RU2770391C1 - Method for conducting and fixing an epidural catheter in the subcutaneous canal with removal to the anterior abdominal wall - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to anesthesiology, and can be used to insert an epidural catheter in the subcutaneous canal when performing combined two-level spinal-epidural anesthesia. Modification of the spinal needle is performed by breaking off the pavilion. Then the epidural catheter is fixed on a modified spinal needle by passing the proximal end of the needle inside the epidural catheter. Next, the modified spinal needle is advanced with an epidural catheter placed on it under the skin of the lumbar region with the first exit to the skin at the level of the scapular line and repeated insertion 10 mm medial and 10 mm above the exit point of the epidural catheter with the formation of a fixing cutaneous loop. Next, the modified spinal needle with an epidural catheter placed on it under the skin of the lumbar region is advanced towards the anterior abdominal wall with the exit of the epidural catheter to the skin of the anterior abdominal wall at the intersection of the horizontal line at the navel level and the vertical anterior axillary line. The epidural catheter is fixed on the skin.EFFECT: method makes it easy and less traumatic to insert an epidural catheter at a distance of up to 25 cm in the subcutaneous canal, to create conditions for long-term, without the risk of dislocation, keeping of the catheter in the epidural space due to the combination of techniques of the claimed invention.1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to anesthesiology. Epidural anesthesia and combined spinal-epidural anesthesia are methods without which it is impossible to imagine surgical interventions in many areas of surgery and traumatology. Highly traumatic surgical interventions objectively require prolonged postoperative analgesia. This task is successfully coped with by constant, within several (from 3 to 7) days, the introduction of a local anesthetic into the epidural space for the purpose of analgesia in the area of surgical intervention (Koryachkin V.A., Terrible V.I. Spinal and epidural anesthesia St. Petersburg Medical Publishing House, 2000. EA Lantsev, VV Abramchenko Anesthesia, Intensive Care and Resuscitation in Obstetrics Moscow: MEDpress-inform). The location of the epidural catheter in the subcutaneous canal makes it possible to keep the epidural catheter safe for a long time (the risk of infection of the epidural space is reduced) and makes it convenient for medical personnel to care for the epidural catheter (processing and changing the aseptic sticker becomes easier). The longer the inner part of the epidural catheter (from the epidural space to the exit to the skin), the less the risk of dislocation and prolapse of the epidural catheter and the occurrence of infectious complications

The closest to this method is the invention (patent RU No. 2727234 C 1, class IPC A61M 19/00 dated 07/21/2020). Along with the advantages, this method has several disadvantages. The first is the short length of the subcutaneous canal - 80 mm (the longer the subcutaneous canal, the stronger the fixation and the lower the risk of infectious complications). The second is that the exit site of the epidural catheter is located on the skin of the lumbar region, which makes it inconvenient to care for the epidural catheter. The position of patients in bed is usually on the back. Therefore, the exit site and the external maintenance part of the epidural catheter is located in an inaccessible area (back of the trunk), which makes it difficult to observe and maintain the epidural catheter. When patients are activated, there is a constant traction effect on the epidural catheter by flexion-extensor movements of patients. Because of this, the outer part of the epidural catheter can bend, up to critical kinks with obstruction, or be subjected to tension, which can lead to dislocation of the catheter from the epidural space and to inadequate pain relief, up to its termination. The longer epidural analgesia is performed with this method of fixing the epidural catheter, the greater the risk of dislocation of the catheter from the epidural space.

Disclosure of invention

We propose a new method for passing and fixing an epidural catheter in the subcutaneous canal, of a greater length (up to 25 cm) with the formation of a fixing skin loop of the epidural catheter and with the removal of the epidural catheter to the anterior abdominal wall during combined two-level spinal-epidural anesthesia. This method uses a modified spinal needle. To pass an epidural catheter in the subcutaneous canal with the formation of a skin fixing loop of the epidural catheter and its removal to the anterior abdominal wall, the following steps must be performed.

