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Clinical Procedures - Non Invasive Ventilation ( CPAP)
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
CAP = continuous positive airways pressure. CAP traditionally
has its own equipment and 'set-up'. Recently more clinicians are delivering CPAP through the BiPAP Vision@. There is also a
'low-flow' version used mainly for transport of CPAP-dependent patients.
Equipment
)rd
• Mask (‡ T-piece), hood
• Head strap (mask), shoulder straps (hood)
• Oxygen circuit and humidification
• High flow generator (e.g. Whisper Flow®, Vital Signs®)
• Positive end-expiratory pressure (PEEP) valves (usually 5, 7.5, or 10cmH,O)
• 'Blow off' safety valve (10cmHO above the PEEP used).
Procedure
• Use available templates to assess appropriate sized interface and minimize air leaks (if using the BiPAP Vision
• Decide on level of PEEP to apply
• Attach PEEP valve to mask (if using traditional set-up, may need T-piece)
• Attach oxygen circuit with humidification including 'blow off' valve (for safety)
• Set inspired oxygen level
• Set flow rate to ensure the PEEP valve opens a small distance and never closes
• Titrate oxygen and PEEP in response to the patient's work of breathing, saturations, pH, Pa02, and PaCO2
• If appropriate, set alarms on ventilator (if using BiPAP Vision®
• Write a prescription chart of PEEP or ventilation settings and acceptable saturations, Pa02 and PaCO, continuous or intermittent.
Procedure Tips
• If valve closing fully, there is an air leak or patient requires higher PEEP
• May need to put more air into the mask rim for patient comfort and a better seal
• Better fit of mask if the patient keeps their dentures in!
• Large-bore nasogastric tubes will cause a leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 1 respiratory failure (e.g. lobar or bibasal collapse post surgery, pneumonia)
• Cardiogenic pulmonary edema
• Obstructive sleep apnoea
• Weaning.
Contraindications /Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• CO, retention if patient breathing small tidal volume against
Documentation
• Oxygen prescription chart
• Clear record of ABGs with evidence of time, inspired oxygen and PEEP
• Continuous or intermittent
• Good practice to document 'ceiling' of treatment in clinical environment (pressure and Fi02).
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
CAP = continuous positive airways pressure. CAP traditionally
has its own equipment and 'set-up'. Recently more clinicians are delivering CPAP through the BiPAP Vision@. There is also a
'low-flow' version used mainly for transport of CPAP-dependent patients.
Equipment
)rd
• Mask (‡ T-piece), hood
• Head strap (mask), shoulder straps (hood)
• Oxygen circuit and humidification
• High flow generator (e.g. Whisper Flow®, Vital Signs®)
• Positive end-expiratory pressure (PEEP) valves (usually 5, 7.5, or 10cmH,O)
• 'Blow off' safety valve (10cmHO above the PEEP used).
Procedure
• Use available templates to assess appropriate sized interface and minimize air leaks (if using the BiPAP Vision
• Decide on level of PEEP to apply
• Attach PEEP valve to mask (if using traditional set-up, may need T-piece)
• Attach oxygen circuit with humidification including 'blow off' valve (for safety)
• Set inspired oxygen level
• Set flow rate to ensure the PEEP valve opens a small distance and never closes
• Titrate oxygen and PEEP in response to the patient's work of breathing, saturations, pH, Pa02, and PaCO2
• If appropriate, set alarms on ventilator (if using BiPAP Vision®
• Write a prescription chart of PEEP or ventilation settings and acceptable saturations, Pa02 and PaCO, continuous or intermittent.
Procedure Tips
• If valve closing fully, there is an air leak or patient requires higher PEEP
• May need to put more air into the mask rim for patient comfort and a better seal
• Better fit of mask if the patient keeps their dentures in!
• Large-bore nasogastric tubes will cause a leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 1 respiratory failure (e.g. lobar or bibasal collapse post surgery, pneumonia)
• Cardiogenic pulmonary edema
• Obstructive sleep apnoea
• Weaning.
Contraindications /Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• CO, retention if patient breathing small tidal volume against
Documentation
• Oxygen prescription chart
• Clear record of ABGs with evidence of time, inspired oxygen and PEEP
• Continuous or intermittent
• Good practice to document 'ceiling' of treatment in clinical environment (pressure and Fi02).
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Clinical Procedures - Non Invasive Ventilation ( BiPAP)
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
BiPAP = bilevel positive airways pressure. Each machine varies
and some are more complicated than others. The steps outlined below are a guide only. All ventilated patients should be in a ward or unit with specialised staff who have been trained in the use of each ventilator.
Equipment
• Interface (face mask, nasal pillows, nasal mask etc.)
• Head straps
• Ventilation circuit (exhalation port unless on mask
• Humidification (if required)
• Ventilator (NIPPY 1/2/3/3+, BiPAP Vision® etc.)
• Entrained oxygen (unless with ventilator e.g. BiPAP Vision®.
Procedure
• Decide on which interface to use
• Use available templates to assess appropriate sized interface and minimize air leaks
• Start with low pressures (EPAP 4cmH,O, |PAP 12cmHO):
• Slowly increase pressures to levels agreed by multidisciplinary team, for patient comfort and in response to pH, PaO2 and PaCO2
• The aim being to reduce RR and work of breathing normalize ABGs (for the individual) using the minimal pressures possible
• Set inspiratory and expiratory times to those of the patient
• Continually reassess respiratory rates as this will change and therefore set times will have to change
• Titrate oxygen and pressures in response to the patient's saturations, pH, Pa0, and PaCO,
• If appropriate set alarms on ventilator
• Write a prescription chart of ventilation settings and acceptable saturations, Pa02, and PaCO2.
Procedure Tips
• Use full face masks usually in the acute setting as patients are usually mouth-breathing
• Better fit with dentures in!
• Large-bore nasogastric tubes will cause increased leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 2 respiratory failure (e.g. exacerbations of COPD, high spinal cord lesions, neuromuscular disease)
• Weaning
• Cardiogenic pulmonary oedema.
Contraindications/Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• Pulmonary barotraumas.
Documentation
• Oxygen prescription charts
• Ventilation prescription charts
• Clear record of ABGs with evidence of time, inspired oxygen, and ventilation levels
• Good practice to document the 'ceiling of pressures and FiO2, for the clinical environment.
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
BiPAP = bilevel positive airways pressure. Each machine varies
and some are more complicated than others. The steps outlined below are a guide only. All ventilated patients should be in a ward or unit with specialised staff who have been trained in the use of each ventilator.
Equipment
• Interface (face mask, nasal pillows, nasal mask etc.)
• Head straps
• Ventilation circuit (exhalation port unless on mask
• Humidification (if required)
• Ventilator (NIPPY 1/2/3/3+, BiPAP Vision® etc.)
• Entrained oxygen (unless with ventilator e.g. BiPAP Vision®.
Procedure
• Decide on which interface to use
• Use available templates to assess appropriate sized interface and minimize air leaks
• Start with low pressures (EPAP 4cmH,O, |PAP 12cmHO):
• Slowly increase pressures to levels agreed by multidisciplinary team, for patient comfort and in response to pH, PaO2 and PaCO2
• The aim being to reduce RR and work of breathing normalize ABGs (for the individual) using the minimal pressures possible
• Set inspiratory and expiratory times to those of the patient
• Continually reassess respiratory rates as this will change and therefore set times will have to change
• Titrate oxygen and pressures in response to the patient's saturations, pH, Pa0, and PaCO,
• If appropriate set alarms on ventilator
• Write a prescription chart of ventilation settings and acceptable saturations, Pa02, and PaCO2.
Procedure Tips
• Use full face masks usually in the acute setting as patients are usually mouth-breathing
• Better fit with dentures in!
• Large-bore nasogastric tubes will cause increased leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 2 respiratory failure (e.g. exacerbations of COPD, high spinal cord lesions, neuromuscular disease)
• Weaning
• Cardiogenic pulmonary oedema.
Contraindications/Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• Pulmonary barotraumas.
Documentation
• Oxygen prescription charts
• Ventilation prescription charts
• Clear record of ABGs with evidence of time, inspired oxygen, and ventilation levels
• Good practice to document the 'ceiling of pressures and FiO2, for the clinical environment.
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Clinical Procedures – Female Urethral Catheterization
Indications
• Relief of acute urinary retention
• Accurate monitoring of urine output in the acutely unwell/ those undergoing surgery
• Prevention of complications of chronic urinary retention (e.g. neurological; consider long-term alternatives)
• Urinary incontinence (consider alternatives e.g. pad).
Contraindications
• Urethral injury.
Risks
• Urinary tract infection
• Septicaemia
• Pain
• Haematuria
• Urethral trauma
• © Beware latex allergy.
