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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.
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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.
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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.
- Published on
Clinical Procedures – Intravenous Infusion
Equipment
• Gloves
• An appropriate fluid bag
• Giving set
• Drip stand
• 10mL syringe with saline flush.
Procedure
• ©Intravenous infusions require intravenous access
• Check the fluid in the bag and fluid prescription chart
• Ask a colleague to double-check the prescription and the fluid and sign their name on the chart
• Flush the patient's cannula with a few mL of saline to ensure there is no obstruction. If there is evidence of a blockage, swelling at the cannula site, or if the patient experiences pain, you may need to replace the cannula
• Open the fluid bag and giving set, which come in sterile packaging
• Unwind the giving set and close the adjustable valve
• Remove the sterile cover from the bag outlet and from the sharp end of the giving set
• Using quite a lot of force, push the giving set end into the bag outlet
• Invert the bag and hang on a suitable drip-stand
• Squeeze the drip chamber to half fill it with fluid
• Partially open the valve to allow the drip to run, and watch fluid run through to the end (it might be best to hold the free end over a sink in case of spills)
• If bubbles appear, try tapping or flicking the tube
• Once the giving set is filled with liquid, connect it to the
cannula
• Adjust the valve and watch the drips in the chamber
• Adjust the drip rate according to the prescription.
Drip Rate
• Most infusions tend to be given with electronic devices which pump the fluid in at the prescribed rate. However, it is still important that healthcare professionals are able to set up a drip at the correct flow rate manually
• Using a standard giving set, clear fluids will form drips of about 0.05mL. that is, there will be approximately 20 drips/mL. You can then calculate
Equipment
• Gloves
• An appropriate fluid bag
• Giving set
• Drip stand
• 10mL syringe with saline flush.
Procedure
• ©Intravenous infusions require intravenous access
• Check the fluid in the bag and fluid prescription chart
• Ask a colleague to double-check the prescription and the fluid and sign their name on the chart
• Flush the patient's cannula with a few mL of saline to ensure there is no obstruction. If there is evidence of a blockage, swelling at the cannula site, or if the patient experiences pain, you may need to replace the cannula
• Open the fluid bag and giving set, which come in sterile packaging
• Unwind the giving set and close the adjustable valve
• Remove the sterile cover from the bag outlet and from the sharp end of the giving set
• Using quite a lot of force, push the giving set end into the bag outlet
• Invert the bag and hang on a suitable drip-stand
• Squeeze the drip chamber to half fill it with fluid
• Partially open the valve to allow the drip to run, and watch fluid run through to the end (it might be best to hold the free end over a sink in case of spills)
• If bubbles appear, try tapping or flicking the tube
• Once the giving set is filled with liquid, connect it to the
cannula
• Adjust the valve and watch the drips in the chamber
• Adjust the drip rate according to the prescription.
Drip Rate
• Most infusions tend to be given with electronic devices which pump the fluid in at the prescribed rate. However, it is still important that healthcare professionals are able to set up a drip at the correct flow rate manually
• Using a standard giving set, clear fluids will form drips of about 0.05mL. that is, there will be approximately 20 drips/mL. You can then calculate
Documentation
• Ensure fluid and/or drug is clearly timed and signed for as per local policy
• Nursing notes should be completed to include the reason for the infusion
• Medical notes should be used to record any causes for concern arising from administration of the infusion
• Cannula site (and cannula documentation) should be dated and signed on insertion
• Ensure any fluid-monitoring chart is complete and updated as appropriate
• Ensure fluid and/or drug is clearly timed and signed for as per local policy
• Nursing notes should be completed to include the reason for the infusion
• Medical notes should be used to record any causes for concern arising from administration of the infusion
• Cannula site (and cannula documentation) should be dated and signed on insertion
• Ensure any fluid-monitoring chart is complete and updated as appropriate
- Published on
Clinical Procedures - Arterial Line Insertion (Radial Artery)
Indications
• Continuous beat-to-beat measurement of arterial blood pressure (inotrope therapy, intraoperatively for major surgery, transfer of critically ill)
• Repeated blood gas sampling.
