Central Line Catheter Insertion by Dr Dave | #anesthesia #anaesthesia #medicalprocedures

Summary

This instructional video script details the process of inserting a central venous catheter (CVC) using ultrasound guidance. It covers patient preparation, aseptic technique, vessel selection, and the importance of monitoring for complications. The script also provides tips for locating the internal jugular vein, avoiding the carotid artery, and ensuring proper wire placement. It emphasizes safety, including checking for correct vessel entry with ultrasound and preventing air embolism, concluding with securing the catheter and dressing the insertion site.

Takeaways

• 🔍 The script discusses a procedure for inserting a central venous catheter (CVC), focusing on the internal jugular vein (IJ).
• 🧼 The importance of aseptic technique is highlighted, including scrubbing below the elbows and ensuring patient consent and preparation.
• 📐 The use of ultrasound to locate the IJ and differentiate it from the carotid artery is emphasized, with tips for avoiding accidental puncture.
• 💉 The process of administering local anesthetic and creating a field block to numb the area is described.
• 🩺 The script mentions the use of the 'V' sign (vowel sound) to help visualize the internal jugular when the patient has a weak pulse.
• 👀 The operator should always be able to see the needle tip during the procedure to ensure safety.
• 🩸 The script describes the technique for advancing the needle and syringe into the vein, pulling back on the plunger to aspirate blood as confirmation.
• 🧵 The insertion of a guidewire through the needle and into the vein, and the importance of not hitting resistance, is explained.
• ✂️ After confirming the wire's placement, the needle is removed, and the script advises holding the wire to prevent it from being sucked back into the vessel.
• 🔪 A small incision is made to facilitate the introduction of the catheter over the guidewire.
• 🩹 The final steps involve securing the catheter with sutures and dressings, and ensuring that blood flow is dark and not arterial to confirm proper placement.

Q & A

What is the initial step described in the script for preparing a patient for a central line insertion?

The initial step is to ensure the patient has been scrubbed below the elbows and is in a sterile setup. Consent and explanation of the procedure have already been done prior to this step.

What is the significance of using an ultrasound in this procedure?

The ultrasound is used to visualize the internal jugular vein and the carotid artery to avoid accidental puncture and to ensure the needle is inserted into the correct vessel.

Why is it important to avoid puncturing the carotid artery during central line insertion?

Puncturing the carotid artery can lead to serious complications, such as bleeding, which can be life-threatening.

What technique can be used to make the internal jugular vein more visible during the procedure?

The 'V' sign or 'Vowel Salva' technique can be used, where the patient is asked to make a vowel sound, which causes the vein to bulge and become more visible.

What is a 'field block' in the context of this procedure?

A field block refers to the local anesthetic being injected in a fan-like pattern around the area where the central line will be inserted to numb the skin and reduce discomfort.

Why is it crucial to always see the needle tip when advancing the needle during the procedure?

Seeing the needle tip helps to avoid accidental complications, such as puncturing through the back wall of the vein or causing unnecessary trauma to the patient.

What does the speaker mean by 'bounce the needle' when trying to puncture a collapsed vein?

Bouncing the needle refers to a technique where the needle is gently tapped or bounced on the surface of the vein to help open it up and make it easier to puncture.

Why is it important to monitor the patient's heart rate and rhythm during the wire insertion?

Monitoring the heart rate and rhythm is important to detect any changes that might indicate the wire has touched the heart, which could cause arrhythmias or other cardiac issues.

What is the purpose of using a scalpel to make a small incision when the wire is in place?

The small incision allows for the easy passage of the catheter over the wire without causing additional trauma to the skin or the vessel.

Why is it necessary to clamp off the ports on the catheter after insertion?

Clamping off the ports prevents blood from flowing back into the catheter, which could lead to clotting and blockage of the catheter.

What is the final step described in the script for securing the central line after insertion?

The final step involves wrapping the catheter with a dressing, suturing it in place, and using a biopatch to secure it, ensuring stability and preventing infection.

