Overview
In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. Intensive care medical treatment can necessitate central venous catheters due to different indications like vasopressor therapy or treatment of the patient with vein irrigating substances. This video shows the placement of central venous catheters for intensive care patients.
Procedure
Indications for a central venous catheter include the need to apply vein irrigating substances, administration of short acting drugs like vasopressors or cytostatic drugs, measurement of central venous pressure and central venous blood oxygenation, or a poor peripheral vein status. A Shaldon-catheter can be placed if the patient needs hemodialysis in renal failure or a high flow volume access.
- Necessary materials should be prepared outside the patient room and placed on a sterile shelf.
- Don personal protective gear (gown, cap, goggles, gloves), as well as a FFP3 / N-95 mask, visor, and a second pair of gloves.
- Position the bed, set up the materials, and place the patient in supine position with their head rotated to the opposite side. Check the vital parameter monitoring and activate the QRS sound. If there are no contradictions for it, bring the patient into Trendelenburg position for better vein filling.
- Put additional towels under the neck and shoulder to absorb excess disinfection liquids.
- Perform a sonography of the puncture area to identify relevant anatomical structures and exclude intravascular clots. In this case, the internal jugular vein is used, but alternative puncture sites can be the femoral or subclavian veins. For a quick sonographic identification of anatomical structures, pressure can be applied to differentiate between the artery and the vein.
- Perform a local anesthesia or deepen the sedation after disinfection of the puncture site.
- Don sterile gown and gloves.
- Perform a generous disinfection of the puncture area and place sterile covers around the disinfected area. Cover the sonic head with a sterile coat.
- The catheter should be prepared and all lumen filled with 0.9% NaCl to avoid air embolism during the procedure.
- Identify the vein you want to puncture using sonography (shown is the access to the internal jugular vein) and advance the cannula towards the vein under sonographic control with continuous aspiration.
- When blood is aspirable, advance the guidewire through the cannula to approximately 20cm. While advancing the wire, observe the ECG for extrasystoles, which indicate that the wire is near the right of the heart.
- Remove the cannula and perform a sonographic position control of the guidewire in the vein.
- If a Shaldon-catheter is needed, the placement of the guidewire must be repeated with another wire.
- Dilate the tissue with the dilatator. A small incision may be necessary in patients with rigid skin.
- Remove the dilatator and insert the central venous catheter. The catheter insertion depth depends on the patient's body height. It is important to hold the guidewire to avoid accidentally losing it in the patient.
- Aspirate all lumen and flush with 0.9% NaCl.
- Secure the catheter with sutures and cover it with sterile bandages.
- If a Shaldon-catheter is needed, repeat the procedure in the same way as for the central venous catheter.
- If needed, blood cultures can be obtained under sterile conditions
- Remove the sterile covers.
- A chest X-ray may be performed for position control and to exclude complications like pneumothoraxes.
Placement of a central venous catheter. Indications-- the application of substances irritant to blood vessels, for instance, potassium chloride, hyperosmolar solutions, for example, sodium bicarbonate, mannitol, solutions with high concentrations of sodium chloride, longer-term parenteral nutrition, the application of medications with a short half life and cardiovascular actions, such as catecholamines. Application from specific cytostatics and anti-infective agents. Measurement of central venous pressure and also central venous oxygen saturation. Poor peripheral venous status.
Placement of a Shaldon catheter. Indication-- application of hemodialysis in renal failure patients at short notice. Large bore venous access.
For the placement of central venous catheters, the following materials are required. Health care personnel must wear full personal protection equipment when carrying out the procedure in COVID-19 patients. Personal protection donning and doffing procedure is not within the remit of this video.
For the purposes of this presentation, placement of both central venous and Shaldon catheters are shown. These are examples of dialysis catheters. There are three variations of dialysis catheters used in our hospital. A double-lumen size 13-French 20 centimeter for the internal jugular vein or subclavian vein, a double-lumen Shaldon catheter size 13-French 25 centimeters for the femoral vein, and a triple-lumen Shaldon catheter size 13-French 20 centimeters for the internal jugular vein or subclavian vein. This is used if an additional central venous lumen is required.