Procedure Tips
• Difficulty passing the catheter may be alleviated by slowly rotating the catheter whilst inserting
• Difficulty seeing the urethral meatus may be overcome by asking the patient to 'bear down'
• If urine fails to drain despite the catheter being fully advanced:
• Palpate the bladder: if palpable, the catheter is inappropriately placed
• Manual pressure on the bladder may express enough urine from a near-empty bladder to show itself
• Aspirate with a bladder syringe, or flush with a little sterile saline
• b If it is impossible to pass the catheter, ask for help. If all else fails, it may be necessary to proceed to suprapubic catheterization.
Equipment
• Foley catheter (female of appropriate French, usually
12-14
• 10mL syringe of sterile water
• Syringe of lidocaine gel 1% (e.g. Instilligel®)
• Catheter bag
• Sterile gloves
• Catheter pack containing drape, kidney dish, swabs/cotton balls, and a small dish
• Sterile water/chlorhexidine sachet.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient with hips externally rotated and knees flexed. Uncover from waist down
• Using aseptic technique, unwrap the equipment and pour the chlorhexidine or sterile water into the dish
• Wash your hands and put on the sterile gloves
• Tear a hole in the middle of the drape and place it over the genitals so as to allow access
• Use your non-dominant hand to part the labia
• Clean around the urethral meatus using the water/ chlorhexidine and a swab, moving from the centre of
• Instil local anaesthetic via urethral meatus:
• Wait at least 1 minute for the anaesthetic to act
• Place the kidney bowl between the patient's thighs
• Remove the tip of the plastic sheath containing the catheter, being careful not to touch the catheter itself
• Insert catheter into urethra, feeding it out of the plastic wrapper as it is advanced
• Insert the catheter to the 'hilt'
• At this point, urine may begin to drain. Let the end of the catheter rest in the kidney bowl to prevent any spills
• Inflate the balloon using sterile water inserted into the catheter side-arm according to the balloon's capacity (written on the cuff of the balloon lumen)
• D Watch the patient's face and ask them to warn you if they feel pain
• Once the balloon is inflated, remove the syringe and attach the catheter bag
• Gently pull the catheter until you feel resistance as the balloon rests against the bladder neck
• Re-dress the patient appropriately.
Documentation
• Date and time
• Indication, informed consent obtained
• Size of catheter inserted
• Aseptic technique used?
• Volume of water used to inflate the balloon
• Residual volume of urine obtained
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Relief of acute urinary retention
• Accurate monitoring of urine output in the acutely unwell/ those undergoing surgery
• Prevention of complications of chronic urinary retention (e.g. neurological; consider long-term alternatives)
• Urinary incontinence (consider alternatives e.g. pad).
Contraindications
• Urethral injury.
Risks
• Urinary tract infection
• Septicaemia
• Pain
• Haematuria
• Urethral trauma
• © Beware latex allergy.
Procedure Tips
• Difficulty passing the catheter may be alleviated by slowly rotating the catheter whilst inserting
• Difficulty seeing the urethral meatus may be overcome by asking the patient to 'bear down'
• If urine fails to drain despite the catheter being fully advanced:
• Palpate the bladder: if palpable, the catheter is inappropriately placed
• Manual pressure on the bladder may express enough urine from a near-empty bladder to show itself
• Aspirate with a bladder syringe, or flush with a little sterile saline
• b If it is impossible to pass the catheter, ask for help. If all else fails, it may be necessary to proceed to suprapubic catheterization.
Equipment
• Foley catheter (female of appropriate French, usually
12-14
• 10mL syringe of sterile water
• Syringe of lidocaine gel 1% (e.g. Instilligel®)
• Catheter bag
• Sterile gloves
• Catheter pack containing drape, kidney dish, swabs/cotton balls, and a small dish
• Sterile water/chlorhexidine sachet.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient with hips externally rotated and knees flexed. Uncover from waist down
• Using aseptic technique, unwrap the equipment and pour the chlorhexidine or sterile water into the dish
• Wash your hands and put on the sterile gloves
• Tear a hole in the middle of the drape and place it over the genitals so as to allow access
• Use your non-dominant hand to part the labia
• Clean around the urethral meatus using the water/ chlorhexidine and a swab, moving from the centre of
• Instil local anaesthetic via urethral meatus:
• Wait at least 1 minute for the anaesthetic to act
• Place the kidney bowl between the patient's thighs
• Remove the tip of the plastic sheath containing the catheter, being careful not to touch the catheter itself
• Insert catheter into urethra, feeding it out of the plastic wrapper as it is advanced
• Insert the catheter to the 'hilt'
• At this point, urine may begin to drain. Let the end of the catheter rest in the kidney bowl to prevent any spills
• Inflate the balloon using sterile water inserted into the catheter side-arm according to the balloon's capacity (written on the cuff of the balloon lumen)
• D Watch the patient's face and ask them to warn you if they feel pain
• Once the balloon is inflated, remove the syringe and attach the catheter bag
• Gently pull the catheter until you feel resistance as the balloon rests against the bladder neck
• Re-dress the patient appropriately.
Documentation
• Date and time
• Indication, informed consent obtained
• Size of catheter inserted
• Aseptic technique used?
• Volume of water used to inflate the balloon
• Residual volume of urine obtained
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures –Suprapubic Catheterization
Indications
• Failed urethral catheterization in acute urinary retention
• Long-term catheterization (performed electively).
Contraindications
• Pregnancy
• Peritonism
• Clot retention (caused by underlying bladder malignancy)
• Previous lower abdominal surgery (bowel may stick to abdominal wall).
Risks
• Intra-abdominal injury (bowel perforation at insertion), peritonitis, infection, hemorrhage.
Procedure Tips
• D Bladder MUST be palpable and urine MUST be aspirated in order to safely insert catheter:
• Examine the patient. If the bladder is not palpable, consider other causes for the patient's symptoms
• Wear a disposable apron to avoid an unexpected shower
• Catheter balloon should be inflated with sterile water, not saline:
• Precipitation of saline can damage balloon and lead to difficult deflation and removal
• If unable to safely perform at bedside, abandon procedure
• Additional use of ultrasound is encouraged to facilitate safe catheter placement
• The first catheter change should be at 6 weeks to allow fistulous tract formation and thereafter 3-monthly changes.
Documentation
• Date, time, indication, informed consent obtained
• Volume and type of local anesthesia infiltrated
• Aspiration of urine?
• Size and type of catheter
• Urine drained freely once catheter placed?
• Amount of sterile water used to inflate the balloon
• Type of dressing used to anchor catheter
• Residual volume of urine drained
• Signature, printed name, and contact details.
Equipment
• lodine solution
• Catheter pack (containing sterile drape, sterile gauze, sterile receptacles)
• 2 x sterile gloves
• 21G (green) needle
• 2 x 10 mL syringe
• 10mL 1% lidocaine
• 10mL sterile water
• Scalpel
• Suprapubic catheter trocar
• 16Ch long-term Foley catheter (Silastic®)
• Catheter bag
• Adhesive dressing
• • Assistant.
Procedure
• Suprapubic catheterization has a mortality rate of
0.8-1.8%. It should only be performed by a suitably experienced individual, ideally a Urologist.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Place trolley on right-hand side of patient and position the patient supine with abdomen exposed
• Wash hands thoroughly
• Ask assistant to open catheter pack onto trolley
• Ask assistant to open first pair of sterile gloves. Put them
on
• Ask assistant to pour iodine into catheter pack receptacle
• Clean suprapubic area with gauze soaked in iodine, starting at site of incision (central and approximately 2-3 finger breadths above pubic symphysis) and working outwards
• Remove gloves and change for second sterile pair
• Attach green needle to 10mL syringe and draw up lidocaine
• Infiltrate skin at incision site and deeper layers of abdominal wall with 10mL of 1% lidocaine:
• Aspirate before each injection. If blood is aspirated, stop, change position of needle and recheck
• Using same needle and syringe attempt to aspirate urine
• If unsuccessful, alter angulation or even position of needle until urine is aspirated
• Use needle puncture site as marker for incision
• Ask assistant to open scalpel, trocar, catheter, and silk suture onto catheter pack
• D Test efficacy of anaesthesia using needle. If anaesthesia is not sufficient, wait a few minutes and recheck. If still not sufficient, infiltrate more anesthetic and repeat process
• Perform a 1cm vertical incision at needle site through skin, subcutaneous fat, and muscle layer
• Hold the trocar in the palm of the right hand (like a corkscrew), with middle finger outstretched for support and to limit depth of entry:
• Left hand is used to steady needle end of trocar
• Insert trocar through incision, in same direction as needle, using twisting motion:
• " You should feel a first 'give through linea alba and a second 'give on entering the bladder
• When urine issues from trocar, remove trocar holding attached sheath in place
• Block the end with right thumb to stop urine leakage
• Insert catheter via sheath
• Insert catheter as far as possible and inflate balloon
• Remove sheath by splitting apart
• Attach catheter bag
• Gently pull the catheter back until resistance is felt
• Secure catheter in place with suitable dressing
• Dress catheter site with gauze and adhesive dressing.