Outlines

00:00

🔍 Ultrasound-Guided Central Venous Catheterization

The script begins with the narrator setting up for a central venous catheterization (CVC) procedure without discussing the use of acid technique. The focus is on aseptic technique with the narrator having scrubbed below the elbows and ensuring patient consent and preparation. The narrator uses an ultrasound to locate the internal jugular vein (IJ), aiming to avoid accidental puncture of the carotid artery. Tips are given for identifying the vein, such as using the 'V' sign maneuver and gentle pressure. The narrator then proceeds to administer local anesthetic and uses the ultrasound to guide the needle through the skin, emphasizing the importance of seeing the needle tip at all times. The process of inserting the needle, aspirating blood, and threading the guidewire is described, along with troubleshooting tips for collapsed veins.

05:06

🧵 Guidewire Insertion and Catheter Placement

This paragraph details the continuation of the CVC procedure, focusing on guidewire insertion and catheter placement. The narrator advises to stop if resistance is encountered, indicating a potential misplacement. Monitoring heart rate and rhythm is emphasized to avoid accidental heart contact. The guidewire is inserted until three marks on the wire are reached, and the narrator demonstrates removing the needle while holding the wire in place. Ultrasound is used to confirm the wire's position within the vein. The next steps involve making a small incision with a scalpel over the wire, ensuring the incision is large enough for the catheter. The catheter is then gently inserted over the wire, and the narrator describes the importance of rotating the catheter to prevent kinking. The wire is carefully removed, and the narrator discusses precautions to avoid air embolism, such as kinking the catheter as the wire is withdrawn.

10:13

🩹 Securing the Catheter and Post-Procedure Care

The final paragraph covers the steps to secure the catheter and the post-procedure care. The narrator describes using a syringe to aspirate blood to confirm proper placement, followed by flushing the catheter ports with saline. The use of pressure bungs to prevent backflow and clotting is explained. The catheter is then secured with sutures and a biopatch, and a dressing is applied. The narrator emphasizes the importance of careful handling during this process to avoid complications. The dressing is secured with Tegaderm, and the insertion site is checked with an X-ray to ensure correct placement. The narrator concludes with advice on what to do if there are issues with feeding the catheter or if bright red blood is aspirated, suggesting stopping and starting again if necessary, and mentions the option of administering vasopressors peripherally if the patient is unstable.

Keywords

💡Aseptic Technique

Aseptic technique refers to the practice of maintaining a sterile environment to prevent infection during medical procedures. In the video, the speaker mentions cleaning and setting up in a sterile fashion, which is crucial for procedures like central venous catheterization (CVC) to avoid introducing bacteria into the patient's bloodstream.

💡Central Venous Catheterization (CVC)

Central Venous Catheterization is a medical procedure where a catheter is inserted into a large vein, typically in the neck, chest, or groin, to administer medication or fluids, or to monitor certain conditions. The video script describes the process of performing a CVC, focusing on the internal jugular vein, and the importance of using ultrasound for guidance.

💡Ultrasound

Ultrasound is a diagnostic imaging technique that uses high-frequency sound waves to create images of structures within the body. In the context of the video, the speaker uses an ultrasound to visualize the internal jugular vein and the carotid artery to guide the insertion of the catheter accurately and safely.

💡Internal Jugular Vein

The internal jugular vein is a large vein in the neck that carries deoxygenated blood from the head back to the heart. The video script discusses targeting this vein for CVC and provides tips on how to avoid puncturing the adjacent carotid artery.

💡Carotid Artery

The carotid artery is a major blood vessel in the neck that supplies blood to the brain and head. The script mentions the risk of accidentally puncturing this artery during CVC and the importance of using techniques like the 'V' sign maneuver to visualize the vein clearly.

💡Vowel Sound

In the script, the vowel sound refers to a maneuver where the patient is asked to make a sound like 'Ah' to tense the neck muscles, which can help in visualizing the internal jugular vein more clearly during the ultrasound-guided CVC procedure.

💡Local Anesthetic

Local anesthetic is a medication that numbs a specific area of the body to prevent pain during a procedure. The speaker describes using a local anesthetic to perform a 'field block' around the insertion site to ensure the patient does not feel pain during the CVC.

💡Needle Tip

The needle tip is the sharp end of a needle used to puncture the skin and insert a catheter. The script emphasizes the importance of always being able to see the needle tip during the procedure to avoid complications and ensure accurate placement.