Contraindications
• Infection at insertion site
• Working AV fistula
• Traumatic injury proximal to the insertion site
• Vascular insufficiency in the distribution of the artery to be cannulated
• Significant clotting abnormalities.
Risks
• Non-vascular: superficial bleeding, infection, inadvertent arterial injection
. Vascular: vasospasm, thrombosis, thromboembolism, air embolism,
blood vessel injury, distal ischaemia
Procedure Tips
• Good positioning is vital. Make sure both you and the patient are comfortable
• © Do not force the guidewire. If there is resistance, try lowering the needle to a shallower angle without removing it from the artery
• © Cover the floor with spill sheets as the procedure can be messy!
• D The modified Allen's test should be used for assessment of the collateral supply to the hand before the radial artery is punctured but may not be completely reliable in predicting ischaemic injury.
Modified Allen's test
• Compress the radial and ulnar arteries at the wrist and ask the patient to clench their fist
• Ask the patient to open the hand
• Release pressure over the ulnar artery
• Watch the palm for return of colour:
• Return of colour should normally occur in 5-10 seconds
• Return of colour taking >15 seconds suggests an inadequate collateral supply by the ulnar artery and radial artery cannulation should not be performed.
Equipment
• Arterial catheter set:
• Arterial catheter (20G), needle, guidewire
• Sterile gloves, sterile gown (‡ surgical hat and mask)
• Dressing pack including a sterile drape
• Sterile preparation solution (e.g. 2% chlorhexidine)
• Local anaesthetic (e.g. 1% lidocaine), 22G needle, and 5mL syringe
• (Optional) A 3-way tap with a short extension (flushed with normal saline) connected to a 10mL syringe containing normal saline
• Suture
• Transducer set with pressurized bag of heparinized saline.
Procedure (Modified Seldinger Technique)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Choose a site for arterial line insertion (e.g. radial artery)
• Position the forearm so that it is supported from underneath and hyperextend the wrist
• Set up a trolley keeping everything sterile:
• Open the dressing pack onto the trolley creating a sterile field
• Open the arterial catheter set and place onto the sterile field
• Wash hands using a surgical scrub technique and put on the sterile gown and gloves
• Clean the wrist, hand, and forearm with a sterile preparation solution and create a sterile field with the drape
• Palpate the radial artery with your non-dominant hand and infiltrate the skin overlying the pulsation with some local
anaesthetic
• Insert the arterial needle, directing it towards the radial pulsation at a 30-45° angle. (Do not attach to a syringe.)
• You can also use a syringe with the plunger removed.
This allows identification of the arterial pulsation without excess spillage
• On hitting the artery, blood will spurt out of the hub of the needle
• Keeping the needle still, insert the guidewire through the hub of the needle. © Don't force the guidewire
• Remove the needle leaving the guidewire in place
• Thread the arterial catheter over the guidewire making sure that guidewire is seen at all times through the distal end of the catheter
• Holding the distal end of the guidewire with one hand, push the arterial catheter through the skin with the other
• Remove the guidewire
• Blood should spill out of the end of the catheter if it is within the artery
• Connect to the short extension of the 3-way tap, aspirate and flush with normal saline, and close off the tap:
• Alternatively, connect immediately to a pressurized transducer set, aspirate, and flush
•Do not delay connection to transducer and flush-bag
• Take extreme care not to allow any air bubbles to flush into the artery (risk of distal embolization)
• Suture in place
• Label catheter as arterial and inform relevant staff.
Documentation
• Time, date, indication and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempts)
• Aseptic technique: gloves, gown, hat, mask, sterile solution
• Local anaesthetic: type and amount infiltrated
• Technique used: modified Seldinger, cannula over needle
• Catheter size used: 20G
• Aspirated and flushed
• Signature, printed name, and contact details.
Indications
• Continuous beat-to-beat measurement of arterial blood pressure (inotrope therapy, intraoperatively for major surgery, transfer of critically ill)
• Repeated blood gas sampling.
Contraindications
• Infection at insertion site
• Working AV fistula
• Traumatic injury proximal to the insertion site
• Vascular insufficiency in the distribution of the artery to be cannulated
• Significant clotting abnormalities.
