What Should The Sonographer Do When The Needle Is Punctured Under The Guidance Of B Ultrasound? How Can We Achieve Aseptic Operation?

In the past, conventional pericardial effusion puncture was performed only by experience and feeling, which was more likely to injure the lungs and liver organs, or penetrate the myocardium too deeply by mistake, resulting in serious consequences. Since 2001, B-ultrasound has been used in our hospital to guide 17 patients aged 8 to 49 during puncture, avoiding blindness. Among them, 8 cases had suppurative pericardial effusion, 5 cases had tuberculous pericardial effusion, and 4 cases had tumor metastatic pericardial effusion. A total of 22 puncture times were performed, all of which were successful. The specific operation method is reported as follows.

First of all, preparations were made before puncture. Three routine examinations, blood biochemistry, coagulation time, cardiac X-ray and electrocardiogram were performed on the patient, and two-dimensional cardiac echocardiography was performed with a common probe to understand the location and amount of pericardial effusion and determine the puncture site. During puncture, puncture instruments, patient position, and other practices are the same as conventional puncture, which is performed jointly by clinicians and sonographers. Specific practices are as follows. (1) Strict aseptic operation: the probe with guide groove and coupling agent should be disinfected before operation. The sonographer should wear disinfection gloves during operation, and a large area of the patient's precardiac area should be disinfected, so that the probe has room to move in the exploration. (2) Selection of puncture points: two puncture points were used for conventional puncture, one was 1 ~ 2cm below the intersection of the sternal xiphoid process and the left costal margin; One is the left margin of the sternum in the fifth intercostal heart flap boundary 1 ~ 2cm. According to the ultrasonic image display, select the most fluid accumulation, can avoid the adjacent organs and heart beat the most obvious parts, to carry out a certain range of adjustment. (3) Limit the maximum length of needle insertion: After the puncture point is determined, the distance between the skin and the myocardium at diastolic stage is measured according to the ultrasonic exploration image, and the distance is shortened by more than 0.5cm, so as to limit the maximum length of needle insertion and keep a certain distance between the needle and the myocardium, so as to avoid the injury of the myocardium due to the shortening of the distance between the needle and the myocardium due to the reduction of fluid during the extraction. (4) Guided puncture under ultrasonic monitoring: the probe was used to determine the puncture site and the direction of injection. When the puncture point was made under the xiphoid process of the sternum, the sound beam pointed to the left shoulder and formed a 30° Angle with the skin. When the puncture point is made at the fifth intercostal point at the left margin of the sternum, the sound beam should be vertically backward or slightly inward backward. After the location to be reached by the needle is determined and the maximum length of needle insertion is limited, the needle can be slowly inserted along the guiding groove of the puncture probe under the guidance of ultrasound. When the needle is inserted into the pericardium, the ultrasound image can be displayed, and there is a feeling of disappointment. Then continue the needle, so that the needle to the intended site, the needle must be at a distance from the heart muscle. When the needle is inserted into the pericardium, there is a more obvious feeling, at this time can be evaluated whether the pericardium is thickened. Generally can feel pericardium toughness, slightly resistance. If the resistance becomes larger and there is a certain hardness, the pericardium is thickened and there is a tendency to develop constrictive pericarditis. (5) The puncture site should be the deepest part of the fluid accumulation, and the liquid dark area above 2.5cm is safer. When the needle reaches the predetermined site, the fluid can be extracted under supervision. When pumping, the needle should be fixed, and the pumping should not be too thorough. When the liquid dark area is reduced to about 1cm, the pumping should be stopped to prevent the needle from injuring the heart. For children, a suction is usually 200 ~ 300ml, and for adults, a suction is usually 400 ~ 600ml. (6) After the liquid extraction, the puncture needle should be slowly pulled out under ultrasonic monitoring, and the puncture site should be disinfected and bandaged with iodine.

In conclusion, B-ultrasound-guided pericardial effusion puncture is safe and convenient, avoiding some injuries caused by blind puncture in the past. So that clinicians can identify the cause of disease in time, effective treatment.