Procedure - Central Lines (TLC, cordis, HD, Trialysis) Flashcards
What do you need to make sure you’re doing with your positioning?
Keep the bed a good height so you’re not hunched over and BE SURE you’re not locking your knees. Flex your knees often to make sure you’re getting good blood flow.
To limit vagal responses, do what?
Take off the face shield so you can breathe a little better, don’t wear the hair nets too tight, and don’t tie your gown too tight. Also make sure you’re not locking your knees. Take deep breaths and remind yourself that there’s always a backup plan.
When you thread a triple lumen catheter over the wire, the wire will come out of the ___________ port.
brown
How far should you insert a triple lumen catheter in an average size adult on the right and left IJs?
- Right: 15 cm
- Left: 20 cm
This is important to know because if you grab a 20 cm TLC kit you need to keep it 5 cm out of the skin.
Which subclavian site is preferable?
Right
It is straighter and does not have the thoracic duct.
Review positioning for R IJ central line insertion.
- Move the bed into a convenient spot in the room
- Remove or lower the side rails, headboard, and unused IV poles
- Flatten the bed
- Slide the patient high into the bed so that their head is just at the end of the bed
- Put the patient into Trendelenburg if they can tolerate it
- Raise the bed to a height that is comfortable for you
- Rotate their neck to the left
- Move your table into position
Although now we use US, in the old days they used to use what landmarks to guide the RIJ insertion?
The apex (superior-most angle) of the triangle that is outlined by the clavicle and the two heads of the SCM (the sternal head and the clavicular head)
Review the supplies you need for a central line.
Setup:
- US
- Table
- Assistant
Sterilization:
- US probe cover
- Chloraprep (usually in the kits but make sure)
- Sterile gloves
- Gown (sometimes this is in the kit but double check)
- Bouffant
Procedure:
- Kit
- Clavs
- Sterile saline (some kits don’t contain this so check)
- Sterile dressing (again, some kits don’t have this so check)
Review the steps of central line insertion (generic for all sites and catheters).
- Gather all your supplies (US, table, assistant, kit, US probe cover, sterile gloves, gown, bouffant, chloraprep, class, sterile saline, and sterile dressing)
- Position the patient, your table, a trash can, and the US where you need them (see that card for more details
- Scan your site to make sure everything looks safe and accessible
- Open the kit on your table
- Open your gloves, probe cover, sterile saline, clavs, Chloraprep, and sterile dressing onto the sterile kit (that is, everything that will need to be sterile that you can’t touch when you are sterile)
- Put on your bouffant, gown, and gloves
- Chloraprep the patient and wait for it to dry
- Drape the patient
- Inject local anesthetic in the site you intend to put the needle and suture (if the patient is conscious)
- Organize your kit
- Put the clavs on the two free ports (blue and white on the TLC) and flush with saline
- Put a clav on a syringe for the distal port
- Put the sterile probe cover on
- Scan for the vessel making sure you know the axis of the vessel and surrounding anatomy
- Inject the syringe and pull back on the plunger
- Stop advancing the needle when you aspirate blood
- Drop the probe and stabilize the needle with your free hand
- Remove the syringe
- Grab the wire and advance through
- Remove the needle and hold gauze over the entry site
- Confirm placement of the wire into the correct vessel
- Cut with the scalpel (blade pointed up, knife pointing the same axis that your wire and dilator will pass)
- Keep gauze on after you have cut to absorb the blood
- Dilate (pinch the dilator need the tip to avoid bending/flexing)
- Keep gauze on after you remove the dilator
- Thread the catheter over the wire, never let go of the wire
- Pull the wire out from the catheter
- Aspirate blood and infuse saline through each port
- Secure the catheter with sutures
- Clean the blood
- Apply dressing
- Order chest XR
When you apply a probe cover, always ______________.
use gel on the underside and then smooth out air bubbles
The two-line marker on the guide wire indicates ______ cm.
20
When you’re aspirating back blood, only aspirate until ________________.
blood enters the catheter tube (not the syringe); this helps to ensure that the blood flushes out easily because it’s hard to flush fully clear if there’s blood in the syringe
When you need to thread the dilator and catheter over the wire, be sure that you hold the wire ______________.
at the skin and the tip with your non-dominant hand
You of course need to always hold the wire near the skin to avoid displacement, but you also need to stabilize the tip to make it easy to thread over it. To do this, pinch the wire just above the skin with your thumb and index finger. Use your free hand to loop the wire back and stabilize the tip with your other fingers.
How deep do you insert the R IJ, L IJ, R subclavian, and femoral CVCs?
- R IJ: 16 cm
- L IJ: 19 cm
Adjust if the patient is tall or short.
Why should you err on the side of being too deep on a CVC insertion?
You can withdraw and use the same line, but you cannot advance farther.