Indications
• Failed urethral catheterization in acute urinary retention
• Long-term catheterization (performed electively).
Contraindications
• Pregnancy
• Peritonism
• Clot retention (caused by underlying bladder malignancy)
• Previous lower abdominal surgery (bowel may stick to abdominal wall).
Risks
• Intra-abdominal injury (bowel perforation at insertion), peritonitis, infection, hemorrhage.
Procedure Tips
• D Bladder MUST be palpable and urine MUST be aspirated in order to safely insert catheter:
• Examine the patient. If the bladder is not palpable, consider other causes for the patient's symptoms
• Wear a disposable apron to avoid an unexpected shower
• Catheter balloon should be inflated with sterile water, not saline:
• Precipitation of saline can damage balloon and lead to difficult deflation and removal
• If unable to safely perform at bedside, abandon procedure
• Additional use of ultrasound is encouraged to facilitate safe catheter placement
• The first catheter change should be at 6 weeks to allow fistulous tract formation and thereafter 3-monthly changes.
Documentation
• Date, time, indication, informed consent obtained
• Volume and type of local anesthesia infiltrated
• Aspiration of urine?
• Size and type of catheter
• Urine drained freely once catheter placed?
• Amount of sterile water used to inflate the balloon
• Type of dressing used to anchor catheter
• Residual volume of urine drained
• Signature, printed name, and contact details.
Equipment
• lodine solution
• Catheter pack (containing sterile drape, sterile gauze, sterile receptacles)
• 2 x sterile gloves
• 21G (green) needle
• 2 x 10 mL syringe
• 10mL 1% lidocaine
• 10mL sterile water
• Scalpel
• Suprapubic catheter trocar
• 16Ch long-term Foley catheter (Silastic®)
• Catheter bag
• Adhesive dressing
• • Assistant.
Procedure
• Suprapubic catheterization has a mortality rate of
0.8-1.8%. It should only be performed by a suitably experienced individual, ideally a Urologist.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Place trolley on right-hand side of patient and position the patient supine with abdomen exposed
• Wash hands thoroughly
• Ask assistant to open catheter pack onto trolley
• Ask assistant to open first pair of sterile gloves. Put them
on
• Ask assistant to pour iodine into catheter pack receptacle
• Clean suprapubic area with gauze soaked in iodine, starting at site of incision (central and approximately 2-3 finger breadths above pubic symphysis) and working outwards
• Remove gloves and change for second sterile pair
• Attach green needle to 10mL syringe and draw up lidocaine
• Infiltrate skin at incision site and deeper layers of abdominal wall with 10mL of 1% lidocaine:
• Aspirate before each injection. If blood is aspirated, stop, change position of needle and recheck
• Using same needle and syringe attempt to aspirate urine
• If unsuccessful, alter angulation or even position of needle until urine is aspirated
• Use needle puncture site as marker for incision
• Ask assistant to open scalpel, trocar, catheter, and silk suture onto catheter pack
• D Test efficacy of anaesthesia using needle. If anaesthesia is not sufficient, wait a few minutes and recheck. If still not sufficient, infiltrate more anesthetic and repeat process
• Perform a 1cm vertical incision at needle site through skin, subcutaneous fat, and muscle layer
• Hold the trocar in the palm of the right hand (like a corkscrew), with middle finger outstretched for support and to limit depth of entry:
• Left hand is used to steady needle end of trocar
• Insert trocar through incision, in same direction as needle, using twisting motion:
• " You should feel a first 'give through linea alba and a second 'give on entering the bladder
• When urine issues from trocar, remove trocar holding attached sheath in place
• Block the end with right thumb to stop urine leakage
• Insert catheter via sheath
• Insert catheter as far as possible and inflate balloon
• Remove sheath by splitting apart
• Attach catheter bag
• Gently pull the catheter back until resistance is felt
• Secure catheter in place with suitable dressing
• Dress catheter site with gauze and adhesive dressing.
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Clinical Procedures - Arterial Blood Sampling (ABG)
Indications
• Evaluation of arterial 02, COz, pH. etc.
• Measurement of response to therapeutic oxygen or diagnostic evaluation (e.g. exercise testing).
Contraindications
• Negative modified Allen's test
• Cutaneous or subcutaneous lesion at puncture site
• Surgical shunt (e.g. in a dialysis patient) in the limb proximal or distal to the puncture site
• Infection or known peripheral vascular disease in the limb
• Coagulopathy.
Risks
• Bleeding
• Haematoma
• Arteriospasm
• Infection
• False aneurysm formation
• Arterial occlusion.
Procedure Tips
• The key is carefully palpating the artery and lining the needle up to puncture it. Take your time!
• The majority of the pain comes from puncturing the skin. If no flash is seen immediately, try repositioning the needle by withdrawing without removing it from the skin
• If several attempts have failed, try a different location or ask for
• If there will be some delay in analysing the sample, store the blood filled syringe on ice
• Errors occur: if there is air in the syringe, if the sample is delayed in reaching the analyser (if this is anticipated, put the sample on ice), or if a venous sample is accidentally obtained.
Documentation
• Date, time, indication, consent obtained
• Artery punctured
• Modified Allen's test?
• How many passes?
• Any immediate complications
• Signature, printed name, contact details.
Equipment
• Gloves
• Sterile wipe (e.g. isopropyl alcohol)
• Cotton wool balls
• Tape
• Gauze
• Heparinized self-filling syringe and needle.
Choosing a Site
The radial artery at the level of the radial styloid is the usual site of choice as it is both superficial and easily accessible.
If the vessel is not obviously palpable, it is also possible to sample arterial blood at the brachial artery in the antecubital fossa or femoral artery just distal to the inguinal ligament.
Procedure: Radial Artery
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient appropriately: sitting comfortably with arm placed on a pillow, forearm supinated, wrist passively dorsiflexed
• D Confirm ulnar arterial supply to the hand before starting (modified Allen's test):
• Compress the radial and ulnar arteries with your thumbs
• Ask the patient to make a fist and to open it
• The hand should appear blanched
• Release pressure from the ulnar artery and watch the palm
• The palm should flush to its normal colour
• D If not, there may be inadequate ulnar arterial supply and damage to the radial artery during blood taking may result in critical ischaemia. Test the other side
• Put on your gloves
• Identify the radial artery with index and middle fingers of your non-dominant hand
• Clean the site, beginning centrally and spiralling outwards
• Whilst the sterilizing solution dries, remove the needle and syringe from packaging and attach the needle to the end of the syringe
• Eject excess heparin from the syringe through the needle:
• © Check local equipment. Some heparinized syringes contain a heparinized sponge and excess heparin/air should not be expelled
• Warn the patient to expect a 'sharp scratch
• Whilst palpating the artery (but not obliterating the pulsation), insert the needle just distal to your fingertips, bevel facing proximally, at an angle of 45-60° until a flashback is seen within the chamber of the needle
• Hold the syringe steady and allow it to fill itself with 1-2mL blood
• As you withdraw the needle, apply the gauze swab to the site, maintaining firm manual pressure over for at least 2 minutes
• Dispose of the needle and apply a vented cap, expelling any excess air:
• (This may not be necessary depending on your equipment see above).
Procedure: Brachial artery
• Similar procedure as above except...
• Position the elbow in extension. Angle the needle 60°
Procedure: Femoral Artery
• Position the patient with hip extended
• The pulse is felt 2cm below the midpoint between pubic symphysis and anterior superior iliac spine
• Angle the needle at 90° to the skin
• Pressure must be applied for at least 5 minutes.
Indications
• Evaluation of arterial 02, COz, pH. etc.
• Measurement of response to therapeutic oxygen or diagnostic evaluation (e.g. exercise testing).
Contraindications
• Negative modified Allen's test
• Cutaneous or subcutaneous lesion at puncture site
• Surgical shunt (e.g. in a dialysis patient) in the limb proximal or distal to the puncture site
• Infection or known peripheral vascular disease in the limb
• Coagulopathy.
Risks
• Bleeding
• Haematoma
• Arteriospasm
• Infection
• False aneurysm formation
• Arterial occlusion.
Procedure Tips
• The key is carefully palpating the artery and lining the needle up to puncture it. Take your time!
