CVL Insertion

STEP 1 - Prepare the 1. Explains the procedure

patient
2. Verbalizes the indications and contraindications (risks and alternative treatment options)

3. Answer patient's questions and obtain informed consent

4. Position patient (supine, Trendelenburg, with head turned away from side of insertion)

Indications Contraindications
CVP measurement, no PIV access, vasoactive Carotid artery aneurysm, coagulopathy,
/ inotropic drugs, hypertonic solutions / Sepsis (in some cases), uncooperative
TPN, hemodialysis / plasmapheresis, patient, infection / trauma at site, cervical
temporary cardiac pacing spine injury
STEP 2 - Identify 1. Use of ultrasound to assist proper placement
desired vessel / vein
(Internal Jugular) 2. Identify any contraindications to procedure.

STEP 3 - Prepare the 1. Confirm that equipment is available (additional items: sterile gloves, saline, hub caps,
equipment probe cover)

2. Don face mask (if not already on), wash hands, dry with provided towel in kit, don gown
and gloves

3. Prepare the equipment for use - discard unnecessary items, crack the seal of syringes,
and remove caps from distal ports of line to be placed

4. Flush the lumens with saline

STEP 4 - Prepare the 1. Perform a "Time Out"

skin
2. Use sterile technique to clean skin

3. Drape the area

*Not required to apply drape. This is verbalized

4. Cover US probe with probe cover

*This can be verbalized

5. Use US to reidentify internal jugular and infiltrate the entry site with 1-2% lidocaine in a
wheel fashion
*Demonstrate without injecting into the
mannequin

6. Confirm adequate anesthesia by testing the site for pain response

STEP 5 - Place 10-mL Identify and state appropriate anatomic landmarks with index finger of non-dominant
syringe on needle hand

*Between two heads of the sternocleidomastoid [clavicular head and sternal head] at the
base of the neck
STEP 6 - Insert the 1. May use 22 or 25-gauge "finder needle" to confirm location of vessel before switching to
needle into vein larger needle through which the wire will pass
(Use of finder *Use of finder needle is NOT required
needle is NOT
required) 2. Aspirates during insertion and during withdrawal.

3. When blood encountered, notes depth and angle of finder needle penetration

4. Pull out finder needle and switch to larger needle

*ONLY if finder needle is used

5. Reinsert larger needle at the same angle and to same depth

STEP 7 When blood flows freely into syringe, removes the syringe from needle placing finger over
hub immediately as to stop the outflow of blood and to avoid the inflow of air

STEP 8 - Insert guide Gently place the guide wire through the needle and ensure the passage of wire occurs
wire without resistance

1. Notes that the wire may bump against a wall causing the curvature like a "J" shape. Does
not force if wire does not easily advance

2. Remove the needle and guide wire together and reposition the needle before reinsertion
of the wire if necessary

3. Watch for ventricular dysrhythmias

*If it occurs, recognize that wire is too deep and must be pulled back until dysrhythmias
stop

STEP 9 - Remove Keeps one hand on wire to maintain proper position in vessel and to avoid losing the wire
needle over the completely into the vessel
guide wire

STEP 10 Nicks the skin at entry site with scalpel

*Verbalize this - do not cut the mannequin

STEP 11 Place dilator over wire, dilate the entry path using only 1⁄4 to 1/3 of the dilator, and then
remove *only place dilator to skin for purposes of this exercise
 1. Use twisting motion when dilating

2. Anticipate increased bleeding at site once dilator removed and applies direct pressure

3. Maintain control over wire

STEP 12 - Place 1. Continue to maintain control of wire at all times

catheter over wire
into vein / vessel 2. If catheter slides easily into vessel, remove wire, hold finger over hub tightly until
flushed. Cap this port

3. Secures all caps

STEP 13 Confirm placement by aspirating blood from each port

*Flush with heparinized or normal saline

STEP 14 Secures catheter to skin with suture

*Do not suture the mannequin - verbalize this

STEP 15 Apply sterile dressing

STEP 16 Confirm by CXR before use of line

STEP 17 Document procedure