Firstly, the bed should be pulled away from the wall at an angle in order to ensure easier access to the patient's head and neck. The patient is prepared by being laid on their back. The bed's headrest is removed to allow easier access. The pillow must be removed, and the head turned to the contralateral side of the planned procedure site. A waterproof drape or cloth is then placed under the head and torso of the patient to ensure that the bed remains dry. The ECG trace tone is now turned on.
The procedure site is sonographically examined. A protective sheet must be stuck to the ultrasound probe in order to reduce the risk of contamination. Apply pressure and slide
the protective film over the ultrasound probe to sufficiently fix it. This will also optimize
picture quality. The neck is then disinfected with a spray in order to improve the contact surface.
Now, the procedure site is examined. In this case, the internal jugular vein. Alternatively, the subclavian or the femoral vein can be utilized for central venous access. On the monitor, we can see the communal carotid artery medially to the vein, which is not compressible. This is the pulsating image in the middle of the screen. Laterally, we can see the internal jugular vein. It's possible to further increase the filling of the vein.
For this, the patient can be placed in an adapted Trendelenburg position. This should, however,
not be performed on neurosurgical patients or those with significant heart failure. Once a venous thrombus is excluded, the vein may be catheterized. The ultrasound probe is required again and can be hung to the side for later usage.
Important-- in awake and agitated patients, sedation may be provided upon request. This could be through usage of a propofol perfusion. When using cardiovascular stabilizing medications, two peripheral venous cannulas are required for application of the intravenous medications. On initiation of sedation, it is important to carry out telemetry in order to monitor the pulmonary and cardiovascular status of the patient.
In already sedated patients, the sedation is now deepened. If necessary, the catheterization site can be shaved and visible dirt cleaned away. The area is disinfected with a spray for a second time. The area is given enough time to fully dry. This is followed by subcutaneous injection of a local anesthetic agent, for example, up to 10 milliliters of 1% mepivacaine. A large aliquot should be deposited at the injection and suture sites.
Prior to each infiltration, the syringe has to be aspirated. An appropriate amount of time must be allowed for the local anesthetic to take effect. This allows time for the preparation of all other equipment. The gloves are removed from their packaging and deposited in the sterile zone. The gloves are then put on following hand disinfection and appropriate drying time. Now, the neck and throat are disinfected in an outward motion from the injection site to the earlobe with colored disinfectant.
As a precaution, the skin over the subclavian vein disinfected so that an alternative catheterization site is available. This process must be carried out at least three times. The disinfected area should be allowed to dry. Next, the table is rearranged. Everything that is not
required is disposed of. The sterile gown is put on and closed and tied by an assistant.
The sterile drapes are now to be positioned. The first drape is stuck to the right edge at the bottom of the disinfected area. Now, you can move closer to the patient in order to position the second drape. If the contact area is not sufficient, then another drape must be used. In order to cover the ultrasound probe, the white band within the sterile sheath should be gripped, loosen, and remove the white protective sheath and dispose of it.
An assistant will now be required. The assistant holds the ultrasound probe by the cable and hands it to the examiner. The probe is gripped by the examiner, and the sterile sheath is pulled
along the cable whilst always maintaining aseptic technique. The adhesive tape is then wrapped around the probe to ensure fixation. The ultrasound cable can be secured to the bed frame with a scissor clamp.
Now, the catheter is prepared. This entails the opening of the catheter lumens and the removal of the protective caps, which are placed to one side. The three-way valves are attached to each of the catheter lumens. The lumens are flushed and filled with sodium chloride, and finally, closed.