Risks
• Non-vascular: superficial bleeding, infection, inadvertent arterial injection
. Vascular: vasospasm, thrombosis, thromboembolism, air embolism,
blood vessel injury, distal ischaemia
Procedure Tips
• Good positioning is vital. Make sure both you and the patient are comfortable
• © Do not force the guidewire. If there is resistance, try lowering the needle to a shallower angle without removing it from the artery
• © Cover the floor with spill sheets as the procedure can be messy!
• D The modified Allen's test should be used for assessment of the collateral supply to the hand before the radial artery is punctured but may not be completely reliable in predicting ischaemic injury.
Modified Allen's test
• Compress the radial and ulnar arteries at the wrist and ask the patient to clench their fist
• Ask the patient to open the hand
• Release pressure over the ulnar artery
• Watch the palm for return of colour:
• Return of colour should normally occur in 5-10 seconds
• Return of colour taking >15 seconds suggests an inadequate collateral supply by the ulnar artery and radial artery cannulation should not be performed.
Equipment
• Arterial catheter set:
• Arterial catheter (20G), needle, guidewire
• Sterile gloves, sterile gown (‡ surgical hat and mask)
• Dressing pack including a sterile drape
• Sterile preparation solution (e.g. 2% chlorhexidine)
• Local anaesthetic (e.g. 1% lidocaine), 22G needle, and 5mL syringe
• (Optional) A 3-way tap with a short extension (flushed with normal saline) connected to a 10mL syringe containing normal saline
• Suture
• Transducer set with pressurized bag of heparinized saline.
Procedure (Modified Seldinger Technique)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Choose a site for arterial line insertion (e.g. radial artery)
• Position the forearm so that it is supported from underneath and hyperextend the wrist
• Set up a trolley keeping everything sterile:
• Open the dressing pack onto the trolley creating a sterile field
• Open the arterial catheter set and place onto the sterile field
• Wash hands using a surgical scrub technique and put on the sterile gown and gloves
• Clean the wrist, hand, and forearm with a sterile preparation solution and create a sterile field with the drape
• Palpate the radial artery with your non-dominant hand and infiltrate the skin overlying the pulsation with some local
anaesthetic
• Insert the arterial needle, directing it towards the radial pulsation at a 30-45° angle. (Do not attach to a syringe.)
• You can also use a syringe with the plunger removed.
This allows identification of the arterial pulsation without excess spillage
• On hitting the artery, blood will spurt out of the hub of the needle
• Keeping the needle still, insert the guidewire through the hub of the needle. © Don't force the guidewire
• Remove the needle leaving the guidewire in place
• Thread the arterial catheter over the guidewire making sure that guidewire is seen at all times through the distal end of the catheter
• Holding the distal end of the guidewire with one hand, push the arterial catheter through the skin with the other
• Remove the guidewire
• Blood should spill out of the end of the catheter if it is within the artery
• Connect to the short extension of the 3-way tap, aspirate and flush with normal saline, and close off the tap:
• Alternatively, connect immediately to a pressurized transducer set, aspirate, and flush
•Do not delay connection to transducer and flush-bag
• Take extreme care not to allow any air bubbles to flush into the artery (risk of distal embolization)
• Suture in place
• Label catheter as arterial and inform relevant staff.
Documentation
• Time, date, indication and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempts)
• Aseptic technique: gloves, gown, hat, mask, sterile solution
• Local anaesthetic: type and amount infiltrated
• Technique used: modified Seldinger, cannula over needle
• Catheter size used: 20G
• Aspirated and flushed
• Signature, printed name, and contact details.
- Published on
Surgery - Knee Joint Injection
Indications
• Iniection of corticosteroids are performed to relieve:
•Acute attack of crystal arthritis (gout, pseudogout)
• Flare of inflammatory arthritis (seronegative arthritis, rheumatoid arthritis, reactive arthritis)
• Pain in patients with osteoarthritis.
Other substances administered by an intra-articular injection
• Yttrium: for chronic monoarticular synovitis
• Hyaluronic acid: for pain in patients with osteoarthritis of the knee.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia and a high IN should be discussed with a rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France)
• Subcutaneous atrophy: rare but may be permanent
• Side effects from systemic absorption of corticosteroids: including facial flushing and transient worsening of diabetic control (uncommon)
• Increased pain: this usually lasts for 2-3 days.
