with the non‐dominant hand. Twist syringe off with dominant hand.
Advance GW into insertion needle until 20 cm mark is just before the entry point into the introducer needle; the 20 cm mark is visualized as two parallel gray lines on the GW. Look at the ECG monitor; if new atrial or ventricular ectopy or arrhythmias are present, immediately withdraw the GW and then reinsert to a shallower depth, e.g. 15 cm.If any difficulty is encountered during GW insertion (wire not advancing, e.g. bouncing back), withdraw GW, reattach introducer syringe and apply negative pressure while visualizing the vein under US. Never force GW into vein as this can cause damage to vessel walls, vein perforation, and artery cannulation. Excessive force placed on GW will result in a bent wire.If insertion needle is noted to be centrally located inside vein (e.g. not buried into the posterior wall) and GW cannot be advanced, turn insertion needle 90° and attempt to advance GW.If friction or bounce is still encountered after several attempts, remove insertion needle and attempt procedure again at a different site.
Remove insertion needle and place in sharps sponge.
Visualize GW in vein and not in artery with US (both criteria must be met) (Figure 3.5).
Load skin dilator onto GW, leaving a gap of 2 cm from the skin.
Using the scalpel, make a small skin nick at point of insertion. Withdraw scalpel into protective sheath before placing on sterile table. Note: in cases of thin skin tissue, it may be possible to advance the dilator without making a scalpel nick. This can help to reduce post‐procedure insertion site bleeding and should be considered especially in coagulopathic patients or patients who will be started on therapeutic anticoagulation post‐procedure.
Advance skin dilator approximately 3–4 cm, then remove dilator. Use the other hand to hold point pressure at insertion site to prevent bleeding.
Advance catheter over the GW, ensuring that contact with the GW is maintained at all times (i.e. there must always be one hand holding the GW when placing the GW and when placing the catheter over the GW).
As the catheter approaches the skin, pull GW out until it exits (brown port of triple lumen catheter or blue port of dialysis catheter). Hold this end of the GW with one hand as the other hand advances the catheter into the vessel.
Remove GW. After GW is completely removed, verbalize to nurse ‘wire out.’
Apply gentle negative pressure until blood is seen in the port tubing, then flush port with sterile saline. Ensure port tubing is free from blood, then clamp. Repeat for all ports. Apply caps onto all ports.
Instill 1 mL of lidocaine near each suture site.
Suture catheter to skin, ensuring sutures are snug, but not overly tight or loose.
Clean insertion site with chlorhexidine gluconate and isopropyl alcohol and allow to dry (1–2 minutes).
Apply dressing, e.g. Biopatch (hydrophilic polyurethane absorptive foam with chlorhexidine gluconate) then Tegaderm (transparent film dressing), or Tegaderm with impregnated chlorhexidine alone (Biopatch not needed).
Jugular and subclavian catheters usually require CXR to confirm position prior to use unless in an emergency; femoral catheters can be immediately used.
If there are signs or symptoms suggestive of pneumothorax at any point in the procedure after vein cannulation, perform pleural US on the side of the procedure. Lung sliding rules out pneumothorax. (See Chapter 4, Videos 4.1 and 4.2.)
Management of complications
Thrombosis: catheter removal, evaluate need for anticoagulation.
Bleeding at insertion site: point pressure (hydrophilic polymer and potassium ferrate powder (e.g. StatSeal) to stop bleeding), suturing.
Inadvertent arterial insertion: call vascular surgery for removal; do not attempt to remove the catheter yourself.
Follow‐up
Catheter site should be examined daily to ensure that insertion site is clean, dry, and without erythema or discharge.
Dressing should be changed when soiled and at least once weekly.
Catheters should be left in place no longer than necessary and should be removed as soon as indications resolve.
Arterial access
Indications
Continuous blood pressure monitoring (e.g. on vasoactive therapy, shock).
Frequent arterial blood sampling (e.g. respiratory failure, shock).
Arterial sites
Radial, axillary, femoral.
Catheter types
Radial, axillary, femoral (Figure 3.6).
Angiocatheter, assembly needle (angiocath and GW incorporated into a single unit), separate GW and needle (Figure 3.7).
Procedure
Prior to procedure, perform time out where the patient’s name, procedure, and site of insertion are confirmed with the patient’s nurse.
Pre‐procedure US: artery (radial, axillary, femoral) is visualized under US at and proximal to insertion site for stenosis.
Optimize site of insertion. For radial, supinate hand and tape hand down. For axillary, place a soft wrist restraint to help pull arm above patient’s head.
Select the depth on the US machine where artery can be easily visualized, i.e. minimum depth needed (a rough guide is approximately 2 cm for radial, 2–3 cm for axillary, and 4–5 cm for femoral). (Note: this requires a transverse orientation of the US probe.)
Clean site of insertion plus a diameter of approximately 15 cm with chlorhexidine gluconate and isopropyl alcohol (Chloroprep).
Wash hands and put on cap, mask, sterile gown, and sterile gloves.
Prepare sterile field: drape patient with sterile sheets and drapes so that only prepped area is exposed.
Place sterile US gel into sterile US probe cover, then insert US into sterile covering; fasten covering with rubber bands.
Place sterile US gel onto insertion site.
Draw