In this case, we will also show you how to place a Shaldon catheter. These are also flushed and filled. Both clamps from each lumen are closed. Next, the guidewire is prepared. This should move easily and freely. The silver guidewire is part of the venous catheter kit. The blue guidewire belongs to the Shaldon catheter kit. Now, we will describe the guidewire insertion. A syringe is half filled with sodium chloride solution, and the appropriate hollow needle attached.
In order to improve the contact surface, the catheterization site is once again moistened. The needle is inserted approximately half a centimeter in front of the ultrasound probe. The needle position is controlled using ultrasound and aspirated as it advances. The needle can be seen
here on the monitor. Dark venous blood is aspirated into the syringe. The ultrasound probe
is laid to the side, and the needle held in position.
Now, the guidewire is inserted into the needle end and pushed into the blood vessel. It is inserted to a maximum depth of 20 centimeters or until extra systolic beats are observed on the ECG monitor. If this occurs, the catheter is then pulled back slightly. The needle is removed. The position of the guidewire is sonographically controlled. As can be seen, the guidewire is positioned within the lumen of the vein.
Now, the guidewire from a Shaldon catheter system is positioned. Another syringe with sodium
chloride solution is prepared.The second needle is punctured 3 centimeters caudally from the first puncture site, and then further inserted, using the same technique as used with the central catheter guidewire. Both guidewires are now positioned within the vein lumen. This is also controlled once more sonographically.
Now, the central venous catheter is positioned which passes over the silver guidewire. A small incision should only be carried out on patients with thick or tough skin. Otherwise, the risk of bleeding is increased. The incision is made in a direction away from the guidewire. Now, the dilator is passed over the guidewire. This is advanced into the vein. And then, removed again.
The central venous catheter will now, in turn, be passed over the guidewire, the protective sheath removed, the three-way valve opened at the distal lumen, and the guidewire threaded through. The guidewire must at all times have contact and be held by the examiner.
The guidewire is threaded through the catheter until it passes through the three-way valve. The central catheter is then inserted to a depth of between 15 and 18 centimeters. A useful way of estimating the appropriate depth is by using the patient's height. This is divided by 10. The guidewire is removed, and the lumen clamped. All lumens aspirated in sequence.
Once all lumens are checked and patent, the fixation clip is attached close to the puncture site. Our patient is 180 centimeters tall therefore the clip is attached at 18 centimeters.
First to the green, and then the white clip for stability. Next, the clips are anchored to the skin. The stitch is carried out caudally to the puncture site to prevent any catheter dislodgement. Once the fixation is complete, the thread is, in turn, threaded through the catheter anchor site and fixated with two oppositely directed knots. This further secures the catheter.
The same technique performed on the opposite side. First, the clip is anchored to the skin, and then further fixed to the catheter anchor site. The central venous catheter is now positioned. Now, we position the Shaldon catheter. When there is no other possibility, a stab incision should
also be performed. This is also directionally away from the guidewire.
The Shaldon dilator is advanced into the vein over the guidewire. The skin is spread, and the dilator held from the end.
Now, the pre-prepared Shaldon is advanced. The bend of the catheter should point laterally. The guidewire is threaded until it appears through the blue lumen opening. The guidewire is fixed with one hand and the catheter advanced. The catheter is advanced to the point where the black mark is just hidden under the surface of the skin. The guidewire and plastic sheath are removed, and the lumen closed.
Both lumens should be able to be aspirated. The lumens are flushed following the test. The catheter fixing point can be slid forward to aid fixation. So that they are positioned well, the black mark must be completely under the skin. Stitching is also initially performed caudally to the puncture site. If blood cultures are required, you may take these from either of the catheters with two 20 milliliter syringes for two sets of blood cultures. The syringes are filled to 24 milliliters, and are, in turn, disseminated into the blood culture bottles by an assistant. The catheter flushed, and then filled with citrate and also marked.
Now, a plaster is placed and the sterile drapes removed. Ultrasound and radiographic imaging may be carried out in order to identify catheter positioning and any potential pneumothorax.
Thank you very much.
Disclosures
No conflicts of interest declared.
