US Guided Central Venous Catheter Kit Walk Through

This is a video from operator point of view of the placement of an ultrasound guided IJ central venous catheter.  The video uses a head mounted camera so there is a bit of movement so warning if you get motion illness early.

Yes I know, the bedside table had to be elevated for the camera angle and images so the edge of the kit wrapping relative to the drape is not ideal for sterile technique.

The video uses a Cook Spectrum antibiotic impregnated catheter with a Biopatch, chlorhexidine impregnated bandage.  Central line kits and contents will vary based upon manufacturer and customization.

Video provided for educational and informational purposes only.

I do not currently receive any funding or support from Cook or Biopatch.

Central Venous Catheter Task Trainer Phantom with Purple Vessels

If you are using task trainer procedural phantoms for ultrasound guided vascular access you may notice a problem over time.  The phantom vessels may start to be filled with purple fluid.  If you have blue and red liquid to differentiate the artery versus vein in the phantom there are 2 reasons you could have purple fluid.

1. Aspiration of fluid from one vessel and re-injection into the other, mixing the red and blue to form purple.
2. There is a fistulous connection between the artery and the vein.

If the purple fluid is due to aspiration and injection of fluid from one vessel into the other that is easy to fix.  Drain and refill the vessels with red and blue.  Then instruct your users not to re-inject the fluid in to the phantom vessel.  Instead dispense of the aspirate into a container on the side with a separate one for each color.  This will prevent mixing and injection of air in to the vessels leading to artifacts.  This will also prevent the accidental injection of fluid in to the phantom tissue itself which can damage the inserts and reduce the life of the phantom.  You can then inject the fluid through the fill port later.

The other reason is if you have a fistula between the vessels.  The following video shows what an aterio-venous fistula can appear like on the phantom with both an electronic and hand pump model.

One way to fix both problems is to fill the vessels with a single color fluid so if there is mixing or a fistula it won’t matter.

Instructional video for the Accucath by Vascular Pathways (Bard)

Originally Published: 2015-Apr-29

Since this was originally published the Accucath has become a Bard product.

As a disclaimer I do not currently receive any funding or support from Vascular Pathways (or Bard). The devices are purchased by the healthcare institution where I practice.

The Accucath device is a peripheral intravenous catheter that has an integrates coil tip wire to allow a seldinger type insertion technique.  Think of your arterial catheters.

Theoretically this would allow you easier placement in smaller and more difficult vessels.  It is also supposed to help you navigate through valves and avoid small side branches (all of which I have had experience with and it can be frustrating).  This is a newer device and I have had good success with smaller vessels, however, we will see what happens as more difficult access cases occur.

Below is an instructional video on using the Accucath 2.25″ device for venous access.

I tend to capture an image of the wire in the vessel and the catheter in the vessel if I am able to based on the clinical situation.  I also tend to document that the wire was removed intact, at least currently since this is a newer device in my institution.

Kyoto Kagaku US Guided PICC Phantom: Hands On

I got the chance to use and evaluate the Kyoto Kagaku Ultrasound guided Peripherally Inserted Central Catheter procedure phantom.  The phantom consists of a torso and an arm that articulates at the shoulder to be able to place the arm in different positions.

The upper arm has a replaceable area that can be ultrasounded and cannulated.  The targets are the cephalic and basilic veins.  The vessels outside of the insert are clear so you can see the wire and/or catheter threading. There is the ability to place the wire in to the SVC and the IJ.  There is a vessel that is used to fill the model and could be considered an azygos vein, but its take off is a little odd.

The video goes over the phantom’s parts and images along with demonstration of access and wire threading.

Disclosure: Phantom model was provided by Kyoto Kagaku for evaluation.

Practical Tips on Emergent Transcutaneous and Transvenous Pacing

Originally Published; 2013-Mar-01

Was one of the faculty for a simulation day with some lecture stations.  The station I had was a short lecture on the setting up of emergent transcutaneous and transvenous pacing followed by some hands on.  Figured I would record the lecture and post it up for whoever was interested.  I did have to put in some echo guided pacemaker insertion clips since I was giving the presentation.

As a side note some of the discussion points may not be applicable depending on what kind of equipment your facility regularly stocks.

Central Line Kit Walkthrough and Line Placement

Originally Published: 2013-Jul-02

This video is a walk through of placing an ultrasound guided internal jugular central line in  a sterile fashion.  The technique and individual steps will depend on the brand of kit and how it has been customized for your institution.

This video was originally created as a review for the residents at my institution.  It focuses on the process of placing the line and less so on the ultrasound guidance.

Single Operator Sterile Sheathing of an Ultrasound Probe for an Ultrasound Guided Procedure

Originally published 2011-Mar-07

During the care of critically ill patients either in the Emergency Department or other settings can involve the placement of Central Venous Catheters.  The literature supports the use of Ultrasound Guidance to prevent mechanical complications and increase success rates.  However, in addition to mechanical complications the patients can be at risk for delayed complications such as central line associated blood stream infections, CLABSI, or line infections.

One method to reduce this is the use of full barrier sterile precautions.  This includes placing the ultrasound probe in a sterile sheath to allow real-time guidance and maintaining the sterile field.  Many sterile sheaths are not designed for a single operator placement in the way they are folded and packaged.  This has lead to frustration, loss of sterility, infamous gel accident stories, and a reliance on an assistant.  However, there is a method to sheath the probe and maintain the sterile field as a single operator.

The procedure can be broken down into the following steps:

1. Place the probe upright in the holder
2. Place adequate nonsterile gel on the probe surface
3. Engage full barrier sterile precautions for the operator
4. Open the sterile sheath and place on non-dominant hand
5. Invert the sheath onto the dominant hand
6. Grasp the top of the probe
7. Unfurl the sheath onto the probe and cord
8. Secure the sheath in place and smooth out air bubbles
9. Place sterile gel on the sheath to allow imaging and procedural guidance

This was also published Academic Emergency Medicine in the Dynamic Emergency Medicine Section with an accompanying manuscript.  Trotter M, Nomura JT, Sierzenski PR. Acad Emer 2010;17:e153.