and John E. Skandalakis1
(1)
Centers for Surgical Anatomy and Technique, Emory University School of Medicine Piedmont Hospital, Atlanta, GA, USA
Abstract
Miscellaneous access device insertion procedures and diagnostic biopsy are presented. Meticulous technique during insertion will avert pneumothorax and vascular or nerve damage. Sural nerve biopsy is a well-established diagnostic procedure for peripheral neuropathies. Muscle biopsies can be useful to help diagnose patients with and without neuropathy who present with symptoms such as weakness, muscle pain, cramps, and fatigue with activity. Temporal artery biopsy is used to diagnose patients with symptoms such as fever, weight loss, or malaise and more specifically headaches, loss of visual acuity, diplopia, and temporal artery tenderness.
Technique
Device Insertion
Subclavian Vein Catheter Insertion
Step 1. Place the patient in Trendelenburg position.
Step 2. Prep and drape the subclavian area. Make sure that the sternal notch is visible.
Step 3. Infiltrate the skin with a local anesthetic just underneath the clavicle at a point approximately halfway to two-thirds out from the sternal notch. While doing this, make sure that the needle gently touches the clavicle. Then, step down the injection so that the position of the needle is underneath the clavicle. Do not go deep enough to access the subclavian vein.
Step 4. Use the Seldinger technique to access the subclavian vein. Access is accomplished by using the needle that has been provided in the kit. The needle punctures the skin and is directed underneath the clavicle and aimed towards the sternal notch. As the needle is advanced, gentle back pressure is placed on the syringe. As the needle is advanced when the vein is accessed, the syringe will easily fill with blood. If on the way in the vein is not accessed, slowly withdraw the syringe, keeping gentle negative pressure. Quite often the vein will be accessed as the needle is withdrawn.
Step 5. Once the vein is accessed, insert the guide wire through the needle and advance into the vein. Remove the needle and continue advancing the guide wire (15 cm should be adequate).
Step 6. Place the introducer sheath over the guide wire and advance.
Step 7. Remove the inner rigid portion leaving the peel-away introducer sheath and insert the catheter into the introducer. Advance approximately 15 cm and then peel away the introducer sheath, leaving the catheter in place.
Step 8. Identify and isolate the superior thyroid artery. Flush all ports and secure the catheter to the skin with a 20 silk suture.