💡Wire

In the context of CVC, a wire is a thin, flexible guide that is inserted through the needle and into the vein to facilitate the placement of the catheter. The script describes the process of feeding the wire into the vein and the importance of not hitting resistance, which could indicate incorrect placement.

💡Scalpel

A scalpel is a small, sharp knife used for making incisions. In the video, the speaker uses a scalpel with a blunt side to make a small incision in the skin to facilitate the passage of the catheter over the wire.

💡Suture

Suture refers to the process of stitching up an incision or wound. The script mentions suturing the catheter in place after it has been inserted to secure it and prevent it from moving or being dislodged.

Highlights

Introduction to aseptic technique without discussing acid technique.

Scrubbing air below the elbows as part of the procedure setup.

Explanation of patient consent and agreement before the procedure.

Use of ultrasound to locate the internal jugular vein for central venous catheterization (CVC).

Technique to avoid puncturing the carotid artery during CVC insertion.

Positioning the patient's head to facilitate vein visualization.

Use of the 'V' sound technique to enhance vein visibility.

Importance of always seeing the needle tip during needle advancement.

Monitoring the patient's vitals during the procedure for safety.

Administration of local anesthetic using a field block technique.

Ultrasound guidance for needle insertion into the internal jugular vein.

Managing dehydrated veins during the procedure.

Technique for wire insertion and avoiding resistance or errors.

Verification of wire placement within the vein using ultrasound.

Ensuring the wire is in the correct vessel before proceeding.

Making a small incision for catheter insertion using a scalpel.

Use of bungs to prevent blood backflow during catheter placement.

Catheter insertion over the wire with careful monitoring.

Removal of the wire after catheter placement and precautions against air embolism.

Securing the catheter with sutures and dressings for stability.

Final verification of catheter placement with X-ray.

Advice on stopping and restarting if there are difficulties or signs of incorrect placement.

Transcripts

[Music] central lines first so let's put one  in i'm not going to talk about acid technique  

today so i am cleaned some aseptic technique  here i've scrubbed air below the elbows there  

below the elbows the patient if they can before  these procedures you've explained to the problem  

you've consented them you've talked about  different options and never agreed they're signed  

um that's all good okay so um i'm going to presume  that this is all set up in a sterile fashion and  

i've got help if i need it okay so without talking  about it anymore i've pre-set myself up here which  

you can see i haven't because it's after the  last session so first thing i'd say is i've got  

a central i've got an ultrasound okay so i'm going  to try to find what vessel do we typically use in  

brim anyway what vessel we're going to aim for for  cvc i j cool internal jugular awesome so does it  

matter where i'm going here's my ultrasound i'm  going up and down my internal jugular can i just  

go anywhere in the neck or can i in relation to  the carotid is there a little trick i might use so  

if the carotid sits right behind the ivc there's  a risk that you can you can puncture through your  

internal jugular and go into your crotted okay  so you're trying to type them down a little bit  

where your eye j sits a little bit to the side of  your carotid so you don't go accidentally through  

and back wall your ij into your crotted a couple  of tricks to yeah if you're finding it difficult  

you can put them head down a little bit you're  going to do a vowel salva and what will happen  

with if you do a vowel sound what happened to  there okay you'll blow exactly it'll blow open um  

uh and you can push down just gently on it  and you'll see that your credible really  

if it's a weak pulse you'll you'll be able  to see the crawler very clearly over your  

internal jugular so you found the spot and what i  would say is you do everything um when you're when  

you're advancing your needle you'll always see  a needle tip so don't do anything without seeing  

your needle tip so once again i'm going to say  one way there's so many different ways of doing it  

i've firstly got some like this person's awake so  after doing all the stuff we talked about i've now  

got a helper the help is monitoring the patient  so full monitoring i'm now concentrating solely on  

this if the patient's sick and the blood pressure  is low then um yeah i want to know about it uh so  

basically my i'm focusing on this and i first  need to put some local anesthetic in so i've got  

my local anesthetic needle in and i do what they  call a field block what i call field block anyway  

so you put it under the skin where you're  gonna go and then you really could give a  

good 5-10 mils so i'll put it in with a small  little 25 gauge needle and i'll fan it this way  