• The majority of the pain comes from puncturing the skin. If no flash is seen immediately, try repositioning the needle by withdrawing without removing it from the skin
• If several attempts have failed, try a different location or ask for
• If there will be some delay in analysing the sample, store the blood filled syringe on ice
• Errors occur: if there is air in the syringe, if the sample is delayed in reaching the analyser (if this is anticipated, put the sample on ice), or if a venous sample is accidentally obtained.
Documentation
• Date, time, indication, consent obtained
• Artery punctured
• Modified Allen's test?
• How many passes?
• Any immediate complications
• Signature, printed name, contact details.
Equipment
• Gloves
• Sterile wipe (e.g. isopropyl alcohol)
• Cotton wool balls
• Tape
• Gauze
• Heparinized self-filling syringe and needle.
Choosing a Site
The radial artery at the level of the radial styloid is the usual site of choice as it is both superficial and easily accessible.
If the vessel is not obviously palpable, it is also possible to sample arterial blood at the brachial artery in the antecubital fossa or femoral artery just distal to the inguinal ligament.
Procedure: Radial Artery
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient appropriately: sitting comfortably with arm placed on a pillow, forearm supinated, wrist passively dorsiflexed
• D Confirm ulnar arterial supply to the hand before starting (modified Allen's test):
• Compress the radial and ulnar arteries with your thumbs
• Ask the patient to make a fist and to open it
• The hand should appear blanched
• Release pressure from the ulnar artery and watch the palm
• The palm should flush to its normal colour
• D If not, there may be inadequate ulnar arterial supply and damage to the radial artery during blood taking may result in critical ischaemia. Test the other side
• Put on your gloves
• Identify the radial artery with index and middle fingers of your non-dominant hand
• Clean the site, beginning centrally and spiralling outwards
• Whilst the sterilizing solution dries, remove the needle and syringe from packaging and attach the needle to the end of the syringe
• Eject excess heparin from the syringe through the needle:
• © Check local equipment. Some heparinized syringes contain a heparinized sponge and excess heparin/air should not be expelled
• Warn the patient to expect a 'sharp scratch
• Whilst palpating the artery (but not obliterating the pulsation), insert the needle just distal to your fingertips, bevel facing proximally, at an angle of 45-60° until a flashback is seen within the chamber of the needle
• Hold the syringe steady and allow it to fill itself with 1-2mL blood
• As you withdraw the needle, apply the gauze swab to the site, maintaining firm manual pressure over for at least 2 minutes
• Dispose of the needle and apply a vented cap, expelling any excess air:
• (This may not be necessary depending on your equipment see above).
Procedure: Brachial artery
• Similar procedure as above except...
• Position the elbow in extension. Angle the needle 60°
Procedure: Femoral Artery
• Position the patient with hip extended
• The pulse is felt 2cm below the midpoint between pubic symphysis and anterior superior iliac spine
• Angle the needle at 90° to the skin
• Pressure must be applied for at least 5 minutes.
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Clinical Procedures – Peripheral Cannulation
Before You Start
Consider:
• Can the drug be given by another route?
• What is the smallest appropriate cannula?
• What is the most appropriate location for the cannula?
Vein Choice
• Avoid areas of skin damage, erythema, or an arm with an AV fistula
• Excessive hair should be cut with scissors before cleaning the skin
• It is best to avoid joint areas such as the antecubital fossa:
• This can cause kinking of the cannula and discomfort
• A straight vein, in an area such as the forearm or dorsum of the hand, where long bones are available to splint the cannula is useful
• Wide-bore access requires siting in large veins and often this is only practicable in the antecubital fossa:
• In practice, especially in patients who have been cannulated many times before, it is often necessary to go wherever you find a vein
Indications
• Drug administration by IV route
• Infusion of fluid or blood.
Contraindications
• Cannulae should not be placed unless IV access is required
• Caution in patients with a bleeding diathesis.
Risks
• Infection, which could be local or systemic.
Procedure Tips
• Local anaesthetic cream may be of benefit if you have time
• Reliable veins are located on the radial aspect of the wrist (*64 antecubital fossa, and anterior to the medial malleolus (long a
• If you fail initially with a large-bore cannula, try a smaller gauge
• If no veins are visible/palpable at first, try warming the limb in want water for a couple of minutes
• It may be useful to get assistance to hold the patient's arm still if they are likely to move it during the procedure
• If you are unable to cannulate after several attempts, try asking someone else. A pair of fresh eyes makes a lot of difference!
Equipment
• Gloves
• Sterile wipe (e.g. chlorhexidine)
• Cannula of appropriate gauge (see next card)
• Sterile saline for iniection ('flush')
• 5mL syringe
• Cannula dressing
• Cotton wool balls/ gauze
• Tourniquet.
Sizing Cannulae
Cannulae are colour-coded according to size. The 'gauge' is inversely proportional to the external diameter.
The standard size cannula is 'green' or 18G but for most hospital patients, a 'pink' or 20G cannula will suffice. Even blue cannulae are adequate in most circumstances unless fast flows of fluid are required.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Put the gloves on
• Apply the tourniquet proximally on the limb
• Once the veins are distended, select an appropriate vein: it should be straight for the length of the cannula
• Wipe with sterile wipe, beginning where you intend to insert the cannula and moving outwards in circles
• Whilst the cleaning fluid is drying, fill the syringe with saline and eject any air bubbles
• Remove the dressing from its packaging
• Unwrap the cannula and check that all parts disengage easily. Fold the wings down so that they will lie flat on the skin after insertion
• Using your non-dominant hand, pull the skin taut over the vein in order to anchor it in place
• Hold the cannula with index and middle fingers in fro the cannula wings, thumb behind the cap (see figure overleaf)
• Warn the patient to expect a 'sharp scratch'
• Insert the needle, bevel up, at an angle of 30° to the skin, until a flashback of blood is visible within the chamber of the cannula.
• Advance the needle a small amount (~1mm) further, then advance the cannula into the vein over the needle, whilst keeping the needle stationary
• Release the tourniquet
• Place your non-dominant thumb over the tip of the cannula, compressing the vein, to prevent blood loss whilst you remove the needle completely
• Flush the cannula with a little saline from the end and replace the cap
• Write the date on the cannula dressing and secure in place.
Before You Start
Consider:
• Can the drug be given by another route?
• What is the smallest appropriate cannula?
• What is the most appropriate location for the cannula?
Vein Choice
• Avoid areas of skin damage, erythema, or an arm with an AV fistula
• Excessive hair should be cut with scissors before cleaning the skin
• It is best to avoid joint areas such as the antecubital fossa:
• This can cause kinking of the cannula and discomfort
• A straight vein, in an area such as the forearm or dorsum of the hand, where long bones are available to splint the cannula is useful
• Wide-bore access requires siting in large veins and often this is only practicable in the antecubital fossa:
• In practice, especially in patients who have been cannulated many times before, it is often necessary to go wherever you find a vein
Indications
• Drug administration by IV route
• Infusion of fluid or blood.
Contraindications
• Cannulae should not be placed unless IV access is required
• Caution in patients with a bleeding diathesis.
Risks
• Infection, which could be local or systemic.
Procedure Tips
• Local anaesthetic cream may be of benefit if you have time
• Reliable veins are located on the radial aspect of the wrist (*64 antecubital fossa, and anterior to the medial malleolus (long a
• If you fail initially with a large-bore cannula, try a smaller gauge
• If no veins are visible/palpable at first, try warming the limb in want water for a couple of minutes
• It may be useful to get assistance to hold the patient's arm still if they are likely to move it during the procedure
• If you are unable to cannulate after several attempts, try asking someone else. A pair of fresh eyes makes a lot of difference!
Equipment
• Gloves
• Sterile wipe (e.g. chlorhexidine)
• Cannula of appropriate gauge (see next card)
• Sterile saline for iniection ('flush')
• 5mL syringe
• Cannula dressing
• Cotton wool balls/ gauze
• Tourniquet.
Sizing Cannulae
Cannulae are colour-coded according to size. The 'gauge' is inversely proportional to the external diameter.
The standard size cannula is 'green' or 18G but for most hospital patients, a 'pink' or 20G cannula will suffice. Even blue cannulae are adequate in most circumstances unless fast flows of fluid are required.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Put the gloves on
• Apply the tourniquet proximally on the limb
• Once the veins are distended, select an appropriate vein: it should be straight for the length of the cannula
• Wipe with sterile wipe, beginning where you intend to insert the cannula and moving outwards in circles
• Whilst the cleaning fluid is drying, fill the syringe with saline and eject any air bubbles
• Remove the dressing from its packaging
• Unwrap the cannula and check that all parts disengage easily. Fold the wings down so that they will lie flat on the skin after insertion
• Using your non-dominant hand, pull the skin taut over the vein in order to anchor it in place
• Hold the cannula with index and middle fingers in fro the cannula wings, thumb behind the cap (see figure overleaf)
• Warn the patient to expect a 'sharp scratch'
• Insert the needle, bevel up, at an angle of 30° to the skin, until a flashback of blood is visible within the chamber of the cannula.
