Contents:
1. TUNNELED DIALYSIS CATHETER PLACEMENT
2. PICC LINE PLACEMENT
---------------------------------------------------
TUNNELED DIALYSIS CATHETER PLACEMENT:
Tunneled Dialysis Catheter (TDC) aka HD catheter aka Permacath
Catheters we use
Pt should be supine on fluoro table. Image pt. R neck prior to starting procedure and mark spot for IJ access.
Basic Overview:
1. Get RIJ access with micropuncture needle. Upsize to working wire using a 4 F dilator+sheaht
2. Numb up a subcu tunnel from the cath exit site to the RIJ access site. Tunnel catheter through.
3. After sequential dilatation of the subcu tissues at the venotomy site, place a 16 F peel-away-sheath at the RIJ over the wire
4. Remove wire, place catheter through sheath. Confirm position with fluoro. Secure catheter.
Detailed Procedure:
1. Clean skin with chlorhexidine. Clean the area of the lower R neck and make wide prep area down to nipple and up to jawline.
2. Drape patient with large drape. Use blue towels for extra coverage. Make sure to cover image intensifier (with help of technologist). Hand tech a blue clip so they can make window for patient.
3. Place sterile cover on ultrasound probe.
4. Draw up lidocaine and start numbing to obtain access. Numb up area of the access site (spot marked as above)
5. Make a skin nick using a scalpel. Open up the fascia using the kelly clamp.
6. Use the 21 gauge echo tip micropunture needle to access the RIJ using ultrasound. Scan in the transverse plane of the RIJ, place probe at the level of the clavicle. The RIJ should be a large venous structure just lateral to the carotid.
7. Under strict ultrasound guidance, and with full visulization of the needle tip at all times, guide the needle into the vein. You will have to "pop through" the vein wall. Clearly visualize tip of the needle within the vessel and save image.
8. At this point you should see blood return at the needle hub. Gently straighten the needle, making it closer in orientation to the long access of the vessel, to facilitate the wire entry into the RIJ.
9. Advance the microwire (.018 inch) make sure floppy tip is leading. Gently advance the wire, there should be slight tension but the wire should slide freely into the vessel. If there is resistance, stop immediately and take a look with fluoro.
10. If wire is advancing freely, check position with flurio. The wire should advance caudal and be within the region of the SVC. It should NOT follow the orientation of the aortic arch or carotid artery.
11. Now have to switch microwire for working wire. In order to do this, take needle off wire. Don't let go of wire and don't let the wire float into the vessel. Advance the 4 french sheath + dilater over the microwire.
12. The inner dilator and wire come out. Now you have a 4 french access to the RIJ.
13. 0.035 or 0.038 amplatz wire goes in the sheath. Watch this fluoroscopically and ensure the wire goes into the IVC. **If having trouble getting wire to go into the IVC, can use a 4-5 French berenstein angled angiographic catheter to help guide wire.
14. At this point you have durable working wire access to the RIJ / right side of the heart. Now you can focus on placing the catheter.
15. Numb the tunnel exit site and numb a track in the subcu from the tunnel exit site to the venotomy site. The tunnel exit site should be approx 2 finger breadths below the clavicle and form a gentle curve to the venotomy.
16. Use scalpel to make a skin nick for the tunnel exit site. Open this up a little bit with the Kelly clamp to open fascia.
17. Now grab the dialysis catheter. Flush both ports with heparizined saline ( big tub) and lock the ports (click closed). Attach the tunneler to the catheter.
18. Tunnel the catheter through. Start at the exit site and gently dissect subcu with the tunneler to exit at the venotomy site. Pull the catheter all the way through. This might hang up at the cuff. Wet the cuff with heparizined saline to help it advance. Use gentle steady pressure to being the catheter through the tunnel.
19. Now the distal aspect of the catheter should be in good position with the cuff in the tunnel. At this point, need to advance the peel away sheath onto the 0.038 working wire.
20. Use the sequential dilators. Advance the dilators over the wire, keeping the wire straight and ensuring under fluoro that the dilators don't bend the wire. Advance the dilator to the level of the vein and then back out. There may be significant bleeding from the venotomty site and use the sponges to tamponade bleeding.
**** IMPORTANT NOTE. DO NOT BEND THE WIRE WHEN USING THE DILATORS OR PEEL AWAY SHEATH. IF THE WIRE BENDS, THE SHEATH COULD GO TRANSVERSE TO THE PLANE OF THE SVC AND TRAUMATIZE/LACERATE THE VESSEL. THIS IS A POTENTIALLY LETHAL COMPLICATION. WATCH THE ADVANCEMENT OF THESE DILATORS AND SHEATHS WITH FLUORO AT ALL TIMES****
21. Finally, advance the 16 french peel away sheath using fluoro guidance and have the tip in the CAJ.
22. Now have to advance catheter through sheath and then peel sheath away. First take out the working wire, leaving the sheath in place. The peel away sheath is valved, meaning that air cannot go into the vessel, therefore avoiding air embolism, another major complication.
23. Now take distal aspect of catheter and quickly but carefully insert the catheter through the sheath. Crack the pell away and continue to advance the catheter through the sheath. Peel the sheath all he way to the end. Check position of the catheter under fluoro.
24. There may be a knuckle at the venotomty site, as the catheter curves around from the tunnel into the vessel. Using your finger, massage the area to get a nice gentle curve, confirm this on fluoro.
25. Save shots of the catheter in place.
26. Flush the catheter to ensure its working correctly. Nice way to do this: take 50 cc syringe, attach to the port while still locked. Aspirate the syringe to maximum and then unlock the port. It should fill in milliseconds. Give the blood back and flush small amt of heparizned saline to clear the port and prevent clotting.
27. Same thing with the venous ports.
28. Can instill heparin in the ports using the volume listed on the catheter. Typically about 2 ml per port.
29. Secure the catheter proximal end using sutures. Make sure to place BIOPATCH. If minimal bleeding, just place Tegaderm over tunnel exit site. At the venotomy site, can either use suture or glue. Plce steristrip and then tegaderm on top.
30. Make sure to place blue caps on the catheter tips. These caps prevent air from being aspirated into the catheter.
31. Procedure complete.
PICC LINE INSERTION:
PICC that we use:
Procedure:
Pt. should be supine with arm board and Right arm extended.
1. Clean patient upper arm with chlorehexidine.
2. Drape patient using sterile blue towels for additional coverage.
3. Prep ultrasound probe with cover, set aside
4. Draw up 1% lidocaine and start to numb vein access site.
5. Use ultrasound to numb tissue deep and in the perivenous tissues. Ensure that no lidocaine goes intravascular by intermittent aspiration
6. Grab the green needle (21 gauge micropuncture needle).
7. Using the ultrasound to image in both transverse and longitudinal planes, access the vein using the needle. This can be quite tricky initially. Try to estimate the depth of the vessel. Alternatively can use the longitudinal view to watch needle entry to the vein. This is a skill which takes time.
8. If feel you are in the vessel, attempt to pass microwire through the needle. Make sure floppy tip is leading. If encounter resistance, stop immediately.
9. Sometimes you can be through and through the vessel. In this case, attach a 50 cc syringe with small amount of flush inside and aspirate on the needle as you pull back. If aspirate blood, needle tip is now intravenous and can try again with the wire.
10. May have to repeat steps 7-9 in order to gain access. This is a difficult process initially but gets easier with time.
11. Once you have wire in the vein need to track wire with fluoro.
12. under fluoro guidance, advance wire til the tip is in the region of the SVC. The wire should stay to the right of midline and not be in the position of the aorta. If suspect arterial access, will have to d/c the wire and start again
13. Get wire to the right position at the SVC/ CAJ region. Remove the access needle.
14. Take the peel away sheath+dilator combo and advance over wire. Make a skin nick at the vein access site to allow dilator to pass through. Make sure not to cut the wire, keep scalpel blade away from the wire.
15. When the dilator peel away sheath is fully advanced over the wire, you now have a stable access to the vein. Clamp the wire at the insertion and remove wire.
16. Now measure the wire so know the length of the Picc catheter.
17. Grab Picc line. Flush all ports with heparinized saline. Measure out the picc to the correct length and cut catheter.
18. Now remove inner dilator of the peel away sheath. Blood will come rushing out. Advance picc line quickly through the sheath, watching fluoroscopically to position catheter in the cavo-atrial junction.
19. Peel the sheath away, leaving the catheter in place. The white plastic hub of the catheter should be nudged up under the vein access site dermotomy, tamponading the bleeding
20. Secure the catheter using the STAT lock deveice. MAKE SURE TO PLACE BIOPATCH DRESSING
21. test catheter flushing and aspirate all ports.
