Procedures: Overview of vascular access technique
Lesson Outline
Review of sterile technique
Standards of sterility generally the same for a sterile procedure as for a surgical procedure
Hat
Mask
Sterile gloves
Generally gown
Maybe omitted in some smaller procedures like arterial lines - dependent on local standards
Eye protection up to you (it’s for you, not them)
Sterile probe cover if using ultrasound
Drapes, preferably large
Video review of self-gowning and gloving technique
Sterility comes down to honesty - nobody will know you broke sterile but yourself - have to truly believe that contamination by non-sterile surfaces will harm patients
When in doubt, restart
Having easy access to new equipment (e.g. a cart) helps
Be aware of high risk times for breaking sterile
Gowning (especially self-gowning)
Draping
Unpacking kit
Consider outer 1 cm of sterile field to be non-sterile
Clip hair, prep with chlorhexadine (preferred), allow to fully dry
Final cleanup should remove all blood and other gunk under dressing area
Most CLABSIs are from the skin (bacteria infiltrates the subcutaneous tract); clean and dress as well as possible
Transparent occlusive dressings generally the norm for all sterile devices now
Maybe chlorhexadine discs/patches as well
It is okay to place non-sterile lines in an emergency - as long as clearly identified and handed over as such, so they can be removed as soon as feasible (usually within 24-48 hours at most)
Only real error is forgetting about them
You can make a non-sterile line more sterile, and that’s probably good, but ultimately it’s either 100% sterile, or it should come out. No “sterile enough.”
When in doubt, change it (sometimes not clear how sterile somebody else placed a line - eg in ED - document it!)
Seldinger overview
Needle (maybe on a syringe), wire, maybe skin nick and dilator(s), railroad catheter or other device into place
Modifications
Wire retained in device
Catheter preloaded on needle
Peel-away sheath
Ultrasound needle guidance
Ultrasound generally improves speed, reliability, safety vs blind placement
Always for IJ
Helps for fem
Subclavian controversial
Huge help for difficult peripheral IVs
Probably speeds up arterial lines
Generally the standard for paracentesis/thoracentesis (at least to find/mark spot)
Can be used in LP, chest tubes, other things
In or out of plane
Consider alignment of all three planes: vessel, probe, needle
Out of plane/transverse/short axis
90 degrees vessel-probe-needle
Pro: see all structures, best tip identification
Con: overpenetration easy if not skilled, takes practice
Maybe most versatile
In plane/longitudinal/long axis
All coplanar
Pro: best visualization of needle depth, avoid overpenetration
Con: minimal steering possible, no other structures (or even the full breadth of the target structure) can be seen in realtime so it’s easier to lose orientation, probe footprint doesn’t always fit anatomy well
Maybe best for a fairly straight, wide target, especially if overpenetration a concern
Mixed approach possible (needle in plane, vessel out of plane)
Out of plane technique
Align probe and axes
Break skin
Angle depending on depth
Identify needle
Dot or tissue movement
Bounce if needed
Bring probe forward until visualization lost
Advance needle until it reappears
Repeat as you advance, steer as needed
Lost needle?
Bounce
Pull back probe until needle seen
Readvance probe until needle lost
Continue to advance until reliably in vessel
Steer aggressively to target 12:00 point on vessel
Break vessel, continue advanced if needed
Complete technique as appropriate for device
In plane technique
Match planes
Break skin
Slight adjustments if needed to fix plane
Adjust depth angle if needed
Guide into vessel
Note: can also access vessel using short axis, then rotate confirm (eg wire placement) in long axis
Tips
Bouncing/brisk movement helps visualization
Toe-in probe angle
Optimize ultrasound image (depth, etc)
Deeper targets are always harder
Avoid air bubbles in gel or probe cover
Practice with peripheral IVs
One method or two?
Some people like to have a “slow” method for routine lines and a “fast” method for an emergency
Some feel doing it the same way every time is fastest/safest
Easy to skip things or mess up changing your process
Emergencies should generally be rare if you plan ahead
Rushing can easily make things take longer due to errors, never mind safety considerations