如何打CVC ? CVC insertion note
tags: tutorials
Prepare
一邊想著操作順序，一邊把東西排好： 三對針筒、三項前菜(Guide wire、Cut、Dilator)、導管、 三個固定(clamp、Suture、Tegaderm)
- 5cc空針for local(接25號針頭)
- 10cc空針for blind try(接23號針頭)，也可以兩隻，一隻來rinse
- 紗布(不要搞得像NEJM示影片的命案現場)，多的血都打在紗布上
- Suture Kit
- Tegaderm (丟個兩片，有一片可以拿來當成把超音波變無菌的小法寶)
CVC kit 裡面有的東西：
-
18號粗針接5cc的藍色 syringe (有屁眼)
- 小技巧：套軟針(sheath)，這樣pun到時，送軟針，syringe跟硬針直接一起退
-
Guidewire：
- 一格為十公分
- 記得送入到兩格，即20cm左右
- 有Syringe的話要自己加10cm，送到3格
- 鋼針/刀片，在送dilator時切開皮膚用，記得鋼針要選針頭有斜面的
- Dilator
- Catheter：記得所有頭都先rinse，除了棕頭，即之後guide會出來的頭，以外，其他的都先clump起來，但蓋子可以不用蓋，因為你最後還是要反抽確認
- clamp一對 (蝴蝶、豆豆)
Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care
Insertion
在未消毒下可以先用Echo看一下
穿衣、第一次消毒、鋪單、消毒
把所有東西擺開來
- 先拆suture包，要個4-0 Nylon，把線先夾好，把所有剪刀、鑷子上的塑膠套都先扒光。把彎盆獨立拿出來，請nurse在裡面加一堆normal saline，放在一個順手好抽水的位置
- 抽Local、抽Normal Saline
- 拿CVC kit裡的小東西，按你要操作順序揹擺好，再拿大的東西e.g.guidewire、長針、CVC，不然先拿大東西小東西勾到就會亂滾GG
- Rinse一下管路
- 請nurse把Echo傘套丟進來，請他把探頭給你，你用傘套接住，慢慢擼套子(?)，讓nurse把套子拉走，沾無菌jelly
開始放
-
Echo看一下IJV走向，水平垂直兩個view，其實如果有Echo guide 不一定要小針試，確定的話大針直接上了，進針時negative pressure
- 看一下表皮到vein妌垂直多遠，也是就入針點到porbe水平多遠 (大概2~3公分)
- 如果是blind try的話，中了，大針再跟上從同一個入針點進入，退小針
- 怎樣打比較準：CV line insertion under the angles 102.15 ± 6.80 degrees in the axial plane, 36.21 ± 3.12 in the sagittal plane and 40.49 ± 5.09 head rotation yield satisfactory results.
意思應該是站在病人的頭的左上側Axial 102±6度往右下打，讓他頭左轉40±5度，用大概Sagittal 35度往下
因為ICA在內側，站右打很容易往左偏，就會打到動脈
Barzegari, Hassan, et al. “Proper angle of sono-guided central venous line insertion.” Emergency 4.3 (2016): 155.
McGee, David C., and Michael K. Gould. “Preventing complications of central venous catheterization.” New England journal of medicine 348.12 (2003): 1123-1133. - 人的站位也很重要，可以幾乎跟床垂直站，因為人緊張時手會一直彎
- 大針上後，接下來的事情就很簡單了，該退軟針的退，送guidewire到20~30公分，也是「█ █」跟「█ █ █」之間
Six-step approach to ultrasound-guided central venous catheter placement
* Saugel et al. Critical Care (2017) 21:225
Procedure Note
Indication: Hemodynamic monitoring/Intravenous access
The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s right/left neck was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen 9-French Cordis catheter was introduced into the the subclavian/internal jugular/common femoral vein using the Seldinger technique ___and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate.
Attending___ was present for the entire procedure.
Estimated Blood Loss: ____ cc The patient tolerated the procedure well and there were no complications.