• Advance the needle a small amount (~1mm) further, then advance the cannula into the vein over the needle, whilst keeping the needle stationary
• Release the tourniquet
• Place your non-dominant thumb over the tip of the cannula, compressing the vein, to prevent blood loss whilst you remove the needle completely
• Flush the cannula with a little saline from the end and replace the cap
• Write the date on the cannula dressing and secure in place.
- Published on
Clinical Procedures - Femoral Venous Catheter Insertion
Indications
• Inotrope therapy, parenteral nutrition (needs dedicated port), poor peripheral access, CVP measurement (trends useful rather than actual numbers).
Contraindications
• Fem-fem bypass surgery, inferior vena cava (IC) filter, infected site, thrombosed vein.
Risks
• Arterial puncture, infection, haematoma, thrombosis, air embolism, AV fistula, peritoneal puncture.
Procedure Tips
• Placing a sandbag underneath the patient's buttock may improve positioning (if a sandbag is not available, roll up a towel or wrap a 1L
bag of fluid in a sheet as an alternative)
• Do not force the guidewire. If there is resistance to insertion:
• Reduce the angle of the needle, attempt a shallower insertion
• Check you are still within the vein by aspirating with a syringe
• Rotate the needle: this moves the bevel away from any obstruction
• D Losing the guidewire can be disastrous always have one hand holding either the proximal or distal end of it
• Always consider the possibility of an inadvertent arterial puncture:
• Signs include pulsatile blood flow, high-pressure blood flow or blood bright red in colour (in the absence of hypotension or hypoxaemia)
• Do not dilate if in any doubt
• Consider sending blood for a blood gas to confirm venous placement
• The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Documentation
• Time, date, indication, informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempt (S)
• Aseptic technique: gloves, gown, hat, mask, sterile solution
• Local anaesthetic: type and amount infiltrated
• Technique used: e.g. landmark, ultrasound guidance
• Catheter used: e.g. triple lumen
• Length of catheter in situ (length at skin)
• Signature, printed name, and contact details.
Equipment
• Central line catheter pack.
• Containing: central line (16-20cm length, multilumen if required), introducer needle, 10mL syringe, guidewire, dilator, blade
• Large-dressing pack including a large sterile drape and gauze
• Normal saline
• Local anaesthetic for skin (1% lidocaine)
• Sterile preparation solution (2% chlorhexidine)
• Securing device or stitch
• Sterile gloves, sterile gown, surgical hat and mask
• Suitable dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Position the patient supine (1 pillow), abduct the leg slightly and place a spill sheet under the patient's leg
• Identify the femoral artery and mid-inguinal point:
• Midway between anterior superior iliac spine and pubic symphysis
• Identify the entry point: 1-2 cm below the mid-inguinal point and 1cm medial to femoral artery
• Wearing a surgical hat and mask, wash hands using a surgical scrub technique and put on the sterile gown and gloves
• Set up a trolley using an aseptic technique:
•Open the dressing pack onto the trolley creating a sterile field
• Open the central line catheter pack and place onto the sterile field
• Flush all lumens of the catheter with saline and clamps the end
• Ensure the guidewire is ready for insertion
• Attach the introducer needle to a 10ml syrins
• Clean the area with sterile preparation solution arr piare a large drape over the area
• Inject local anaesthetic into the skin over the entry point
• Identify the femoral artery with your non-dominant hand
• Pierce the skin through the entry point with the introducer needle
• Direct the needle at a 30 45° angle to the skin and aim for the ipsilateral nipple, aspirating as you advance the needle
• On hitting the vein the syringe will fill with blood
• Keeping the needle still, carefully remove the syringe blood should ooze (and not pulsate) out through the hub of the needle
• Insert the guidewire part-way through the hub of the needle.
• Guidewires tend to be over 50cm in length; it is unnecessary to insert more than 20cm into the vein
• Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire
• Thread the dilator over the wire, firmly pushing it through the skin:
• This may require a small stab incision in the skin with a blade
• Aim to get 2-3cm of dilator into the vein, not its full length
• Check the guidewire has not been kinked by ensuring it moves freely through the dilator
• Remove the dilator and apply pressure over the site with gauze to stop oozing
• Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!):
• This may require withdrawing some of the inserted guidewire
• Holding the guidewire at its port exit site with one hand push the catheter through the skin with the other:
• Avoid handling the catheter, in particular its tip
• Remove the guidewire
• Blood should flow out of the end of the catheter
• Aspirate and flush all ports
• Fix catheter to skin using either a securing device or stitches
• Cover with transparent dressing.
- Published on
Clinical Procedures - Central Venous Access: Internal Jugular Vein
Indications
• Inotrope therapy
• Parenteral nutrition (needs dedicated port)
• Poor peripheral access
• CVP measurement.
Contraindications
• Infected insertion site
• Thrombosed vein
• Coagulopathy.
Risks
• Pneumothorax
• Arterial puncture
• Haematoma
• Air embolism
• Arrhythmias
• Thrombosis
• AV fistula
• Infection
• Malposition.
Documentation
• Time, date, indication, and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempt
• Aseptic technique: gloves, gown, hat, mask, type of ster
• Local anaesthetic: type and amount infiltrated
• Technique used: e.g. landmark, ultrasound guidance
• Catheter used: length and number of lumens
• Aspirated and flushed
• Length of catheter in situ (length at skin)
• CXR: site of tip, absence/presence of pneumothorax
• Signature, printed name, and contact details.
Equipment
• Central line catheter pack:
• Central line (16cm length for right side, 20cm for left side), introducer needle, and 10mL syringe, guidewire, dilator, blade
• Large-dressing pack including a large sterile drape and gauze
• Normal saline
• Local anaesthetic for skin (1% lidocaine) with suitable
(25G) needle and syringe
• Sterile preparation solution (2% chlorhexidine)
• Sterile gloves, sterile gown, surgical hat and mask
• Trolley and ECG monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Position the patient supine (1 pillow), tilt the bed head down, and place a spill sheet under the patient's head
• Attach ECG monitoring to the patient
• Turn the patient's head away from the side of insertion
• Identify triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle
• Identify the entry point at the apex of the triangle
• Wash hands using a surgical scrub technique and put sterile gown and gloves
• With assistance, set up a trolley using an aseptic tech
Open the dressing pack onto the trolley creating a sterio
• Open the central line catheter pack and place onto the sterile field
Flush all lumens of the catheter with saline and clamp the ends
• Attach the introducer needle to a 10mL syringe
• Clean the area with sterile preparation solution and place a large drape around it
• Iniect local anaesthetic into the skin over the entry point
• Identify the carotid artery with your non-dominant hand
• Pierce the skin through the entry point with the introducer needle ensuring the needle is lateral to the artery
• Direct the needle at a 30° angle to the skin and advance using continuous aspiration, aiming for the ipsilateral nipple
• On hitting the vein, the syringe will fill with blood
• Keeping the needle still, carefully remove the syringe:
• Blood should ooze (not pulsate) through the hub of the needle
• Insert the guidewire through the needle and watch the ECG:
• Guidewires tend to be over 50cm in length but do not introduce more than 20cm as this may lead to arrhythmias
• Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire
• Thread the dilator over the wire, firmly pushing it through the skin:
• This may require a small stab incision in the skin with a blade
• Aim to get 2-3cm of dilator into the vein, not its full length
• Check the guidewire has not been kinked by ensuring it moves freely through the dilator
• Remove the dilator over the guidewire and apply pressure over the site with gauze
• Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!)
• This may require withdrawing some of the guidewire
• Holding the guidewire at its port exit site with one hi push the catheter through the skin with the other
• D Avoid handling the catheter, in particular its tip:
• Insert 16cm for a right-sided line and 20cm for a left-sided line
• Remove the guidewire:
• Blood should flow out through the end of the catheter
• Aspirate and flush all ports with normal saline
• Fix catheter to skin with a fixing device or sutures
• Cover with a transparent dressing
• Request a chest radiograph to confirm position.
Procedure Tips
• The right internal jugular vein is usually favoured due to its relatively straight course and the absence of the thoracic duct on this side
• Tilting the bed head down will minimize the risk of air embolism and help distend the veins of the neck.
Getting started
• Asking the patient to sniff or lift their head off the bed will help identify the sternocleidomastoid muscle
• Asking the patient to perform the Valsalva manoeuvre will distend the veins of the neck and help identify the internal jugular vein
• For added safety, you may wish to start by using a 21G (green') hypodermic needle instead of the introducer needle to 'seek out the vessel using the same technique
• Check clotting prior to insertion. Aim for IN <1.5 and platelets >50 x 109/L
• Minimize spillage.