After catheterization of the epidural space at the level of L3-L4 (the catheter in the epidural space is inserted at a distance of 40-45 mm), below the position of the epidural needle, a skin incision is made with a 3-4 mm long guide needle for G 20 or G 22 spinal needles. the need to use a scalpel, since these needles are not inferior in sharpening to a scalpel. In order to create a convenient access for passing the needle, the skin incision is expanded with a mosquito-type surgical clamp. The epidural needle is removed. The epidural catheter is retracted upward, in a cranial direction. The skin and subcutaneous fat below the epidural catheter are anesthetized with a local anesthetic solution at a distance of 120-130 mm lateral to the epidural catheter site, at an angle of 90 degrees to the axial axis, and the skin and subcutaneous fat of the anterior abdominal wall are anesthetized along the anterior axillary line at the site estimated exit of the epidural catheter. The lumbar puncture is performed one segment higher at the L2-L3 level. After a local anesthetic has been injected into the spinal canal, the needle is removed. Next, the used spinal needle is modified (needle size G 26 - 120 mm). To do this, take the needle as close as possible to the needle pavilion with a surgical clamp and break off the needle pavilion. Since the spinal needles have a very small diameter (G 26 needle has an outer diameter of 0.45 mm), this manipulation is very easy to perform. The pavilion of the spinal needle is broken off with the mandrin removed. The next step is to fix the epidural catheter on a modified spinal needle.

The proximal end of the needle is passed into the epidural catheter for a distance of 5 mm to 10 mm (Fig. 1). The fixation is very strong, since the outer diameter of the spinal needle corresponds to the inner diameter of the epidural catheter. For example, the G 20 epidural catheter is ideal for the G 26 needle, and the G 19 catheter fits the G 22 needle. with an epidural catheter, it moves under the skin of the lumbar region in the lateral direction from the injection site (the first conduction is the first stage). After the needle has perforated the skin, advance it no more than 10 mm above the skin (FIG. 2). The perforation is expanded with a guide needle. To do this, a guide needle, corresponding in diameter to the spinal needle (for a G 26 needle, guide needles G 22-G 20 is suitable), a skin puncture is made at the exit point of the spinal needle, and the spinal needle enters the lumen of the guide needle. The guide needle perforates the skin for a short distance - no more than 5 mm. Next, the spinal needle is captured by the distal end with a surgical clamp and the needle with the epidural catheter dressed on it is smoothly removed (Fig. 3). An epidural catheter is placed under the skin of the lumbar region. Then a needle with an epidural catheter through a skin puncture, which is made at a point located 1 cm above and 1 cm medial to the exit point of the epidural catheter, is passed under the skin in the lateral direction towards the anterior abdominal wall to the level of the anterior axillary line (second injection - second stage ). The skin is perforated with a spinal needle on the anterior abdominal wall in the area of the anterior axillary line and removed 10 mm above the skin. The perforation hole is expanded with a guide needle according to the method described above. Next, the spinal needle is grasped by the distal end with a surgical clamp and the needle is smoothly removed with the epidural catheter dressed on it (Fig. 4). As a result of the second passage of the epidural catheter, a skin fixing loop of the epidural catheter is formed in the subcutaneous canal (Fig. 5). At the junction of the needle and the epidural catheter, the catheter is cut with scissors. The epidural catheter is removed, while carefully laying it in the subcutaneous canal, making sure that there are no kinks in the epidural catheter. Next, they are treated with an antiseptic solution and aseptic stickers are applied to the sites of epidural and spinal puncture, to the location of the fixing skin loop of the epidural catheter, and to the exit site of the epidural catheter on the skin of the anterior abdominal wall (Fig. 6).

The advantage of our proposed method lies in the fact that after combined spinal-epidural anesthesia, the used spinal needle after modification is used to pass an epidural catheter in the subcutaneous canal 20-25 mm long, the epidural catheter is brought to the anterior abdominal steak and a skin fixing loop of the epidural catheter is formed. The exit point of the epidural catheter is the intersection of the horizontal line at the level of the umbilicus and the vertical anterior axillary line. This method makes it easy and less traumatic to pass an epidural catheter in the subcutaneous canal over a long distance (up to 25 cm), to additionally ensure the fixation of the epidural catheter by its skin location in the form of a loop in the middle part of the subcutaneous canal, between two sections of the subcutaneous canal (first and second insertion) , and place the outer part of the epidural catheter on the front surface of the trunk, and not on the back of the trunk (back). Conditions are created for a long, without the risk of dislocation, finding the catheter in the epidural space. Conditions are also created for more convenient care of the epidural catheter, since the exit site of the epidural catheter and its outer part are located in the accessible visible zone of the anterior surface of the body (abdomen and chest).

On FIG. 1 shows the fixation of an epidural catheter on a modified spinal needle.

