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So You Know How to Insert a Central Line

June 9, 2011

I am not a very smart guy. Probably, that’s why I’m afraid to do an IQ test. However, I have brains enough to understand that if you use a simple list or step by step approach you can get things done in a less painful way, especially under pressure.

I have been looking for a step by step guide for “how to put a central line”. I found tones of information and videos. Most of the info is the same just the writers or the actors are different. So, I decided to make my own step by step on how to put a central line. It looks like a long list, but everything you need to know is there. Don’t forget that the docs making the youtube videos already have lots of experience and forgot when their hands were shaking and their mind was going all over the place just trying to put a skin stitch. They tend to miss many important details.

Here it goes the step by step on how to put a central line. It’s still a draft though. I will make some changes and add some information (such as how to distinguish venous from arterial blood) down the road. Feel free to correct me or add something. Share your favorite guides or videos.

1. Bring the supplies cart and the ultrasound machine, plug it in. Enter patient’s information.
2. Check the IJ location with the ECHO.
3. Clean the bedside table with Virox.
4. Put a drape on the table.
5. Open the saline basin and ask for normal saline, poor some NS in the basin. Update: currently we used sterile normal saline syringes.
6. Prepare your gloves x 2 (just in case if you touch something non sterile).
7. Wash hands with soup and water.
8. Put on the gown (grab by the lateral pockets), give the little cartoon paper on the front side of the gown to your assistant, turn around and tie yourself with the other end given to you by the assistant.
9. Put on the gloves with as much area of your hands covered by the gown sleeves.
10. Be sure that there is no non-sterile objects (hospital gown, wires, ET tube, etc) in close proximity to the IJ area. Ask your assistance to help.
11. Clean the skin with chlorhexidine x 2.
12. Cover the patient with the big sheet.
13. Put local anesthetic.
14. Put the ultrasound probe in the sterile sleeve.
15. Flash the precept cath. Leave the brown one open (the wire will come out through it), close the other 2 ports.
16. Your assistant will adjust the bed in Trendelenburg position about 15 degrees below the horizontal line.
17. Check if the needle is not too firmly attached to the syringe. Take it off and put it back.
18. Find the vein with the ECHO–>press with the probe, if the vessel collapses this is the IJ–>the right position of the probe diagonal to the clavicle–>when the vein is in the middle on your screen lift up the probe a little bit and place the needle at 45 degrees in the middle of the probe, put back the probe firmly on the skin.
19. Don’t look at the needle, but at the screen. Make a few bouncing movements with the needle to see where it is. Insert the needle forward and aspirate as you advance the needle until you see venous blood feeling up the needle. Insert the needle just a little bit more. Check again for blood return.
20. Hold firmly the needle with the fingers of one of your hands, and remove the syringe.
Start putting the wire. It should go smoothly without significant resistance. If slight resistance unroll a bit of the wire and try to insert by fingers. It usually works.
21. Remove the needle.
22. Make a small skin incision with the scalpel.
23. Insert the dilator about 2/3, and pull it out.
24. Insert the precept cath b/w 15 and 16 cm.
25. Remove the wire, which will come out
26. Flash each of the 3 ports until no blood is seen in the tubings. Close the port and put the cap on it.
27. Put the 2 plastic pieces from the set on 2 cm from the skin. First goes the round one, second is more flat. It goes over the first one.
28. Put the stitches, but before that be sure that the precept cath is till inserted at the right length (16-16 cm). Use 5-7 mm of skin, put the needle trough the hole in the plastic piece, make 5-6 knots. Repeat on the other side.
29. Put 4 x 4 gauzes and hold it with hand. Remove the covering sheets but be careful not to pull the precept cath. Put a tape on the top of the gauzes.
30. Clean up the mess. Sharps go in the sharp container.
31. Put order for stat X-ray. The nurse will call IV therapy to take care of the dressing.
32. Write the post-procedure note. Dictate the procedure note.
And a few general advice. Keep your area clean. Be calm. Even if you don’t get the vein from the very first time, that’s OK.
Relax. Try again a few times. If it doesn’t work, take out the needle and “stop the assembly line”. Take a few deep breaths. Find the vein with the US again. Follow the above steps again.

Central Venous Access via Posterior Approach to the Internal Jugular Vein

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