so a good blend of skin this way and then  turn it around and fan it this way too  

so i've got a big bulge of inner thighs skin  there okay so then after i've done that you have  

to go too deep but just around the skin surface  once i've done that i've got i'm just going to  

assume i've got my ultrasound on so ultrasound's  in cross-section i'm going to do just a straight  

needle we can do this with a cannula but i'll show  you this way first in fact let's get this ready

last session

okay so

in fact that's good okay um what i've got is my  ultrasound here i've gone in through the skin  

it's really neat sized skin i just know that  that's where this hole is and that's so what  

i'm now doing everyone's a bit different  is i will pull back on the plunger okay  

so i'm pulling back on the plunger this  needle this syringe comes in the pack  

and i should say it's got a little hole in  the back but you can see that it's got a  

little hole in the back that's where your wire  is going to go down so i go in through the skin  

ultrasound's on i can see the point of my needle  and i've now got a problem because i'm looking  

up at my my ultrasound screen and forced us to  be really easy because it's a big black hole  

but there's a problem it's he's a bit dehydrated  and every time i push on it that stupid veins  

collapsing now how annoying is that what happened  i don't know it's what happens it's a big thick  

vein it's big big vein for sure but it can be  quite easy to close on itself if they're a bit  

dry and getting that needle through this so any  tricks how would i blow the vein up into so you  

can bow several you can do when the ventilator is  pushing the air in whichever one but yeah getting  

the vowel sour so i get in a good position i'm  pulling back on the on the syringe and i'm it's  

squeezing down and i say okay i'm bound i tend to  bounce it down so bounce bounce on the surface of  

it bounce bounce bounce bounce and then four  seven pop okay okay and now pulling back and  

all this blood coming back okay so there's blood  coming okay cool there's blood coming back awesome  

so good there's blood there so i stop and i  feed my wire with a little introduced to the  

tip actually comes in the hole all rounded  up but that goes in the end of this syringe  

and i feed my wire down is it ever hard to  feed your wire did you ever hit resistance  

so if you hit resistance it means something's not  right so stop and start again i would say clearly  

if you're like oh actually i hit resistance  i can't go any further you're probably in the  

wrong spot it should be really easy to pass and  when you're doing that what you have to watch on  

the screen heart rate and heart rhythm yeah you  can tickle up the heart a little bit by putting  

a wire into it cause low rhythm is and if you do  it's okay it just means you're definitely in a  

hot place you're doing a little bit far probably  but yeah so cool so stop that 15 about the three  

little marks on the on the on this on the wire  there i've stopped there okay i'm now going to  

pull my needle out okay so here we go i'm holding  my wire always it won't get sucked in but i might  

accidentally push it in or pull it out so i hold  my wire on this side as i pull my needle out  

and stabilize my mannequin and now i can see my  wire on this side of the skin hold that there  

and that goes away the sharp  container will you know somewhere safe  

so now it's got a wire inside the vessel do i  definitely know i'm inside the right place 100  

sure life on it that this is in the vein not the  artery so i get the ultrasound and i go down again  

on the vein and make sure i see the i see the  why inside interesting cross section then cross  

squash squash squash and you'll see the bright  spark of a piece of metal inside the vein on the  

ultrasound and you think okay cool if you stuck  this into artery it's okay i've not done it yet  

but it it's okay if you put little wire a little  wire into it into a crowded it's not going to hurt  

the patient realistically pressure on go the other  side but if you dilate the artery that's where  

you're starting your problems okay so you don't  want to dilate the arteries so this if you're in  

an artery this is where you want to stop and start  again okay so i now know i'm definitely inside the  

um definitely inside the um the vessel the the  ij so now what do i do next the skin's there  

scalpel's got two sides so the blunts are  the scalpel on the wire not the sharp and  

push push oh okay i've still got pushed  through so it pushed through the um the  

skin so differently into the skin the trick here  what somebody just do a little tiny little nick  

and that's not probably enough you actually go  through the whole skin level skin layer come out  

and get you you get your y and actually rotate  it around a bit and actually make sure that you  

it has frick and you can move and like because  that's the next problem you're going to have  

so make sure you can move that that y around and  you'll find this is the same triggers you use  

