we discovered at registrar training last week that many of our team had not placed a central line so here is a walk through the process….
PREPARATION
Patient:
Why does the patient need CVC – access, multiple lumens, centrally active medications, monitoring
Where should the CVC go – IJ, subclavian, femoral
Position – complications to lying flat, Trendelenburg, sedation/intubated
Potential complications – bleeding, pneumothorax, failure
Consent the patient – procedure, options, complications (pain, allergic reaction, bleeding, pneumothorax, infection, failure, neuropraxia)
Equipment:
Set it up yourself
US – cover, sterile gel, positioning
Procedure tray – large area
Dishes – antiseptic wash, saline, disposing sharps
CVC kit – introducer/seeker, guidewire (check glides, some unwrap but care doesn’t become unsterile), dilator, CVC – check each lumen/leave brown uncapped, caps, adjustable hubs)
Syringes – 5ml for local, 20ml for saline + needles
Gauze
Gown, gloves, mask, goggles, drapes
Suture material and instruments
Local anaesthetic
Antiseptic skin wash
Clear dressing to fix line
Department:
Team – performing clinician, assistant, supervising doctor, backup
Monitoring of patient – ECG (BP + Sats if sedated)
Timing
Nurse in charge aware
PROCEDURE
Check vein with US first – position, anatomy, thrombus
Position patient/US/procedure tray/staff to monitor
Scrub hands, glove + gown
Wash patient + drape – large sterile area
Draw up LA
Position equipment in order of use so easy to reach
Check CVC lumens with saline flush + leave brown lumen uncapped
US to identify vein
50mg lignocaine with adrenaline into skin
Seeker needle with saline in syringe, using US in longitudinal to guide and cannulate vein
Hold with other hand to fix position on skin
Remove syringe
Feed guidewire, remove needle
Confirm position of wire with US before dilating
Dilate vein
Feed CVC with one hand always holding guidewire (care that wire does not become unsterile), depth determined by line markings 10-15cm – confirm ECG trace
Remove wire – announce to staff to document
Aspirate and flush each lumen before capping
Fix to skin with hub (clamp and fastener)
Suture 4 points (hub and distal) position
Cover with clear dressing
Confirm position with CXR
Dispose of sharps/wire and biohazard material
DOCUMENTATION:
Aseptic technique
Location
Local anaesthetic
Vein cannulated – number of attempts
Guide wire inserted, vein dilated, CVC inserted, GUIDE WIRE REMOVED, fixed at “x”cm
Complications
Confirmed with CXR – position in SVC at junction with RA (level of right main bronchus), no pneumothorax
For more information about MENTAL REHEARSAL and how this can help in critical situations and performing procedures, read this link:
EMCrit-RACC / EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria
Other key points: