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Chlorhexidine swab is used to prep the skin in the right groin area. We use a wide prep to prepare for a right central venous catheter insertion. After the prep dries we will place a wide sterile barrier. The sterile drape should cover the entire lower half of the body including the bed between the patient and the operator. We're now using a sterile sheath to grasp the ultrasound probe that has had a non-sterile ultrasound gel applied to the top. You grasp the ultrasound probe and then carefully pull the sterile sheath over the probe so that you can have a sterile probe to do real time ultrasound.

Now we're going to prepare the catheter. We're applying needleless caps on to the blue port and the white port of the catheter and we're going to use sterile saline to flush each of the ports. Here we're flushing the white and the blue port of the catheter that have the caps in place. And with the brown port which is the distal port the wire will be coming out of that port so we do not have a cap in place but after we flush that port we'll have to clip the line before removing the sterile saline syringe.

Now with the 1 percent lidocaine we're applying a sterile label so that all the syringes can have sterile identification. Sterile ultrasound gel is then used on the skin and now we're looking at the right femoral artery and the femoral vein in transverse orientation. The femoral artery is on the top left-hand side. With compression you can see that the right femoral vein compresses but that the right femoral artery which is more superficial and to the left does not compress. We're using 1 percent lidocaine for local anesthesia of the skin and the underlying soft tissue.

Now we're introducing a introducer needle at about a 45 degree angle inserted the same depth away from the probe as the vein is deep to the probe. We are inserting so that we gradually can see the needle advance into the vein and now we have return of venous blood. We're going to grasp the hub of the needle and withdraw the syringe to confirm that it is nonpulsatile blood. Now we're going to insert the sterile wire through the sheath and through the needle. We are going to rotate the probe into the longitudinal orientation and we can see that the wire is threading into the vein as the wire is advanced through the needle.

In the femoral location the wire can be advanced even as deep as 30 centimeters. Now the sheath is removed and the wire is left in place. It is important to never let go of the wire as it can embolize and travel through the vein. The needle is now withdrawn and leaving the wire in place you can still see that the wire is in the vein on the ultrasound image. And now the probe can be dropped and sterile gauze can be used to identify the insertion site clearly, and then a scalpel could be used to nick the skin over the wire. Now a dilator is inserted over the wire and the wire is grasped on the opposite side of the dilator. The dilator is advanced with a twisting motion to dilate a tract through the subcutaneous tissue and into the femoral vein.

Now the dilator is withdrawn leaving the wire in place. The wire is then threaded back through the central venous catheter until you can grasp the wire on the opposite end of the brown or distal port of the catheter. Now the wire is grasped on the distal end of the catheter and then the catheter is advanced all the way to the end of the catheter. And now the wire is withdrawn back into its sterile sheath and completely withdrawn out of the body. Once the wire is completely withdrawn the brown port is clipped.

Now we're introducing the last needleless cap onto the brown port and then it will be unclipped and then you will withdraw the blood into the syringe and then the whole line is flushed, care being taken not to inject any air into the port. Now the white and the blue ports of the central venous catheter are flushed with sterile saline. Now some local anesthesia is used to numb up the skin adjacent to the central venous catheter, a bio-patch is applied at the insertion site with the blue side angled towards the ceiling. This is a patch that's impregnated with chlorhexidine to minimize the risk of catheter related bloodstream infections.

And now suture is used to secure the catheter in place in two locations. After this is secured, a sterile occlusive dressing will be applied over the central line to complete the procedure. Here an instrument tie is being used to secure the central line using suture which is done in two locations.

Пацієнт розміщується у положенні Тренделенбурга, потім за допомогою тампону з хлоргексидином виконується обробка лівої передньої частини стінки грудної клітки повністю догори, до половини шиї, а потім широко для охоплення лівого плеча. Для належного протисепсису необхідно дати хлоргексидину принаймні дві хвилини, щоб він повністю висох. Тепер накладається стерильне широке простирадло з отвором, розташованим по центру місця введення. Це стерильне простирадло має покривати голову і майже все ліжко.

Тепер ми складаємо 1 відсоток лідокаїну, який ми використовуватимемо для місцевої анестезії. Оскільки вся рідина в стерильному полі повинна бути маркована після заповнення шприца лідокаїном, на шприц наноситься стерильна етикетка з 1-відсотковим вмістом лідокаїну. Шприци з фізіологічним розчином вже попередньо промарковані, тому на них не потрібно наклеювати додаткову стерильну етикетку. Тепер ми наносимо стерильний інтродюсер на лінійний зонд, щоб ми могли виконувати ультразвукове керівництво в режимі реального часу для цієї підключичної лінії з ультразвуковим керуванням. Стерильний інтродюсер повинен покривати все стерильне простирадло.

Тепер ми накладатимемо декілька стерильних гумових стрічок, щоб тримати стерильний футляр на місці. Тут ми використовуємо стерильний фізіологічний розчин для промивання всіх портів катетера. Ми також змінюємо класичні ковпачки голки для безголкових ковпачків, які застосовуються до синього та білого портів цього двопросвітного катетера. Бурий порт двопросвітного катетера — це дистальний порт, який буде залишений без ковпачка, оскільки дріт зрештою буде намотуватися назад через цей коричневий порт. Після промивання коричневого порту порт необхідно обрізати перед зняттям шприца.

Тепер ми використовуємо місцеву анестезію, щоб знеболити шкіру та підшкірну тканину в місці введення. Ми використовуємо лінійний зонд із технікою площини, щоб можна було побачити голку зі шкіри аж до пахвової вени, яка візуалізується в поздовжній площині. У цей момент Ви бачите, що голка майже потрапила у вену. У цей момент він просто спливає прямо зараз, щоб можна було провести аспірацію фіолетової крові, як видно тут. Потім знімають роз'єм голки, шприц знімають, а потім провід з J-подібним наконечником прорізують через роз'єм голки з кривою, спрямованою до серця. Ви бачите, що голка — провід візуалізується, проникаючи через вену, коли ми поступово проводимо провід через голку. Провід різьбиться на 20-сантиметрову глибину шкіри.

Тепер інтродюсер знімається, а потім голка знімається над дротом. Потім над дротом у місці введення створюється скальпельний гребінь, і ми гарантуємо, що дріт може вільно рухатися всередині цієї упорної рани. Тепер дилятатор вводиться через дріт, а потім розширювач поступово просуватиметься скручуючим рухом для розширення підшкірного тракту аж до кінця пахвової вени. Тепер розширювач знятий, слідкуючи за тим, щоб не випадково не витягти провід. Тепер катетер вводиться через провід і поступово відтягується назад, поки провід не буде захоплено за дистальний коричневий порт.

Після захоплення дроту за коричневий порт можна ввести катетер до відповідної глибини введення, яка в лівій підключичній вені зазвичай становить 16-17 сантиметрів. Однак, з ультразвуковими вказівками ви додали б ще 3 сантиметри на додаток до цього. Тому ми вводимо цей катетер до 19 сантиметрів на шкірі. Зараз ми промиваємо всі три порти: синій, білий і, нарешті, коричневий порт стерильним фізіологічним розчином.

Тепер до місця введення накладається пластир із просоченою антимікробною речовиною або біопластир, щоб мінімізувати ризик інфікування кровотоку, пов’язаного з катетером. Для місцевої анестезії ми використовуємо ще трохи 1-процентного розчину лідокаїну, а потім накладаємо шви, щоб закріпити катетер у двох місцях. Для фіксації катетера на місці можна використовувати хомут інструмента. Тепер ми накладаємо стерильну оклюзійну пов'язку з біонакладкою та всім місцем введення, візуалізованим у відкритому вікні, а потім накладають крила внизу, щоб мінімізувати отвір, через який проходять три порти. І процедуру завершено.

Chlorhexidine swab is used to do a sterile prep of the right anterior chest wall. We’re using the swab in a back and forth motion to prep a large area of the anterior chest wall and the right shoulder.

Now we’re applying a sterile drape over the area. This sterile drape covers the entire bed.

Now we are using sterile saline flush, to flush all three ports of a triple lumen catheter. We can switch the normal caps on the triple lumen catheter to needleless caps. We’re applying the needleless caps on the white port and the blue port of the triple lumen catheter. We’re not going to apply the needleless cap on the brown port which is the distal port of the triple lumen catheter, as that is the port that the wire will eventually come out of.

When we flush the brown port, as is shown here, we have to clip the line before we take off the syringe.

We’re now going to get all of our equipment that we need including an introducer needle, the sterile wire, the scalpel and the dilator in a position where we can easily grasp them. The J-Curve of the wire will be directed towards the heart, which in a subclavian line is directed towards the feet, as is shown here for the right side and the left side.

Now we’re going to draw up some 1% lidocaine which will be used for local anesthesia of the skin and the periosteum of the clavicle.

All of these syringes that contain sterile fluid have to be labeled on your sterile field. The sterile saline flushes are pre-labeled as sodium chloride, but the 1% lidocaine syringe is not labeled and therefore, these sterile labels can be used to label the 1% lidocaine syringe, as is shown here.

Now we’re using our two hands to identify the curve of the clavicle which is the primary landmark that you have to identify when you’re performing an infraclavicular subclavian line placement. Once you identify the curve of the clavicle, you will make the insertion site one centimeter towards the deltopectoral groove from the curve of the clavicle. At that insertion site, we’ll use 1% lidocaine for local anesthesia, as is shown here. We also insert deeply until we can anesthetize the periosteum of the clavicle along the track.

Now we’re inserting the introducer needle underneath the clavicle with the needle as parallel to the floor as possible. We put our index finger in the sternal notch and used the thumb of the non-syringe hand to help guide that needle underneath the clavicle inserting towards the top of the index finger and the sternal notch until we see this flash of venous blood. We then advance that introducer needle about two millimeters. Then take off the syringe when we see non-[inaudible] blood, we can now advance the wire through the needle until you reach the 20 centimeters mark of the wire.

Now the needle is removed over the wire with a careful control of the wire. We’re using a scalpel to nick the skin. Now we are advancing a dilator over the wire to dilate a tract through the skin, subcutaneous tissue and into the subclavian vein. We’re advancing the dilator with a twisting motion until it is at the hub of the dilator for an infraclavicular subclavian line placement.

Now we’re removing the dilator and keeping control of the wire. We are introducing the catheter over the wire now. The wire will come out the brown port of the catheter. The wire is grasped at the distal end, beyond the brown port and then the catheter is advanced to the appropriate depth of insertion, which in a right subclavian line is approximately 15 centimeters at the skin. For a left subclavian line, you would advance the catheter until about 17 centimeters at the skin.

Now we are withdrawing the wire from the catheter, directly into the wire sheath. As you do this, you have control of the catheter to make sure that the catheter is not pulled out as you’re pulling the wire out.

Now we’re going to insert the last needleless cap onto the brown port. We withdraw blood into that brown port until you can see it in the syringe that contains sterile saline. Then the port is flushed with a saline.

Now the blue port and the white port will be flushed and you just have to withdraw the saline until you see a little bit of blood in the line in both the blue port and the white port. Then flush the saline to clear out that blood.

Now we’re applying a white and blue central line clip, approximately two centimeters from the insertion site so that we can secure the central line to the skin in four places. We’re using 1% lidocaine to numb up the skin in these four places.

Now we’re applying a bio patch, which is a chlorhexidine impregnated patch, with the blue side of the patch up towards the ceiling over the insertion site. This decreases the risk of central line associated blood stream infections.

We’re using a needle driver with a curved needle to suture the central line in place in these four locations. Here an instrument tie is being used to secure the suture.

Once all four of those sites have been sutured into place, we can apply a sterile occlusive dressing with the window that has the insertion site, including the bio-patch, in view. Then the notch of the sterile occlusive dressing, will have the three ports of the central line, come through that notch.

Then the second part of the sterile occlusive dressing has these wings that will go underneath the three ports of the central line to fully secure the central line in place. A sterile pin can then be used to place your initials, the date and time of the central line.

Here we're prepping with a chlorhexidine swab and we're doing a full sterile drape. Notice that we have a wide sterile drape on this procedure just as we do with the central line. Here's a sterile sheath that goes over the ultrasound probe. The probe has been preset with non-sterile gel that is over the probe prior to the sterile sheath going over it. We are drawing up one percent sterile lidocaine. Here we're applying the sterile rubber bands over the probe sheath to secure it and applying a sterile ultrasound gel. This is 1 percent lidocaine for local anesthesia.

We're identifying the radial artery, first in the transverse plane, and when it's in the center of the ultrasound screen we're slowly rotating the probe to the longitudinal plane so that we are now seeing the radial artery in the longitudinal plane. With the radial artery visualized in the longitudinal plane we are now inserting the radial artery needle that is now being visualized in an in-plane technique that is going into the radial artery until we see a flash. We're now inserting the wire over or through the needle and now advancing the catheter over the wire in a rotating motion. We're going to use some gauze underneath the catheter and then using a sterile 4 x 4 gauze to grasp the tubing that is to the arterial line. This is so that you don't mess up your sterile gloves. We're screwing the arterial tubing to the catheter.

Now we're going to take a straight needle connected to 2-0 silk suture to secure the catheter to the skin. We're inserting the needle through a section of the skin that is adjacent to a groove in the catheter. We will then run the blunt end of the needle lateral to medial underneath the groove of the catheter several times and then we will tie the suture securing the catheter to the skin. Here, we are securing the suture onto the catheter. At this point we're applying a bio-patch with the blue side of the patch oriented towards the ceiling. This is a patch that's impregnated with chlorhexidine to minimize the risk of a catheter related bloodstream infection. Now a sterile occlusive dressing is being applied over the bio-patch and the catheter. And the procedure is complete.