Here are some resources that I’ve found useful.
- How to scrub. This is often done badly in ED – there’s no excuse for this. Please make sure that the insertion site, the patient and the bed are all covered by drapes.
- Blind insertion. This is not recommended. There is a ton of evidence supporting the use of ultrasound.
- Ultrasound-guided insertion:
- The evidence
- IJV, SCV and femoral vein approaches
- transverse, longitudinal and oblique techniques
- How to confirm line placement and avoid complications.
- Using an angiocath instead of the needle to avoid inadvertent displacement outside of the lumen of the vein.
- Where should the tip sit?
- Setting up the transducer.
- Which ports to use?:
- distal port (usu ~ 16-gauge lumen): the largest lumen; used for CVP monitoring, emergency access, blood products
- medial and distal port (smaller lumens, more chance of extravasation): used for everything else
- don’t run anything else with inotropes/pressor
- radiocontrast media (RCM) – CAN go through the CVC – any port ≥ 18-gauge – check CVC type and max flow rate; discuss with radiology
After all of this, you should be a line guru!