22. Place sterile tegaderm over catheter access site. Catheter is ready for current use.
1. TUNNELED DIALYSIS CATHETER PLACEMENT
2. PICC LINE PLACEMENT
---------------------------------------------------
TUNNELED DIALYSIS CATHETER PLACEMENT:
Tunneled Dialysis Catheter (TDC) aka HD catheter aka Permacath
Catheters we use
Pt should be supine on fluoro table. Image pt. R neck prior to starting procedure and mark spot for IJ access.
Basic Overview:
1. Get RIJ access with micropuncture needle. Upsize to working wire using a 4 F dilator+sheaht
2. Numb up a subcu tunnel from the cath exit site to the RIJ access site. Tunnel catheter through.
3. After sequential dilatation of the subcu tissues at the venotomy site, place a 16 F peel-away-sheath at the RIJ over the wire
4. Remove wire, place catheter through sheath. Confirm position with fluoro. Secure catheter.
Detailed Procedure:
1. Clean skin with chlorhexidine. Clean the area of the lower R neck and make wide prep area down to nipple and up to jawline.
2. Drape patient with large drape. Use blue towels for extra coverage. Make sure to cover image intensifier (with help of technologist). Hand tech a blue clip so they can make window for patient.
3. Place sterile cover on ultrasound probe.
4. Draw up lidocaine and start numbing to obtain access. Numb up area of the access site (spot marked as above)
5. Make a skin nick using a scalpel. Open up the fascia using the kelly clamp.
6. Use the 21 gauge echo tip micropunture needle to access the RIJ using ultrasound. Scan in the transverse plane of the RIJ, place probe at the level of the clavicle. The RIJ should be a large venous structure just lateral to the carotid.
7. Under strict ultrasound guidance, and with full visulization of the needle tip at all times, guide the needle into the vein. You will have to "pop through" the vein wall. Clearly visualize tip of the needle within the vessel and save image.
8. At this point you should see blood return at the needle hub. Gently straighten the needle, making it closer in orientation to the long access of the vessel, to facilitate the wire entry into the RIJ.
9. Advance the microwire (.018 inch) make sure floppy tip is leading. Gently advance the wire, there should be slight tension but the wire should slide freely into the vessel. If there is resistance, stop immediately and take a look with fluoro.
10. If wire is advancing freely, check position with flurio. The wire should advance caudal and be within the region of the SVC. It should NOT follow the orientation of the aortic arch or carotid artery.
11. Now have to switch microwire for working wire. In order to do this, take needle off wire. Don't let go of wire and don't let the wire float into the vessel. Advance the 4 french sheath + dilater over the microwire.
12. The inner dilator and wire come out. Now you have a 4 french access to the RIJ.
13. 0.035 or 0.038 amplatz wire goes in the sheath. Watch this fluoroscopically and ensure the wire goes into the IVC. **If having trouble getting wire to go into the IVC, can use a 4-5 French berenstein angled angiographic catheter to help guide wire.
14. At this point you have durable working wire access to the RIJ / right side of the heart. Now you can focus on placing the catheter.
15. Numb the tunnel exit site and numb a track in the subcu from the tunnel exit site to the venotomy site. The tunnel exit site should be approx 2 finger breadths below the clavicle and form a gentle curve to the venotomy.
16. Use scalpel to make a skin nick for the tunnel exit site. Open this up a little bit with the Kelly clamp to open fascia.
17. Now grab the dialysis catheter. Flush both ports with heparizined saline ( big tub) and lock the ports (click closed). Attach the tunneler to the catheter.
18. Tunnel the catheter through. Start at the exit site and gently dissect subcu with the tunneler to exit at the venotomy site. Pull the catheter all the way through. This might hang up at the cuff. Wet the cuff with heparizined saline to help it advance. Use gentle steady pressure to being the catheter through the tunnel.
19. Now the distal aspect of the catheter should be in good position with the cuff in the tunnel. At this point, need to advance the peel away sheath onto the 0.038 working wire.
20. Use the sequential dilators. Advance the dilators over the wire, keeping the wire straight and ensuring under fluoro that the dilators don't bend the wire. Advance the dilator to the level of the vein and then back out. There may be significant bleeding from the venotomty site and use the sponges to tamponade bleeding.