During the procedure
• The internal jugular vein is relatively superficial and should be encountered within 2-3 cm. Do not continue advancing the needle if the vein has not been hit by this point
•Do not force the guidewire in. If there is resistance to guidewire insertion:
• Try lowering the angle of the needle making it more in line with the long-axis of the vessel
• Check you are still within the vein by aspirating with a syringe
• Try rotating the needle thereby moving the bevel away from any obstruction
• D Losing the guidewire can be disastrous. Always have one hand holding either the proximal or distal end of it
• The use of saline in the aspirating syringe may make flushing the no easier but also makes it more difficult to differentiate between a and arterial blood
• Always consider the possibility of an inadvertent arterial puncture
• Signs include pulsatile blood flow, high-pressure blood flow or blood bright red in colour (in the absence of hypotension or hypoxaemia)
• Do not dilate if in any doubt
• Consider sending blood for a blood gas to confirm venous placement.
Finishing off
• There is an increased incidence of vascular injuries and thrombosis with left-sided catheters mainly because of insufficient catheter depth leading to the tip abutting the lateral wall of the upper SVC. You must ensure left-sided lines are long enough so that their tip lies within the lower part of the SVC
• On the chest radiograph, confirm catheter position and the absence of a pneumothorax:
• The tip of the catheter should lie at the junction of the superior vena cava and right atrium which is approximately at the level of the carina.
Alternative approaches
• Anterior approach: midpoint of sternal head of sternocleidomastoid aiming towards ipsilateral nipple
• Posterior approach: posterior border sternocleidomastoid at the crossing of the external jugular vein aiming for the sternal notch.
Structures your needle may hit!
• In front of the vein: internal carotid artery (upper part of neck)
• Behind the vein: transverse process cervical vertebrae, sympathetic chain, phrenic nerve, dome of pleura, thoracic duct on left-hand side
• Medial to vein: internal carotid artery and cranial nerves IX-XII (upper part of neck), common carotid and vagus nerve (lower part).
Indications
• Inotrope therapy
• Parenteral nutrition (needs dedicated port)
• Poor peripheral access
• CVP measurement.
Contraindications
• Infected insertion site
• Thrombosed vein
• Coagulopathy.
Risks
• Pneumothorax
• Arterial puncture
• Haematoma
• Air embolism
• Arrhythmias
• Thrombosis
• AV fistula
• Infection
• Malposition.
Documentation
• Time, date, indication, and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempt
• Aseptic technique: gloves, gown, hat, mask, type of ster
• Local anaesthetic: type and amount infiltrated
• Technique used: e.g. landmark, ultrasound guidance
• Catheter used: length and number of lumens
• Aspirated and flushed
• Length of catheter in situ (length at skin)
• CXR: site of tip, absence/presence of pneumothorax
• Signature, printed name, and contact details.
Equipment
• Central line catheter pack:
• Central line (16cm length for right side, 20cm for left side), introducer needle, and 10mL syringe, guidewire, dilator, blade
• Large-dressing pack including a large sterile drape and gauze
• Normal saline
• Local anaesthetic for skin (1% lidocaine) with suitable
(25G) needle and syringe
• Sterile preparation solution (2% chlorhexidine)
• Sterile gloves, sterile gown, surgical hat and mask
• Trolley and ECG monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Position the patient supine (1 pillow), tilt the bed head down, and place a spill sheet under the patient's head
• Attach ECG monitoring to the patient
• Turn the patient's head away from the side of insertion
• Identify triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle
• Identify the entry point at the apex of the triangle
• Wash hands using a surgical scrub technique and put sterile gown and gloves
• With assistance, set up a trolley using an aseptic tech
Open the dressing pack onto the trolley creating a sterio
• Open the central line catheter pack and place onto the sterile field
Flush all lumens of the catheter with saline and clamp the ends
• Attach the introducer needle to a 10mL syringe
• Clean the area with sterile preparation solution and place a large drape around it
• Iniect local anaesthetic into the skin over the entry point
• Identify the carotid artery with your non-dominant hand
• Pierce the skin through the entry point with the introducer needle ensuring the needle is lateral to the artery
• Direct the needle at a 30° angle to the skin and advance using continuous aspiration, aiming for the ipsilateral nipple
• On hitting the vein, the syringe will fill with blood
• Keeping the needle still, carefully remove the syringe:
• Blood should ooze (not pulsate) through the hub of the needle
• Insert the guidewire through the needle and watch the ECG:
• Guidewires tend to be over 50cm in length but do not introduce more than 20cm as this may lead to arrhythmias
• Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire
• Thread the dilator over the wire, firmly pushing it through the skin:
• This may require a small stab incision in the skin with a blade
• Aim to get 2-3cm of dilator into the vein, not its full length
• Check the guidewire has not been kinked by ensuring it moves freely through the dilator
• Remove the dilator over the guidewire and apply pressure over the site with gauze
• Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!)
• This may require withdrawing some of the guidewire
• Holding the guidewire at its port exit site with one hi push the catheter through the skin with the other
• D Avoid handling the catheter, in particular its tip:
• Insert 16cm for a right-sided line and 20cm for a left-sided line
• Remove the guidewire:
• Blood should flow out through the end of the catheter
• Aspirate and flush all ports with normal saline
• Fix catheter to skin with a fixing device or sutures
• Cover with a transparent dressing
• Request a chest radiograph to confirm position.
Procedure Tips
• The right internal jugular vein is usually favoured due to its relatively straight course and the absence of the thoracic duct on this side
• Tilting the bed head down will minimize the risk of air embolism and help distend the veins of the neck.
Getting started
• Asking the patient to sniff or lift their head off the bed will help identify the sternocleidomastoid muscle
• Asking the patient to perform the Valsalva manoeuvre will distend the veins of the neck and help identify the internal jugular vein
• For added safety, you may wish to start by using a 21G (green') hypodermic needle instead of the introducer needle to 'seek out the vessel using the same technique
• Check clotting prior to insertion. Aim for IN <1.5 and platelets >50 x 109/L
• Minimize spillage.
During the procedure
• The internal jugular vein is relatively superficial and should be encountered within 2-3 cm. Do not continue advancing the needle if the vein has not been hit by this point
•Do not force the guidewire in. If there is resistance to guidewire insertion:
• Try lowering the angle of the needle making it more in line with the long-axis of the vessel
• Check you are still within the vein by aspirating with a syringe
• Try rotating the needle thereby moving the bevel away from any obstruction
• D Losing the guidewire can be disastrous. Always have one hand holding either the proximal or distal end of it
• The use of saline in the aspirating syringe may make flushing the no easier but also makes it more difficult to differentiate between a and arterial blood
• Always consider the possibility of an inadvertent arterial puncture
• Signs include pulsatile blood flow, high-pressure blood flow or blood bright red in colour (in the absence of hypotension or hypoxaemia)
• Do not dilate if in any doubt
• Consider sending blood for a blood gas to confirm venous placement.
Finishing off
• There is an increased incidence of vascular injuries and thrombosis with left-sided catheters mainly because of insufficient catheter depth leading to the tip abutting the lateral wall of the upper SVC. You must ensure left-sided lines are long enough so that their tip lies within the lower part of the SVC
• On the chest radiograph, confirm catheter position and the absence of a pneumothorax:
• The tip of the catheter should lie at the junction of the superior vena cava and right atrium which is approximately at the level of the carina.
Alternative approaches
• Anterior approach: midpoint of sternal head of sternocleidomastoid aiming towards ipsilateral nipple
• Posterior approach: posterior border sternocleidomastoid at the crossing of the external jugular vein aiming for the sternal notch.
Structures your needle may hit!
• In front of the vein: internal carotid artery (upper part of neck)
• Behind the vein: transverse process cervical vertebrae, sympathetic chain, phrenic nerve, dome of pleura, thoracic duct on left-hand side
• Medial to vein: internal carotid artery and cranial nerves IX-XII (upper part of neck), common carotid and vagus nerve (lower part).
- Published on
Clinical Procedures - Central Venous Access: Subclavian Vein
Indications
• Inotrope therapy
• Parenteral nutrition (needs dedicated port)
• Poor peripheral access
• CVP measurement.
Contraindications
• Hyperinflated lungs (e.g. COPD patients)
• Coagulopathy
• Infected insertion site
• Thrombosed vein.
Risks
• Pneumothorax
• Haemorrhage
• Arterial puncture
• Air embolism
•Arrhythmias
• Thrombosis
• AV fistula
• Infection
• Malposition.