On FIG. 2 shows the passage of the epidural catheter from the central wound in the lateral direction in the subcutaneous canal using a modified spinal needle (first pass).

On FIG. 3 shows the extraction of a modified spinal needle with an epidural catheter on it and the passage of the epidural catheter in the subcutaneous canal of the lumbar region (the first passage is the first stage).

On FIG. Figure 4 shows the passage of an epidural catheter using a modified spinal needle from a point located 10 mm medially and 10 mm above the site of exit to the skin of the epidural catheter in the lateral direction in the subcutaneous canal with access to the anterior abdominal wall (second passage - second stage).

On FIG. 5 shows the process of forming a cutaneous fixing loop of an epidural catheter.

On FIG. 6 shows the final stage - the epidural catheter is brought to the anterior abdominal wall. Adhesive stickers are applied to the epidural catheter exit site on the skin of the anterior abdominal wall and the location of the epidural catheter fixing loop on the skin. The patient is in a horizontal position on the back.

Clinical example

Patient D., 80 years old. Diagnosis: Main: Closed pertrochanteric fracture of the left femur with displacement of fragments. Concomitant: coronary artery disease. ABS. Hypertension 3 tbsp., Arterial hypertension 1 tbsp. (medication achieved), the risk of CVC 3. CHF 1 (FC 2). Physical status according to ASA 2 Art. Operation: Open reposition of a pertrochanteric fracture of the left femur, osteosynthesis with a dynamic femoral screw.

30 minutes before the operation, the patient in the sitting position underwent a combined two-level spinal-epidural anesthesia. Epidural anesthesia set B/Braun, Tuohy needle G 18, epidural catheter G 20. Epidural puncture was performed in the interval L3-L4. An epidural catheter was inserted into the epidural space by 45 mm. Spinal puncture was performed in the L2-L3 interval with a spinal needle G 26 - 120 mm. A solution of the anesthetic bupivacaine hyperbaric 20 mg was introduced into the spinal canal. The spinal needle in a modified form was used according to the method described above for passing the epidural catheter in the subcutaneous canal at a distance of 24 cm with the removal of the epidural catheter on the skin of the anterior abdominal wall and the formation of a skin fixing loop of the epidural catheter. The outer part of the epidural catheter is passed along the anterior surface of the abdomen and chest. The port of the epidural catheter with an antibacterial filter is located in the left subclavian region and is fixed with a patch sticker. After passing and fixing the epidural catheter in the subcutaneous canal, the patient was placed in a horizontal position. The beginning of anesthesia 10 minutes after the introduction of the anesthetic into the spinal canal. Start of the operation 30 minutes after the start of anesthesia. The level of anesthesia to the navel (T10 level). The operation lasted 1 hour and 20 minutes. Postoperative analgesia was carried out in the intensive care unit, after a test dose, for 4 days with Naropin solution 2 mg/ml at a dose of 14 mg/hour. Treatment with an antiseptic solution of the exit site of the epidural catheter on the anterior abdominal wall, the location of the skin fixing loop of the epidural catheter and the central wound (epidural puncture site) and the change of aseptic stickers were carried out once a day without technical difficulties. No infectious complications were noted. The removal of the epidural catheter was performed 4 days after the installation of the epidural catheter without technical difficulties.

Claims (1)

A method for passing and fixing an epidural catheter in the subcutaneous canal and bringing it to the anterior abdominal wall with the formation of a skin fixing loop of the epidural catheter during combined two-level spinal-epidural anesthesia, including modification of the spinal needle, characterized in that the modification of the spinal needle is carried out by gripping the needle with a surgical clamp and breaking off the pavilion of the needle, then the epidural catheter is fixed on the modified spinal needle by passing the proximal end of the needle inside the epidural catheter at a distance of 5 mm to 10 mm, then the modified spinal needle with the epidural catheter put on it is advanced with translational movements under the skin of the lumbar area, thus forming a subcutaneous canal in two stages in the lateral direction from the exit site of the epidural catheter, at the first stage to the scapular line under the skin of the lumbar region and repeated injection 10 mm medially and 10 mm above the exit point of the epidural catheter on the skin of the lumbar region with the formation of a fixing skin loop of the epidural catheter; catheter on the skin of the anterior abdominal wall at the point of intersection of the horizontal line at the level of the navel and the vertical anterior axillary line, then the epidural catheter is fixed on the skin of the anterior abdominal wall and chest with patch stickers.

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