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