Updated: Jun 10
24 March 2022
Author: Dr Jadumani Singh
Trolley set up
I believe in organising my procedure trolley myself, in doing that I don't miss out on any sterile or other essential instruments that I need for the procedure. Starting from bungs, local, stitches, syringes, sticky stuff, bowls to heparin saline, etc. Streamlining this on a daily basis will hasten the procedure, and minimise complications every time.
Please get a spacious trolley for all central line procedures to avoid unnecessary contamination and overcrowding of your trolley, which can make your procedure difficult and longer, thus making it very frustrating at times
3 x 5ml syringes, and a size 11 scalpel blade to puncture the skin at the insertion site.
1 x 20G (blue needle) for local anaesthesia (LA)
Stitches - 2-0 cotton/silk, needle holder, stitch cutter or scissor,
Heparin saline or normal saline is preferable - I use heparin saline unless contraindicated.
Local anesthetics and some patients may require a touch of sedation, my preference is 0.5 to 1 mg of Midazolam or whatever one chooses to use in small amounts without any side effects. I usually use about 7-8mls of 1% lignocaine and infiltrate the area well in advance.
Ultrasound machine (optional) - important to know how to use it, and the probe to use, and don't forget the sterile probe cover and gel.
Usually 2 Lumen - Red and Blue. Red indicates arterial port for sucking blood and blue indicating venous for blood return
Usually, internal jugular and femoral veins are preferred
Catheters 12-13F and 250mm long. The catheter comes in a sterile package including an introducer needle, dilator, guide wires plus dressing. Always flush them and bung them, as they contain at least 2-4 ml of air.
Once the trolley is prepared - I prepare myself for the procedure by wearing sterile gowns and gloves. I prefer to cover my patients from top to bottom as much as I can, depending on the situation of the patients in the ICU. Properly scrub the area of the procedure, and explain clearly to the patient the importance of sterility.
Explain the procedure to the patient, its potential complications, and how you would treat the complications if there are any. Ask the patient to let you know or the nurse about any distress or discomfort during or after the procedure. I take time to talk to my patient during which the cleaning and scrubbing to sterilise the area go hand in hand.
Examine the puncture area, either the neck or the femoral area properly for any broken or infected skin or any other abnormalities. Feeling the carotid and femoral pulse before the procedure also helps in visualising the anatomical position of the vein.
It is essential to cut the skin at the insertion site a little bigger than that for CVC due to the size of the catheter.
It's easy to puncture the artery so always try about 2cm below the inguinal ligament after feeling the pulse; remember the femoral vein is always medially located. One can use USG to visualise the femoral vessels.
It is always good to go on aspirating while inserting the needle as one goes deeper in case of an arterial puncture.
I mostly use 5 mls syringes without any saline because sometimes in ventilated patients in shock or severely oedematous patients - it becomes hard to distinguish between the arterial and venous blood. This is optional.
It is always advisable to run a blood gas (ABG/VBG) before introducing the dilator in case of any confusion. It is now recommended to do so in many ICUs. Always confirm the removal of the guidewire with the nurse or a colleague (especially with femoral vein cannulation as no check X-Rays are usually ordered to review)
Also, note the procedure in the case record of the patient with the date and time etc. as per ICU protocol.
Always try to choose the same side as the other central lines, for example, if CVC and arterial line are on the left side then Vascath on the left femoral is a better choice for patient comfort.
While inserting the dilator, a slow push with circular motion makes the dilator slide easily over the guidewire and also keeps the track open for the Vascath.
It is always advisable to keep the blue (venous) facing away from the patient as it prevents vascath clogging as explained in pictures Fig A and B below.
A good clean, and re-flush of the catheter to feel the flow of blood is advisable. It also helps to identify guide wire misplacement. Finally, flush with heparin saline to lock the catheter for use.
Disclaimer: The information contained does not serve as a standard of medical care, this is from the author's personal clinical experience.