Documentation
• Time, date, indication, and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempt (s)
• Aseptic technique: gloves, gown, hat, mask, type of sterite
• Local anaesthetic: type and amount infiltrated
• Technique used: e.g. landmark, ultrasound guidance
• Catheter used: length and number of lumens
• Aspirated and flushed
• Length of catheter in situ (length at skin)
• CXR: site of tip, absence/presence of a pneumothorax
• Signature, printed name and contact details.
Equipment
• Central line catheter pack:
• Central line (16cm length for right side, 20cm for left side), introducer needle and 10mL syringe, guidewire, dilator, blade
• Large-dressing pack including a large sterile drape and gauze
• Normal saline
• Local anaesthetic for skin (1% lidocaine) with suitable
(25G) needle and syringe
• Sterile preparation solution (2% chlorhexidine)
• Sterile gloves, sterile gown, surgical hat and mask
• Trolley and ECG monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Position the patient supine (1 pillow), place a sandbag between shoulder blades, and tilt the bed head down
• Attach ECG leads onto the patient making sure they are not in the surgical field
• Turn the patient's head away from the side of insertion
• Identify the entry point, just inferior to the midpoint of the clavicle
• Wash hands using a surgical scrub technique and put on the sterile gown and gloves
• With assistance, set up a trolley using an aseptic technique:
• Open the dressing pack onto the trolley creating as
• Open the central line catheter pack and place on to the sterile field
• Flush all lumens of the catheter with saline and clamp the ends
• Ensure the guidewire is ready for insertion
• Attach the introducer needle to a 10mL syringe
• Clean the area with sterile preparation solution and place a large drape around it
• Inject local anaesthetic into the skin over the entry point
• Insert the introducer needle under the clavicle at a very shallow angle almost parallel to the floor
• Advance the needle towards the sternal notch, aspirating as you advance
Structures your needle may hit!
• In front of the vein: clavicle, subclavius muscle
• Behind the vein: phrenic nerve, anterior scalene muscle, subclavian artery
• Below the vein: first rib, pleura
• On hitting the vein the syringe will fill with blood
• Keeping the needle still, carefully remove the syringe:
• Blood should ooze (not pulsate) through the hub of the needle
• Insert the guidewire through the needle and watch the ECG:
•
Guidewires tend to be over 50cm in length but do not introduce more than 20cm as this may lead to arrhythmias
• Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire
• Thread the dilator over the wire, firmly pushing it through the skin:
• This may require a small stab incision in the skin with a blade
• Aim to get 2-3cm of dilator into the vein, not its full length
• Check the guidewire has not been kinked by ensuring it moves freely through the dilator
• Remove the dilator over the guidewire and apply gauze to the site to mop up any spills
• Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!):
• This may require withdrawing some of the guidewire
• Holding the guidewire at its port exit site with one hand, push the catheter through the skin with the other
Avoid handling the catheter, in particular its tip:
• Insert 16cm for a right-sided line and 20cm for a line
• Remove the guidewire:
• Blood should flow out through the end of the car
• Aspirate and flush all ports with normal saline
• Fix catheter to skin with a fixing device or sutures
• Cover with a transparent dressing
• Request a chest radiograph to confirm catheter position and the absence of a pneumothorax.
Procedure Tips
Getting started
• Check clotting prior to insertion. Aim for INR <1.5, platelets >50 × 10°/L
• © Direct pressure cannot be applied on the subclavian vessels so this route should be avoided in patients with a coagulopathy
• © There is a greater risk of pneumothorax than with internal jugular cannulation. A subclavian approach should, therefore, be avoided in patients with hyperinflated lungs
• Minimize spillage
• The underside of the clavicle can be reached by first directing the needle onto the clavicle and then carefully walking off it. The angle of the needle should, however, remain parallel to the floor
• Asking an assistant to pull the ipsilateral arm caudally can improve access
• If a sandbag is not available, roll up a towel or wrap a 1L bag of fluid in a spill-sheet as an alternative.
During the procedure
• D The subclavian vein should be encountered within 3-4 cm. Do not continue advancing the needle if the vein has not been hit by this point
• D Do not force the guidewire in. If there is resistance to guidewire insertion:
• Try lowering the angle of the needle making it more in line with the length of the vessel
Check you are still within the vein by aspirating with a syringe
• Try rotating the needle thereby moving the bevel away from any
obstruction
• Catheter malposition, particularly into the ipsilateral internal jugular vein, is more common using the subclavian vein approach. Many guidewires have a ' ' tip. Directing the J' tip caudally may help correct placement
• D Losing the guidewire can be disastrous. Always have one hand holding either the proximal or distal end of it
• Always consider the possibility of an inadvertent arterial pressure
• Signs include pulsatile blood flow, high-pressure blood flow,or blood red in colour (in the absence of hypotension or hypoxemia
•Do not dilate if in any doubt
• Consider sending blood for a blood gas to confirm venous placement
• The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Finishing off
• The incidence of vascular injuries and thrombosis is increased with left-sided catheters mainly due to insufficient catheter depth leading to the tip abutting the lateral wall of the upper SC. You must ensure left-sided lines are long enough so that their tip lies within the lower part of the SVC
• On the chest radiograph, confirm catheter position and the absence of
a pneumothorax:
•The tip of the catheter should lie at the junction of the SVC and right atrium which is approximately at the level of the carina.
Alternative approaches
• Medial approach: junction of medial and middle thirds of the clavicle
• Lateral approach: lateral to the mid-clavicular point. Often used with ultrasound guidance
Indications
• Inotrope therapy
• Parenteral nutrition (needs dedicated port)
• Poor peripheral access
• CVP measurement.
Contraindications
• Hyperinflated lungs (e.g. COPD patients)
• Coagulopathy
• Infected insertion site
• Thrombosed vein.
Risks
• Pneumothorax
• Haemorrhage
• Arterial puncture
• Air embolism
•Arrhythmias
• Thrombosis
• AV fistula
• Infection
• Malposition.
Documentation
• Time, date, indication, and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempt (s)
• Aseptic technique: gloves, gown, hat, mask, type of sterite
• Local anaesthetic: type and amount infiltrated
• Technique used: e.g. landmark, ultrasound guidance
• Catheter used: length and number of lumens
• Aspirated and flushed
• Length of catheter in situ (length at skin)
• CXR: site of tip, absence/presence of a pneumothorax
• Signature, printed name and contact details.
Equipment
• Central line catheter pack:
• Central line (16cm length for right side, 20cm for left side), introducer needle and 10mL syringe, guidewire, dilator, blade
• Large-dressing pack including a large sterile drape and gauze
• Normal saline
• Local anaesthetic for skin (1% lidocaine) with suitable
(25G) needle and syringe
• Sterile preparation solution (2% chlorhexidine)
• Sterile gloves, sterile gown, surgical hat and mask
• Trolley and ECG monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Position the patient supine (1 pillow), place a sandbag between shoulder blades, and tilt the bed head down
• Attach ECG leads onto the patient making sure they are not in the surgical field
• Turn the patient's head away from the side of insertion
• Identify the entry point, just inferior to the midpoint of the clavicle
• Wash hands using a surgical scrub technique and put on the sterile gown and gloves
• With assistance, set up a trolley using an aseptic technique:
• Open the dressing pack onto the trolley creating as
• Open the central line catheter pack and place on to the sterile field
• Flush all lumens of the catheter with saline and clamp the ends
• Ensure the guidewire is ready for insertion
• Attach the introducer needle to a 10mL syringe
• Clean the area with sterile preparation solution and place a large drape around it
• Inject local anaesthetic into the skin over the entry point
• Insert the introducer needle under the clavicle at a very shallow angle almost parallel to the floor
• Advance the needle towards the sternal notch, aspirating as you advance
Structures your needle may hit!
• In front of the vein: clavicle, subclavius muscle
• Behind the vein: phrenic nerve, anterior scalene muscle, subclavian artery
• Below the vein: first rib, pleura
• On hitting the vein the syringe will fill with blood
• Keeping the needle still, carefully remove the syringe:
• Blood should ooze (not pulsate) through the hub of the needle
• Insert the guidewire through the needle and watch the ECG:
•
Guidewires tend to be over 50cm in length but do not introduce more than 20cm as this may lead to arrhythmias
• Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire
• Thread the dilator over the wire, firmly pushing it through the skin:
• This may require a small stab incision in the skin with a blade
• Aim to get 2-3cm of dilator into the vein, not its full length
• Check the guidewire has not been kinked by ensuring it moves freely through the dilator
• Remove the dilator over the guidewire and apply gauze to the site to mop up any spills
• Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!):
• This may require withdrawing some of the guidewire
• Holding the guidewire at its port exit site with one hand, push the catheter through the skin with the other
Avoid handling the catheter, in particular its tip:
• Insert 16cm for a right-sided line and 20cm for a line
• Remove the guidewire:
• Blood should flow out through the end of the car
• Aspirate and flush all ports with normal saline
• Fix catheter to skin with a fixing device or sutures
• Cover with a transparent dressing
• Request a chest radiograph to confirm catheter position and the absence of a pneumothorax.
