Listen to Part I - Avoiding Complications

* Confirmation of Proper Placement

Micro-Skills and Deliberate Practice

Image from S. Rezaie

* You definitely need to watch the central line micro-skills video

Steps Of Central Line Insertion

* Go to the Central Line Page

Subclavian Insertion

* Go to the Central Line Page

Dilation

* The wire CAN'T BE ALLOWED TO ADVANCE

* I need to record dilator use as a microskill

* Move wire in out sequentially during dilation (racking the wire)

Internal Jugular

* Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)

Subclavian

* Subclavian is safe in mech vent pts (Anesthesiology:2009 – Volume 111 – Issue 2 – pp 334-339)

* Use lower shoulder position puncture site just lateral to mid-clavicular line [cite source='pubmed']15564937[/cite]

* Shoulder retraction (padding behind the back) was not helpful (Br. J. Anaesth. (2013) 111 (2): 191-196.)

* If you miss twice, consider abandoning the site (3 on a match)

Ambesh Maneuvers

* Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Anesthesiology.  2002; 97(2): 528-529.)

Checking Subclavian Placement after Catheter is In

* After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC (Anesthesiology 2002;97(2):528), IJ occlusion test (Anesthesiology 2001;95(6):1377) and (Anesthesiology 2006;105(5):1062-1063)

Can We Place Central Lines in Anti-Coagulated Patients?

* Central line insertion while anti-coagulated seems safe and complications probably correlate with skill of physician (emerg med j 2011;28(6):536)

* Micropuncture Sets seem to be a very clever way to go

Guidewire Exchange

Guidewire exchange seems safe [cite source='pubmed']24004883[/cite] GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk, guide-wire exchange may be an acceptable initial approach to line insertion.

Tips for Flushes

Drop a sterile 50 ml bag on to field; slash that bad boy with a scalpel. (Thanks Haney)

Update:

Chris Bond does an interview on hand motion analysis as a means of demonstrating expertise on the procedure