**** IMPORTANT NOTE. DO NOT BEND THE WIRE WHEN USING THE DILATORS OR PEEL AWAY SHEATH. IF THE WIRE BENDS, THE SHEATH COULD GO TRANSVERSE TO THE PLANE OF THE SVC AND TRAUMATIZE/LACERATE THE VESSEL. THIS IS A POTENTIALLY LETHAL COMPLICATION. WATCH THE ADVANCEMENT OF THESE DILATORS AND SHEATHS WITH FLUORO AT ALL TIMES****
21. Finally, advance the 16 french peel away sheath using fluoro guidance and have the tip in the CAJ.
22. Now have to advance catheter through sheath and then peel sheath away. First take out the working wire, leaving the sheath in place. The peel away sheath is valved, meaning that air cannot go into the vessel, therefore avoiding air embolism, another major complication.
23. Now take distal aspect of catheter and quickly but carefully insert the catheter through the sheath. Crack the pell away and continue to advance the catheter through the sheath. Peel the sheath all he way to the end. Check position of the catheter under fluoro.
24. There may be a knuckle at the venotomty site, as the catheter curves around from the tunnel into the vessel. Using your finger, massage the area to get a nice gentle curve, confirm this on fluoro.
25. Save shots of the catheter in place.
26. Flush the catheter to ensure its working correctly. Nice way to do this: take 50 cc syringe, attach to the port while still locked. Aspirate the syringe to maximum and then unlock the port. It should fill in milliseconds. Give the blood back and flush small amt of heparizned saline to clear the port and prevent clotting.
27. Same thing with the venous ports.
28. Can instill heparin in the ports using the volume listed on the catheter. Typically about 2 ml per port.
29. Secure the catheter proximal end using sutures. Make sure to place BIOPATCH. If minimal bleeding, just place Tegaderm over tunnel exit site. At the venotomy site, can either use suture or glue. Plce steristrip and then tegaderm on top.
30. Make sure to place blue caps on the catheter tips. These caps prevent air from being aspirated into the catheter.
31. Procedure complete.
PICC LINE INSERTION:
- For right arm vein access:
- First image the patient veins on the R upper arm using ultrasound.
- Image both short and long axis orientations. Goal is place in basilic, then deep brachial veins.
PICC that we use:
Procedure:
Pt. should be supine with arm board and Right arm extended.
1. Clean patient upper arm with chlorehexidine.
2. Drape patient using sterile blue towels for additional coverage.
3. Prep ultrasound probe with cover, set aside
4. Draw up 1% lidocaine and start to numb vein access site.
5. Use ultrasound to numb tissue deep and in the perivenous tissues. Ensure that no lidocaine goes intravascular by intermittent aspiration
6. Grab the green needle (21 gauge micropuncture needle).
7. Using the ultrasound to image in both transverse and longitudinal planes, access the vein using the needle. This can be quite tricky initially. Try to estimate the depth of the vessel. Alternatively can use the longitudinal view to watch needle entry to the vein. This is a skill which takes time.
8. If feel you are in the vessel, attempt to pass microwire through the needle. Make sure floppy tip is leading. If encounter resistance, stop immediately.
9. Sometimes you can be through and through the vessel. In this case, attach a 50 cc syringe with small amount of flush inside and aspirate on the needle as you pull back. If aspirate blood, needle tip is now intravenous and can try again with the wire.
10. May have to repeat steps 7-9 in order to gain access. This is a difficult process initially but gets easier with time.
11. Once you have wire in the vein need to track wire with fluoro.
12. under fluoro guidance, advance wire til the tip is in the region of the SVC. The wire should stay to the right of midline and not be in the position of the aorta. If suspect arterial access, will have to d/c the wire and start again
13. Get wire to the right position at the SVC/ CAJ region. Remove the access needle.
14. Take the peel away sheath+dilator combo and advance over wire. Make a skin nick at the vein access site to allow dilator to pass through. Make sure not to cut the wire, keep scalpel blade away from the wire.
15. When the dilator peel away sheath is fully advanced over the wire, you now have a stable access to the vein. Clamp the wire at the insertion and remove wire.
16. Now measure the wire so know the length of the Picc catheter.
17. Grab Picc line. Flush all ports with heparinized saline. Measure out the picc to the correct length and cut catheter.
18. Now remove inner dilator of the peel away sheath. Blood will come rushing out. Advance picc line quickly through the sheath, watching fluoroscopically to position catheter in the cavo-atrial junction.
19. Peel the sheath away, leaving the catheter in place. The white plastic hub of the catheter should be nudged up under the vein access site dermotomy, tamponading the bleeding
20. Secure the catheter using the STAT lock deveice. MAKE SURE TO PLACE BIOPATCH DRESSING
21. test catheter flushing and aspirate all ports.
22. Place sterile tegaderm over catheter access site. Catheter is ready for current use.