Needle, wire, nick, dilate, catheter. Sounds simple right? However, simple doesn’t always mean easy. Placing a central line on a mannequin can be much easier than the 250lb ESRD patient with peripheral vascular disease and a MAP of 50. Below are ten tips to help assist with successful line placement:
1) Manipulate the syringe plunger prior to the procedure.
This will lower the initial resistance of a brand new syringe and help make it easier to get blood return when you enter the vein.
2) Don’t attach the needle to the syringe too tightly.
The needle should be firmly attached to the syringe, but remember the goal is to be able to remove the syringe without moving the needle tip at all.
3) Stabilize your needle!
This is often the step that gives people the most trouble. After you get flash, you must put your entire hypothenar eminence AND all 3 other digits on the patient with a wide base, while you firmly grasp the needle hub with digits 1 and 2.
4) Wiggle the wire within the nick.
After you make your nick, wiggle the wire in the nick to make sure it is freely moveable throughout the length of the nick. It is possible to make a nick that is not actually contiguous with your wire tract.
5) Wet the dilator.
This helps create less resistance during the dilation process. You can use normal saline from the sterile syringe.
6) Hold the dilator close to the skin.
Doing this will give you more control over the dilator and also prevent you from dilating too deeply.
7) Twist to dilate.
Remember back to your days of physics class. The coefficient of kinetic friction is usually lower than the coefficient of static friction. Meaning… it’s easier to advance and retract the dilator while it’s already in motion. Twisting upon retraction of the dilator can also be very useful, especially with larger catheters, as the act of removing the catheter often has just as much dilation potential as the insertion.
8) Dilate at the same angle as you entered the skin.
Dilating at a different angle from the wire can kink your wire and also lead to additional tissue or vascular trauma.
9 Keep a shallow angle with big catheters.
The bigger the dilator and catheter (for example hemodialysis catheters), the more likely you are to penetrate the back wall of the vessel if you advance too steeply.
10) Double Glove.
If done under sterile conditions at the beginning of the procedure, one can take off the outer pair of bloody gloves, then secure and bandage the line in place with clean gloves. Cleaner bandage, better protection against needlesticks. Watch for slightly reduced dexterity though.
Sources:
Yang L, Mullan B. Reducing needle stick injuries in healthcare occupations: an integrative review of the literature. ISRN Nurs. 2011;2011:315432
Scott Weingart. EMCrit Wee – Central Line MicroSkills – Dilation. EMCrit Blog. Published on August 29, 2017. Accessed on April 9th 2019. Available at [https://emcrit.org/emcrit/microskills-dilation/ ].
Scott Weingart. EMCrit Wee – Central Line MicroSkills (Deliberate Practice). EMCrit Blog. Published on September 12, 2015. Accessed on April 9th 2019. Available at [https://emcrit.org/emcrit/central-line-micro-skills-deliberate-practice/ ].
Triple Lumen Catheter. Digital Image. Nursejanx. April 2018, https://forum.nursejanx.com/t/what-are-the-different-ports-of-a-triple-lumen-central-venous-catheter-used-for/226