Procedure Tips
• It is good practice to send the joint aspirate for routine crystal study Ch stain, and culture. This establishes if the joint was infected before joins aspiration and corticosteroid injection
• Microbiology request forms should provide information on the date, time, and site of joint aspirated.
Injecting smaller joints
• Hydrocortisone (short acting) should be used for small superficial joints rather than triamcinolone
• For MCP joints, 25mg of hydrocortisone and 0.5mL of 2% lidocaine will suffice
• Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• Corticosteroid injection:
• Triamcinolone (long acting) for large joints (knee, shoulder)
• Lidocaine 1% or 2%
• 21G (green) needles
• 10mL syringe
• 5mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• Draw up 40mg triamcinolone and 2mL of 2% lidocaine
• A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• If there is no suspicion of septic arthritis and, once a significant proportion of synovial fluid has been aspirated, attach the syringe containing a mixture of corticosteroids and lidocaine to the needle
• Aspirate a little more to confirm intra-articular, extra-vascular placement and inject the steroid mixture
• • If there is any suspicion of septic arthritis, injection of corticosteroids should not be carried out in the same sitting as synovial fluid aspiration:
•Signs and symptoms of septic arthritis may be indolent in the immunosuppressed and a high index of suspicion needs to be maintained. The clinical suspicion of septic arthritis is further strengthened by aspirating cloudy or purulent fluid
• Withdraw the needle and dress the site with a suitable plaster
• Advise the patient to rest the injected area for 24 48 hours.
Procedure (Superolateral Approach)
For large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be aimed inferiorly and medially.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested
• Type and amount of anaesthetic and steroid used
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Iniection of corticosteroids are performed to relieve:
•Acute attack of crystal arthritis (gout, pseudogout)
• Flare of inflammatory arthritis (seronegative arthritis, rheumatoid arthritis, reactive arthritis)
• Pain in patients with osteoarthritis.
Other substances administered by an intra-articular injection
• Yttrium: for chronic monoarticular synovitis
• Hyaluronic acid: for pain in patients with osteoarthritis of the knee.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia and a high IN should be discussed with a rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France)
• Subcutaneous atrophy: rare but may be permanent
• Side effects from systemic absorption of corticosteroids: including facial flushing and transient worsening of diabetic control (uncommon)
• Increased pain: this usually lasts for 2-3 days.
Procedure Tips
• It is good practice to send the joint aspirate for routine crystal study Ch stain, and culture. This establishes if the joint was infected before joins aspiration and corticosteroid injection
• Microbiology request forms should provide information on the date, time, and site of joint aspirated.
Injecting smaller joints
• Hydrocortisone (short acting) should be used for small superficial joints rather than triamcinolone
• For MCP joints, 25mg of hydrocortisone and 0.5mL of 2% lidocaine will suffice
• Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• Corticosteroid injection:
• Triamcinolone (long acting) for large joints (knee, shoulder)
• Lidocaine 1% or 2%
• 21G (green) needles
• 10mL syringe
• 5mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• Draw up 40mg triamcinolone and 2mL of 2% lidocaine
• A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• If there is no suspicion of septic arthritis and, once a significant proportion of synovial fluid has been aspirated, attach the syringe containing a mixture of corticosteroids and lidocaine to the needle
• Aspirate a little more to confirm intra-articular, extra-vascular placement and inject the steroid mixture
• • If there is any suspicion of septic arthritis, injection of corticosteroids should not be carried out in the same sitting as synovial fluid aspiration:
•Signs and symptoms of septic arthritis may be indolent in the immunosuppressed and a high index of suspicion needs to be maintained. The clinical suspicion of septic arthritis is further strengthened by aspirating cloudy or purulent fluid
• Withdraw the needle and dress the site with a suitable plaster
• Advise the patient to rest the injected area for 24 48 hours.
Procedure (Superolateral Approach)
For large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be aimed inferiorly and medially.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested
• Type and amount of anaesthetic and steroid used
• Any immediate complications
• Signature, printed name, and contact details.
