Central Line placement - PowerPoint Presentation

Slide1

Central Line placement

By Clare Di Bona

November 2015Slide2

Indications

IV Access

Difficult peripheral access

Irritant drugs

Chemo

TPN

Vasoactive drugs

ie

noradrenaline

Calcium chloride

KCL

CVP monitoring

Dialysis

Transvenous

pacingSlide3

Contraindications/precautions

Coagulopathy

Benefit versus risk

Femoral and IJV less risky than subclavian (can’t apply direct pressure over puncture site)

Respiratory failure

Difficult to lie flat therefore probably better to use the femoral approach

Raised ICP

Cannot tilt head down better to use the femoral approach

Other

Obstructed vein (thrombus, tumour)

Overlying skin infection, burn

Uncooperative patient…seriously reconsider or sedatives or after intubation if requiredSlide4

Complications/consent

Sometimes the patient is not fit to consent

ie

altered GCS, hypoxic, low BP….in this case act in the best interests of the patient

Otherwise it helps to keep the patient calm if you describe the procedure simply and talk frankly about risk versus benefitsSlide5

Complications/consent

Pneumothorax (highest subclavian)

Infection

Thrombosis including DVT

Hemorrhage

including

haemothorax

and haematoma formation

Arrhythmia on insertion guide wire

Guide wire embolus

Other: Air embolus, discomfort, unsuccessful procedureSlide6

Procedure

Preparation

Patient:

Is the patient stable

ie

can you lie them flat for a long period

Space at the head of the bed, exposure of the area

Staff: Need a dedicated nurse to help you draw up

Equipment

US machine positioned, turned on and set correctly

CVC line, cleaning equipment, local anaesthetic, suturing material, dressings, sterile gowns, drape, US probe cover, syringes for local and NS, drawing up needlesSlide7

procedure

-Prepare yourself: wash hands-

surgical wash, place on gown

and gloves using aseptic technique

-Prepare the Equipment:

Line it up in order, draw up local and Normal saline in separate syringes (different sizes and different colours!!), Prime the line, leave the brown portal open, remember all bungs need to be primed too

-Trendelenburg position patient, head to the left (get nurse to help)

-Prepare the patient: clean (circle from middle out-repeat three times), drape

-Prepare the US probe (cover

)

-Use landmarks (triangle formed by clavicle, lateral and medial head of sternocleidomastoid muscle target is the apex)

-Give local anaesthetic to the skinSlide8

Procedure

-At the apex of the triangle insert needle from the CVC kit (wide bore) to locate the IJV under US guidance by advancing and aspirating (head towards the ipsilateral nipple)

-Once blood is aspirating unscrew the syringe and hold needle in place, use thumb to cap it to prevent air embolism

-Thread through the guidewire to 20cm (2 black lines go through)

-Take out the needle

-Use scalpel to open the skin around the insertion of the wire (don’t cut wire!)

-Thread over the dilator then take it out

-Thread over the line….length=height/10 around 15-17cm for an adult.

NEVER LOSE SITE OF THE WIRE MAY HAVE TO PULL WIRE OUT A LITTLE IF IT GETS LOST IN THE CVC LINESlide9

Procedure

-Take the wire out

-Cap the brown port initially with thumb to prevent air embolus, then with bung

-Check all ports by aspirating and flushing with normal saline

-Suture in central line and place dressing over the top

-Check positioning

Use US to visualise the wire in the vein

CXR to check at junction of SVC and heart and to make sure no PTX

Blood gas if still unsure

-Document in notes: consent, procedure, depth of CVC Slide10

VIDEO

https://www.youtube.com/watch?v=Lb1Z3bndmA8