in other places not in other other procedures  now are you drunk or not i don't know

this here has already been um flushed  i should've done it straight off that  

was flushed with saline or with it but  the satellite's been flushed and then

what are these bungs why use these bungs

yeah what does it do like that nothing crazy but  if you had to explain yeah perfect stops you don't  

want blood still coming back here and blocking off  and clotting off so yeah it stops the backflow so  

here we go put them all on i'm a bit thinny i will  also clamp off them as well but i'll leave this  

brown one open it says distal on it what does  that mean just do a hole there's three three  

little injecting ports there's a hole it's the  distal hole where the wire is going to go through  

but there's also another one and another hole  okay it's where the mid is going to go through  

everything while i'm injecting in but when i'm  going to fit this over the wire the wire's going  

to come out the brown hole the distal wall so i'll  go leave that open so i'll leave that open that's  

all ready to go so once again holding my wire  if i let go of my wire does it get sucked down  

it won't go it won't automatically get sucked down  so that's exactly i've heard one person go oh if  

you look over your wife it's going to get stuck in  it doesn't get sucked in but what will happen is  

is as i'm pushing it in i'm just going to start  pushing the wire and pushing the wire in and  

then something gets in and go with my wire and  potentially i won't get it back and then i have  

to go to get that fixed or taken out so hold my  wire until it comes out oh there the brown hole  

so wires come out there and now i just feed this  in gently twizzled about a little a couple of  

centimeters up and just twizzle as you go down  this isn't total this is going into plastic pvc  

pipe so just bear with me a little bit because i  get that little little sweet one right through the  

pvc pipe it has yeah anyway it's gone through  it's gone in as it's going in this is probably  

not an ultrasound but anyway it's in there we go  it's now in about five to about 10 centimeters  

okay so i put it down to 10 centimeters there  it is there's 15. and when i've done that  

i can now pull my wire out as i put my wire out  i might see a bit of blood coming out the back  

of it here and what i tend to do is i tend to  as it comes out fold it over and just kink it  

off as it comes out why air embolism so you can  suck air in it can go into here and cause near  

embolism as well so you really don't want open  ports to open there so i i'm a bit over careful  

with it because i've heard some horror stories  whether that be true or not i've never seen it  

but as soon as that was coming out i  can't get over put my bung on and i'm done  

i'm a bit naughty now there's this thing being  honest what i'll then do is i'll get a syringe  

i'll pull back some blood because i like to see  dark blood come out of it and then as soon as i  

see a dark blood come out i'm happy i then  get a sail line and i flush all three ports  

with the pressure bungs on i doubt it's going  to clog the next in 10 seconds and be doing that  

and then securing it um i'll tend to  wrap it up in a little little loop  

and i'll suture these in i'll just turn on the  suture i'll get one of these little bio patches  

once again there's a thousand ways of doing this  i'm sure but by a patch um which side goes towards  

the sky blue towards the sky so blue towards the  sky that goes we're inserting like that okay and  

then i'll put a couple of just a proline suture  we run through our four kind of protein switches  

through each side here some local anesthetic in  there if you haven't put local through your fill  

block there because that will sting otherwise  um but switch to that once that's sutured  

i then will do i'll ask help from the nurses but  i'll then do for me a sandwich um so like that  

now i'm the worst person else about dressing  is i'll put a sandwich dressing on like that  

and then i'll put tegadem around the  outside also fix them all around the outside  

so they can always see the insertion can i just  use it now x-ray perfect everything's just being  

really careful i am where i think i am i've been  really careful at any time the kind of places  

you're going to know you're wrong would be if you  can't feed something so i can't feed it gets stuck  

just stop you know if i can't feed the wife i  can't feed the catheter just stop you know and  

start it again because it's probably not  the right place it was too hard to feed  

if you pull back and bright red blood comes out  it's not good and if you ultrasound it and you  

can't see in your vein it's probably not in the  right place either okay so that's the three things  

there's anything which just smells if  you just stop and start again there's no  

harm in stuff something's starting again you  can give vasopresses peripherally while you  

do all that stuff we can come back to it in a  couple of hours when the patient's more stable  

for us there's no great reason to  have to do it quickly [Music] you