Procedure Tips
Getting started
• Check clotting prior to insertion. Aim for INR <1.5, platelets >50 × 10°/L
• © Direct pressure cannot be applied on the subclavian vessels so this route should be avoided in patients with a coagulopathy
• © There is a greater risk of pneumothorax than with internal jugular cannulation. A subclavian approach should, therefore, be avoided in patients with hyperinflated lungs
• Minimize spillage
• The underside of the clavicle can be reached by first directing the needle onto the clavicle and then carefully walking off it. The angle of the needle should, however, remain parallel to the floor
• Asking an assistant to pull the ipsilateral arm caudally can improve access
• If a sandbag is not available, roll up a towel or wrap a 1L bag of fluid in a spill-sheet as an alternative.
During the procedure
• D The subclavian vein should be encountered within 3-4 cm. Do not continue advancing the needle if the vein has not been hit by this point
• D Do not force the guidewire in. If there is resistance to guidewire insertion:
• Try lowering the angle of the needle making it more in line with the length of the vessel
Check you are still within the vein by aspirating with a syringe
• Try rotating the needle thereby moving the bevel away from any
obstruction
• Catheter malposition, particularly into the ipsilateral internal jugular vein, is more common using the subclavian vein approach. Many guidewires have a ' ' tip. Directing the J' tip caudally may help correct placement
• D Losing the guidewire can be disastrous. Always have one hand holding either the proximal or distal end of it
• Always consider the possibility of an inadvertent arterial pressure
• Signs include pulsatile blood flow, high-pressure blood flow,or blood red in colour (in the absence of hypotension or hypoxemia
•Do not dilate if in any doubt
• Consider sending blood for a blood gas to confirm venous placement
• The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Finishing off
• The incidence of vascular injuries and thrombosis is increased with left-sided catheters mainly due to insufficient catheter depth leading to the tip abutting the lateral wall of the upper SC. You must ensure left-sided lines are long enough so that their tip lies within the lower part of the SVC
• On the chest radiograph, confirm catheter position and the absence of
a pneumothorax:
•The tip of the catheter should lie at the junction of the SVC and right atrium which is approximately at the level of the carina.
Alternative approaches
• Medial approach: junction of medial and middle thirds of the clavicle
• Lateral approach: lateral to the mid-clavicular point. Often used with ultrasound guidance
- Published on
Clinical Procedures – Central Venous Access – Ultrasound Guidance
Current recommendations in the UK are that ultrasound guidance should be considered when inserting any central venous catheter (NICE guidelines 2002).
Ultrasound Basics
• 'Ultrasound' refers to sound waves of such a high frequency as to be inaudible to the human ear (>20kHz).
• Medical ultrasound uses frequencies between 2-14MHz.
• The linear' (straight) transducer is the probe of choice for imaging the vessels and other superficial structures.
• The frequency of the probe should be between 7.5-10MHz for central venous access.
Basic Controls
• Frequency. Higher frequency may result in a better resolution but will not penetrate the tissues as deeply
• Gain. The gain control alters the amplification of the returned signals. This changes the greyscale of the image (can be thought of as increasing the brightness) but may not improve its quality
• Depth. The depth of the image on screen can be manually adjusted. It is wise to see the structures deep to the vessel to be cannulated
• Focal length. The focal point is usually displayed arrow at the side of the image. At this point, the image will
be sharpest but resolution of the deeper stit suffer. The focal point should be positioned in line with the vein to be cannulated.
Orientation
• By convention, the left of the screen should be that part of the patient to your left (i.e. the patient's right if you are facing the patient, the patient's left if you are scanning from behind them):
• Touch the edge of the probe and watch for the movement on screen to be sure you have the transducer the right way round.
Equipment
• Ultrasound machine (linear probe, high frequency)
• Sterile lubricating jelly
• Sterile probe cover.
Procedure (Internal Jugular Vein Catheterization)
• With the patient positioned, squeeze sterile gel onto the patient's neck
• Hold the probe cover open like a sock. Ask an assistant to squeeze ultrasound gel into the base and carefully lower the probe in after it. You can then unfurl the probe cover along the length of the wire using aseptic technique
• Place probe over the surface markings of the vein (short axis of vessel)
• On the screen, look for two black circles side by side. These represent the vein and the artery
• Identify the vessels by pressing down with the probe:
• The vein will be compressible and the artery will not
• The artery will also be pulsatile.Note that the IV may also be pulsatile with the patient head down (the JVP)
• The artery is often circular in cross-section; the vein may be oval or a more complex ovoid shape
• Follow the course of the vein up the patient's neck and identify a site where the artery sits relatively medial to the vein. At this point, centre the vein onto the screen holding the probe still with your non-dominant hand
• Don't press too hard with the probe you may compress the vein
• Inject local anaesthetic into the skin around the midpoint of the probe using your dominant hand
• Insert the introducer needle through the skin at the midpoint of the probe
• Gently move the needle in and out to help locate the tip and its course on the screen:
•The tip of the needle will only be visualized if it is advancing in the same plane as the ultrasound beam
• Advance the needle (with continuous aspiration) towards the vein ensuring the tip is always in view
• On hitting the vein, blood will be aspirated into the syringe. Flatten the needle ensuring blood can still be aspirated. At this point, the probe can be removed and the vein be catheterized using the Seldinger technique
• The ultrasound can be used later in the procedure to ensure that the guidewire lies within the vein, if necessary.
Current recommendations in the UK are that ultrasound guidance should be considered when inserting any central venous catheter (NICE guidelines 2002).
Ultrasound Basics
• 'Ultrasound' refers to sound waves of such a high frequency as to be inaudible to the human ear (>20kHz).
• Medical ultrasound uses frequencies between 2-14MHz.
• The linear' (straight) transducer is the probe of choice for imaging the vessels and other superficial structures.
• The frequency of the probe should be between 7.5-10MHz for central venous access.
Basic Controls
• Frequency. Higher frequency may result in a better resolution but will not penetrate the tissues as deeply
• Gain. The gain control alters the amplification of the returned signals. This changes the greyscale of the image (can be thought of as increasing the brightness) but may not improve its quality
• Depth. The depth of the image on screen can be manually adjusted. It is wise to see the structures deep to the vessel to be cannulated
• Focal length. The focal point is usually displayed arrow at the side of the image. At this point, the image will
be sharpest but resolution of the deeper stit suffer. The focal point should be positioned in line with the vein to be cannulated.
Orientation
• By convention, the left of the screen should be that part of the patient to your left (i.e. the patient's right if you are facing the patient, the patient's left if you are scanning from behind them):
• Touch the edge of the probe and watch for the movement on screen to be sure you have the transducer the right way round.
Equipment
• Ultrasound machine (linear probe, high frequency)
• Sterile lubricating jelly
• Sterile probe cover.
Procedure (Internal Jugular Vein Catheterization)
• With the patient positioned, squeeze sterile gel onto the patient's neck
• Hold the probe cover open like a sock. Ask an assistant to squeeze ultrasound gel into the base and carefully lower the probe in after it. You can then unfurl the probe cover along the length of the wire using aseptic technique
• Place probe over the surface markings of the vein (short axis of vessel)
• On the screen, look for two black circles side by side. These represent the vein and the artery
• Identify the vessels by pressing down with the probe:
• The vein will be compressible and the artery will not
• The artery will also be pulsatile.Note that the IV may also be pulsatile with the patient head down (the JVP)
• The artery is often circular in cross-section; the vein may be oval or a more complex ovoid shape
• Follow the course of the vein up the patient's neck and identify a site where the artery sits relatively medial to the vein. At this point, centre the vein onto the screen holding the probe still with your non-dominant hand
• Don't press too hard with the probe you may compress the vein
• Inject local anaesthetic into the skin around the midpoint of the probe using your dominant hand
• Insert the introducer needle through the skin at the midpoint of the probe
• Gently move the needle in and out to help locate the tip and its course on the screen:
•The tip of the needle will only be visualized if it is advancing in the same plane as the ultrasound beam
• Advance the needle (with continuous aspiration) towards the vein ensuring the tip is always in view
• On hitting the vein, blood will be aspirated into the syringe. Flatten the needle ensuring blood can still be aspirated. At this point, the probe can be removed and the vein be catheterized using the Seldinger technique
• The ultrasound can be used later in the procedure to ensure that the guidewire lies within the vein, if necessary.