- Published on
Clinical Procedures – Knee Joint Aspiration
Indications
• Differential diagnosis of acute hot swollen joint
• Recurrent aspiration for joint sepsis.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia or a high IN should be discussed with rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint. This is a relative contraindication. A prosthetic joint should be aspirated by an orthopedic surgeon in a theatre using full surgical sterile precautions.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France).
Procedure Tips
• If you are unable to aspirate synovial fluid:
•Simply withdraw the needle and insert at a different angle (aiming inferomedially)
• Change the position of the patient. Ask them to sit on the edge of a bed with their feet on a stool or chair and repeat the procedure in this position
• Other joints may be aspirated using a similar technique. Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Aspiration of a prosthetic joint should be performed by an Orthopaedic Surgeon in a theatre with full surgical sterility.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• 21G (green) needles
• 10mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• ( A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• Withdraw the needle and dress the site with a suitable plaster
• Send the samples for crystal study, Gram stain, and culture.
Procedure (Superolateral Approach)
Used for large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be inserted at a 45° angle and aimed inferiorly and medially under the patella
• Continue to advance the needle with negative pressure on the plunger until fluid is aspirated.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested:
• The pathology request form should provide the pathologist with information on the date, time, and site of joint aspirate
• The sample should be sent to the laboratories and analysed fresh for crystals, Gram stain, and culture.
The laboratory should be alerted if septic arthritis is suspected
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Differential diagnosis of acute hot swollen joint
• Recurrent aspiration for joint sepsis.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia or a high IN should be discussed with rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint. This is a relative contraindication. A prosthetic joint should be aspirated by an orthopedic surgeon in a theatre using full surgical sterile precautions.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France).
Procedure Tips
• If you are unable to aspirate synovial fluid:
•Simply withdraw the needle and insert at a different angle (aiming inferomedially)
• Change the position of the patient. Ask them to sit on the edge of a bed with their feet on a stool or chair and repeat the procedure in this position
• Other joints may be aspirated using a similar technique. Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Aspiration of a prosthetic joint should be performed by an Orthopaedic Surgeon in a theatre with full surgical sterility.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• 21G (green) needles
• 10mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• ( A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• Withdraw the needle and dress the site with a suitable plaster
• Send the samples for crystal study, Gram stain, and culture.
Procedure (Superolateral Approach)
Used for large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be inserted at a 45° angle and aimed inferiorly and medially under the patella
• Continue to advance the needle with negative pressure on the plunger until fluid is aspirated.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested:
• The pathology request form should provide the pathologist with information on the date, time, and site of joint aspirate
• The sample should be sent to the laboratories and analysed fresh for crystals, Gram stain, and culture.
The laboratory should be alerted if septic arthritis is suspected
• Any immediate complications
• Signature, printed name, and contact details.
- Published on
Clinical Procedures - Fine Needle Aspiration
Indications
• Diagnosis of a lump; commonly thyroid and lymph node.
Contraindications
• Bleeding diathesis
• Overlying infection
• Adjacent vital structures. Image-guidance should always be used if available.
Risks
• Bleeding
• Local infection
• Damage to surrounding structures depending on site, e.g. blood vessels, nerves.
Procedure Tips
• © Radiological guidance should always be used if available
• Contact the histopathology department in advance to ensure appropriate transport medium is used. It may be possible to arrange immediate analysis, allowing diagnosis and repeat FNA if insufficient cells are obtained.
A method for obtaining a cytological sample of a mass lesion.
• This procedure should only be performed by, or under strict supervision of, an experienced practitioner.
• Fine-needle aspiration (FNA) usually takes place in the Radiology Department and is performed by an experienced Radiologist under ultrasound or CT guidance. The following describes the older, 'blind' technique.
