Progressão do cateter central de inserção periférica em região hemiclavicular de recém-nascidos

Abstract

Objetivo: avaliar a progressão do cateter central de inserção periférica em região hemiclavicular direita, através da veia basílica e cefálica direita, em recém-nascidos. Métodos: pesquisa quase experimental, realizada em unidade neonatal. Amostra de 64 inserções de cateteres, em 58 recém-nascidos. A intervenção consistiu em manobra de elevação, protração e abaixamento do ombro, aplicada após não progressão do cateter, em região hemiclavicular, na punção direta em região cubital, em veia basílica ou cefálica direita. Resultados: das 64 inserções, progrediram sem manobra 28(43,7%); em mais da metade, aplicou-se manobra, obtendo-se 28(77,8%) progressões, sendo que 15(41,7%) progrediram após elevação, 12(57,1%) após protração e 1(11,1%) abaixamento do ombro, destes que progrediram, 21(75%) estavam em posição central. Verificou-se significância estatística (p<0,05) entre progressão com manobra e veia cefálica, progressão sem manobra e veia basílica. Conclusão: a intervenção facilitou progressão do cateter, principalmente por veia cefálica.

Maneuvers to Facilitate Central Venous Catheter Advancement in the Clavicular Region

“…The selected scientific articles allowed the detailed identification of the following maneuvers used in cases of nonadvancement of the CVC: abduction of the arm for insertion of the catheter at 90°; infusion of saline solution during the insertion of the catheter; head-turn supraclavicular pressure maneuver; shoulder elevation, protraction, and lowering (EPL) maneuver; anterior rotation of the shoulder with downward traction; internal rotation of the arm with upward pressure on the scapula; increased contralateral rotation of the head; twisting the head of the patient to the side of the vein; direct finger pressure on the ipsilateral internal jugular vein directly above the jugular notch; continuous Valsalva maneuver; ipsilateral shoulder elevation; twisting the head to the side of the vein that has been catheterized; and downward traction on the ipsilateral arm. Five articles in this review revealed the difficulty of catheter advancement 3,[12][13][14][15] for peripheral central insertion. One study addressed the central venous route, indicating that the catheter can be positioned in the central position, through both the central and peripheral routes.…”

“…Therefore, the shoulder and clavicle must be healthy and without fractures or dislocation so that the movement of the joint does not cause injury (Figure 2). 3 These analyses indicate that difficult catheter advancement may occur in both peripheral and central veins in adult, pediatric, and neonatal patients. The explanation for this phenomenon is that the catheter does not advance due to anatomic venous imperfections, narrow angles between the central vessels, venous spasms, and obstructions.…”

“…15 Only 1 article in this review addressed the nonadvancement of a CVC inserted in peripheral veins of neonatal patients. Nobre et al 3 suggested that the obstruction that makes catheter advancement difficult is in the hemiclavicular region, and they proposed an intervention capable of facilitating catheter advancement through the central venous system. The intervention consisted of shoulder elevation, protraction, and a lowering maneuver, applied after the catheter had not progressed in the hemiclavicular region by direct puncture in the cubital region, in the right basilic or cephalic vein.…”

“…Shoulder, arm, and head movements are maneuvers that facilitate advancement of the CVC in the shoulder and clavicular region and are associated with temporary changes in positioning of the shoulder and upper limbs, modifying the natural course of the large vessels and facilitating the rectification of probable venous curvatures, promoting the advancement of the catheter to the cavoatrial junction. 3,[12][13][14][15][16] Knowledge of anatomic variation of the clavicular region and shoulder can facilitate decision making regarding the insertion of a CVC and the use of practices that reduce nonconformity from the procedure. 17,18 The advancement of the CVC into the thorax is difficult, as described in a study conducted among adults, 19 which may be related to the acute angle at which the cephalic arch joins the axillary vein 4 to the venous plexus that exists between the external jugular vein and above the clavicle.…”

“…Figure2Maneuvering the shoulder in newborn (EPL maneuver) 3. Abbreviation: EPL, elevation, protraction, and lowering.…”