CSC Standardized Procedure Curriculum

Transcription

1 CSC Standardized Procedure Curriculum USpecialty:U Internal Medicine USimulation:U Ultrasound Guided Central Venous Catheter (CVC) Insertion UContributed by:u LTC Alex Niven, MD UTarget Audience:U Resident and Staff Physicians UACGME Competencies Addressed: - Patient Care - Systems Based Practice - Interpersonal and Communication Skills UABIM / RRC Requirements and Objectives:U Critical Care Other Topics, Infectious Diseases Nosocomial Infections Interns: - Understand the steps required to place a central venous catheter - Understand the importance of aseptic technique to prevent infectious complications. Residents, staff: - Successfully insert a central venous catheter - Understand the importance of aseptic technique to prevent infectious complications. 1

2 UCase ScenariosU Primary (PGY-1): CLINICAL SCENARIO An 82 year old male presents with 5 days or urinary symptoms and mental status changes. The patient has clinical evidence of septic shock, with persistent hypotension despite 3 L NS and a lactate of 4. Your ICU attending asks you to place a central line to measure CVP and facilitate ongoing resuscitation. Alternate (Resident, Staff): A 23 year old AD E-5 male presents to your CSH s/p IED attack and vehicle rollover with multiple pelvic fractures and urethral disruption. He is taken emergently to the OR for suprapubic catheter placement and then is brought to the ICU for recovery. He is hemodynamically stable but your team decides to place a central line due to the risk of recurrent pelvic bleeding during air evacuation. 2

3 UBasic Instructions for participants: Please read the scenario and then enter the room when instructed by your staff. You may ask questions if you have them, and please remember to: 1. Treat the scenario as real as possible 2. Use the equipment that is available to you 3. Use universal precautions as in a real clinical situation 4. A nurse is available for assistance if needed 5. Ignore the camera (if present) 3

4 USimulation Setup: Simulators to be used: Blue Phantom Central Venous Access System SimMan Monitor only Simulator Set Up: Task trainer is placed at top of bed Sheets / blankets positioned to give the appearance of a torso and legs BP 90/60 HR 110 SpO2 98% NC in place Monitor display shows rhythm strip, heart rate, pulse oximetry, and NIBP Room Set Up: Intensive Care / Recovery Bed Hospital bed with sheets, blanket, pillow (alternate litter with base) Oxygen source and flow meter Nasal cannula Bag of normal saline hanging from IV pole 4

5 Additional Equipment Needed Sonosite ultrasound with gel Ultrasound probe sterile sheath kit with sterile gel Triple lumen or cordis introducer kit Chlorhexidine scrubs, sterile half sheet (if not provided in CVC kit) Gown, sterile and nonsterile gloves, mask, hat, eye protection Saline flush Needleless caps - Portable chest radiograph (IJ or subclavian catheters in place, with and without pneumothorax) Optional Equipment: - None Personnel Needed: - Assistant to play role of ward nurse (1) - Staff to observe and film procedure (if desired) - Assistant for patient voice, ectopy (if overhead microphone available,optional) Basic Scenario Tips: The major steps expected for this scenario include - Attempt to obtain informed consent - Position patient appropriately and identify anatomic landmarks o Utilize ultrasound to assist in vessel identification - Prepare operating area and employ standard barrier precautions - Reconfirm vessel site with ultrasound using sterile technique - Cannulate vein - Insert catheter using Seldinger technique PLEASE NOTE: Use only the 19 gauge (brown) needle supplied in the CVC kit to cannulate the Blue Phantom task trainer to preserve the life of the replacible tissue insert module. We generally have trainees gain access using the simulator and then perform the Seldinger maneuvers through the disposable CVC drape. 5

6 UCase Flow/Algorithm with branch point and completion criteria: Give learner clinical situation prior to entering the room Learner enters room Nurse greets learner and says I understand we are going to do a central line. What would you like me to get for you? Learner requests materials. Nurse will return with equipment above and say I just found a new central line placement kit that I guess they have started doing. I just brought the whole thing for you. (Optional If a microphone is available for patient voice, patient can ask learner what is going on. Learner explains procedure and obtains informed consent. Learner should consider use of conscious sedation if he interacts with the patient, and nurse can ask about sedation to prompt if necessary) Learner performs central line procedure, with assistant and staff monitoring actions using the critical actions checklist below. Nurse asks learner if he/she would like a chest x-ray at the completion of the procedure Nurse provides chest x-ray for review Learner interprets chest x-ray 6

