leso de nervos perifricos Hematoma Perfurao venosa: hemo e hidrotrax Posio inadequada do cateter. Para pacientes neutropnicos, imunocomprometicos e outros pacientes de risco, cobertura para bactrias gram tb deve ser feita!
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