Equipment
• Local anaesthetic (e.g. 1% lidocaine)
• Small-gauge (blue) needle and 10mL syringe
• Sterile pack
• Cleaning solution (e.g. chlorhexidine)
• Medium-gauge (green) needle
• 10mL or 20mL syringe for aspiration
• Sterile gloves.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient according to the biopsy site, allowing easy palpation of the mass
• Expose appropriately
• Wash your hands and put on sterile gloves
• Clean the area with the cleaning solution and apply drapes
• Instil local anesthetic to the skin and subcutaneous tissues withdrawing the plunger prior to each injection to avoid intravenous injection and warning the patient to expect a
'sharp scratch'
• Immobilize the mass with your non-dominant hand
• Using your dominant hand, insert the needle through the skin into the lump, maintaining negative pressure on the plunger as you go
• Once in the lump, the needle may be moved gently back and forth to obtain a greater volume of cells
It may be necessary to insert the needle several times to obtain a sufficient sample
• Do not expect a large amount of material within the syringe! A tiny sample within the needle will usually suffice
• Remove the needle and send the sample for cytology (you will need to gently expel the sample from the needle into a suitable container)
• Apply a sterile dressing to the site.
Alternative Method
• There are two schools of thought in FNA
• Some practitioners use a small (blue) needle without a syringe attached. This is moved in and out very quickly within the mass whilst also applying rotation. Capillary action deposits a cellular sample within the needle which can then be gently expelled using an empty syringe
• This capillary action technique may result in a larger number of intact cells in the resultant sample as the negative pressure created when using a syringe can disrupt cell membranes.
Documentation
• Date and time
• Indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of puncture
• Aseptic technique used?
• How many passes?
• Volume and colour of sample obtained
• Any immediate complications
• Tests requested on resultant sample
• Signature, printed name, and contact details.
Indications
• Diagnosis of a lump; commonly thyroid and lymph node.
Contraindications
• Bleeding diathesis
• Overlying infection
• Adjacent vital structures. Image-guidance should always be used if available.
Risks
• Bleeding
• Local infection
• Damage to surrounding structures depending on site, e.g. blood vessels, nerves.
Procedure Tips
• © Radiological guidance should always be used if available
• Contact the histopathology department in advance to ensure appropriate transport medium is used. It may be possible to arrange immediate analysis, allowing diagnosis and repeat FNA if insufficient cells are obtained.
A method for obtaining a cytological sample of a mass lesion.
• This procedure should only be performed by, or under strict supervision of, an experienced practitioner.
• Fine-needle aspiration (FNA) usually takes place in the Radiology Department and is performed by an experienced Radiologist under ultrasound or CT guidance. The following describes the older, 'blind' technique.
Equipment
• Local anaesthetic (e.g. 1% lidocaine)
• Small-gauge (blue) needle and 10mL syringe
• Sterile pack
• Cleaning solution (e.g. chlorhexidine)
• Medium-gauge (green) needle
• 10mL or 20mL syringe for aspiration
• Sterile gloves.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient according to the biopsy site, allowing easy palpation of the mass
• Expose appropriately
• Wash your hands and put on sterile gloves
• Clean the area with the cleaning solution and apply drapes
• Instil local anesthetic to the skin and subcutaneous tissues withdrawing the plunger prior to each injection to avoid intravenous injection and warning the patient to expect a
'sharp scratch'
• Immobilize the mass with your non-dominant hand
• Using your dominant hand, insert the needle through the skin into the lump, maintaining negative pressure on the plunger as you go
• Once in the lump, the needle may be moved gently back and forth to obtain a greater volume of cells
It may be necessary to insert the needle several times to obtain a sufficient sample
• Do not expect a large amount of material within the syringe! A tiny sample within the needle will usually suffice
• Remove the needle and send the sample for cytology (you will need to gently expel the sample from the needle into a suitable container)
• Apply a sterile dressing to the site.
Alternative Method
• There are two schools of thought in FNA
• Some practitioners use a small (blue) needle without a syringe attached. This is moved in and out very quickly within the mass whilst also applying rotation. Capillary action deposits a cellular sample within the needle which can then be gently expelled using an empty syringe
• This capillary action technique may result in a larger number of intact cells in the resultant sample as the negative pressure created when using a syringe can disrupt cell membranes.
Documentation
• Date and time
• Indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of puncture
• Aseptic technique used?
• How many passes?
• Volume and colour of sample obtained
• Any immediate complications
• Tests requested on resultant sample
• Signature, printed name, and contact details.