7 UCritical Actions Checklist 1. Obtain informed consent and prepare equipment 2. Position patient and identify anatomic landmarks a. Internal Jugular i. Position patient in a 15 degree head down (Trendelenberg) position ii. Stand at head of bed iii. Identify medial (sternal) and lateral (clavicular) bellies of sternocleidomastoid and clavicle (triangle) and palpate the carotid pulse iv. Using ultrasound, identify internal jugular vein and carotid artery at the apex of this triangle. b. Subclavian i. Position patient in a 15 degree head down (Trendelenberg) position ii. Stand at the side of the bed and place a rolled towel vertically between the scapulae iii. Identify medial and middle thirds, bend of clavicle iv. Using ultrasound, identify subclavian vein and artery lateral to bend in clavicle. 3. Prepare operating area a. Chlorhexidine scrub in two directions for 30 seconds each 4. Don cap, mask, and eye protection 5. Wash hands 6. Don sterile gown and gloves 7. Create a sterile field a. Sterile bed drape b. Local sterile drape over area of interest 8. Assemble equipment a. Organize equipment in the order that you will use it b. Flush catheter and insert needleless caps c. Estimate the length of CVC necessary to rest just above the junction of SVC and right atrium (second intercostals space) 9. Reconfirm anatomic landmarks and vessel location based on ultrasound and identify needle entry site, angle, and depth of insertion a. Internal Jugular i. The skin is punctured at the apex of the triangle (usually 2 fingers above clavicle); the needle tip is directed caudally at a 45 to 60 degree angle to the frontal (horizontal) plane and laterally towards the ipsilateral nipple. The needle is advanced to a depth of 3-5 cm, depending on the size of the patient b. Subclavian i. The skin is punctured at the junction of the lateral and middle thirds of the clavicle, just inferior and medial to the bend; the needle tip is advanced beneath the clavicle parallel to the frontal (horizontal) plane and directed towards the sternal notch. The needle is advanced to a depth of 3-5 cm, depending on the size of the patient 7

8 10. Infiltrate local anesthetic a. Raise subcutaneous wheal with 22G needle (blue) b. Infiltrate subcutaneous tissue with local, 22G then 19G (brown), using a stepwise approach (advance aspirate (no blood) inject) 11. Using ultrasound guidance, advance 19G needle (bevel up) at the specified angle, direction, and depth while applying suction to the syringe a. Entry to vein signified by ultrasound visualization and a rapid flush of blood into the syringe NOTE: At this point your learner should switch from the Blue Phantom trainer and simulate obtaining venous access with the 18G needle and all other steps using the adjacent disposable drape. 12. Insert the 18G needle provided into the central vein. 13. Rotate the needle 90 degrees once in the central vein and immobilize needle with your free hand 14. Advance guide wire through needle or needle/catheter system. Minimal to no resistance should be met. a. Monitor for ectopy on monitor while passing guide wire 15. Withdraw needle from insertion site over wire, leaving the guide wire in place a. Maintain control of the guide wire during this and all further steps 16. Use scalpel to open the skin along the path of the guide wire. (NOTE: this step can be performed prior to 18G needle insertion to optimize ultrasound picture) 17. Use dilator to open the subcutaneous tissue along the path of the guide wire. 18. Advance the central venous catheter over the guide wire using a rotating motion, holding the catheter close to the skin a. Insert the dilator through introducer (cordis) prior to catheter insertion; advance triple lumen without dilator 19. Remove guide wire (and dilator if present) and aspirate free flow of venous blood to confirm that catheter tip is within the vessel lumen 20. Secure the catheter with suture to the skin in 2 places and apply sterile dressing 21. Obtain chest radiograph to confirm correct position 8

9 UAnswers to Common Questions - If requested, another physician can come to the bedside to coach the learner through the procedure (optional). - Midazolam and fentanyl are available for sedation if required. - Do not infiltrate the tissue insert model with lidocaine. Trainer blood may be carefully returned to the vessel, provided the needle is clearly within the lumen by ultrasound. Common pitfalls to monitor: - The subclavian vein can be difficult to image and access on the Blue Phantom trainer unless one selects a location far lateral of the usual subclavian access location. - Make sure the ultrasound probe is positioned so that the groove on the side of the probe is on the same side as the blue dot on the monitor. This will ensure that the images that you obtain are anatomically correct for your vantage point. - To maximize your ultrasound guidance, a) center the image of the vein in the middle of the screen using the ultrasound probe, b) insert your needle directly adjacent and in the center of the probe, and c) rock the ultrasound probe toward and away from yourself while slowly advancing the needle until you can visualize the tip. 9

10 Evaluation Forms: CENTRAL VENOUS CATHETER INSERTION SCORING SHEET Physician # / Name Date Training Site Grader Training Level: (Circle One) PGY-1 PGY-2 PGY-3 Fellow Staff 1. Assess actual performance during central venous catheter placement: CRITICAL TASKS: Obtained informed consent Yes No N/A Identified vessel using anatomic landmarks / ultrasound Yes No Used appropriate sterile technique during procedure Yes No Successfully cannulated vessel Yes No Demonstrated proficiency in Seldinger technique Yes No Correctly interpreted chest radiograph Yes No IMPORTANT TASKS: Identified appropriate equipment needed for the procedure Yes No Correctly positioned the patient Yes No Correctly identified anatomic landmarks Yes No Identified vessel using ultrasound Yes No N/A Put on non-sterile gloves Yes No N/A Cleaned the skin with topical chlorhexidine scrub Yes No Avoided touching the procedure site after cleaning the area Yes No Washed hands and dressed in appropriate sterile attire Yes No Created adequate sterile field Yes No Assembled and organized equipment Yes No Reconfirmed vessel location with ultrasound Yes No Obtained and infiltrated area with appropriate local anesthetic Yes No 10

11 Used correct technique to advance the needle Yes No Visualized needle advancement using ultrasound Yes No Recognized vessel cannulation Yes No Advanced guide wire through needle Yes No Withdrew needle from insertion site over wire Yes No Used scalpel to make skin nick Yes No Used dilator along the guide wire path Yes No Advanced central venous catheter over guide wire Yes No Removed guidewire (and dilator if present) Yes No Aspirated blood to confirm placement Yes No Secured catheter to skin with suture Yes No Disposed of needles and syringes into sharps container Yes No Obtained and reviewed chest radiograph Yes No Additional Procedural Components: Estimated CVC length necessary for appropriate placement Yes No Flushed catheter with saline prior to procedure Yes No Time to CVC placement: (minutes : seconds) 11

12 Please answer the following questions about this provider s performance: 1. Provider easily identified central vessel using anatomic landmarks and/or ultrasound Strongly Disagree Neither agree Strongly Agree Or disagree Provider followed current guidelines in site preparation and sterile technique Strongly Disagree Neither agree Strongly Agree Or disagree Provider easily accessed vessel using anatomic landmarks and/or ultrasound Strongly Disagree Neither agree Strongly Agree Or disagree Provider comfortably performed proper Seldinger technique during catheter placement Strongly Disagree Neither agree Strongly Agree Or disagree How prepared do you feel the provider was to place a central venous catheter? Not prepared at all Reasonably prepared Very prepared

13 Key Teaching Points/Critical Actions to discuss in debriefing: Review criteria for CVC site selection Subclavian site preferred due to decreased risk of infection Avoid subclavian site if coagulopathy, thrombocytopenia present Review importance of aseptic technique Catheter related bloodstream infections are common, costly, and preventable complications of CVC insertion Proper technique can reduce the rate of catheter-related blood stream infection (CRBSI) by up to 66% Average cost of care of patient with CRBSI $45,000 Review steps for appropriate CVC insertion Show procedure video Suggested time length for modules: minutes for scenario, 15 minutes debriefing Brief Didactic: More than 5 million central venous catheterizations (CVCs) are performed per year in the United States. Common indications for CVC placement include: - Hemodynamic monitoring / transvenous pacing - Administration of vasoactive drugs or hypertonic solutions (3% NS, TPN) - Acute hemodialysis / hemofiltration - Rapid infusion during large volume resuscitation - Inability to obtain peripheral access Although a potentially life saving procedure, CVC placement is not without risks. Up to 15% of recipients will experience one or more complications directly related to the central line that they receive. Complications can be divided into three general categories: 1) Mechanical Including inadvertent aterial puncture, hematoma / bleeding, and pneumothorax. Most common complications, generally related to insertion technique. CVC placement in the internal jugular (IJ) or subclavian (SC) sites has an equal risk of mechanical complications, with an increased risk of arterial puncture at the IJ site and of pneumothorax at the SC site. As the SC site is not compressible, it is generally avoided in the setting of coagulopathy or thrombocytopenia. 2) Venous Thrombosis - Although published data varies widely, the incidence of catheterassociated thrombosis has been reported to be as high as 30%. The clinical significance of these clots remains unclear, although the larger diameter of the femoral veins is believed to increase the likelihood of significant sequellae from clot at this location. The SC site is believed to be associated with the lowest risk of venous thrombosis. 3) Catheter-Related Bloodstream Infections (CRBSI) - Infections related to CVCs are common, and are associated with significant attributable morbidity and mortality in addition to an healthcare cost of $45,000 per infection. Infections increase with poor 13

14 sterile technique during insertion and daily catheter care, longer duration of catheter use, and underlying patient immune compromise. The SC site has been associated with a decreased risk of CRBSI. CVC-related complications are strongly associated with insertion technique. More than three unsuccessful attempts to insert a CVC are associated with significant increased risk of mechanical complications, and inexperienced operators should seek assistance if they find themselves in this situation. Direct vein visualization and insertion using ultrasound can dramatically improve the safety of this CVC placement, and should strongly be considered for elective and even emergent procedures. Simple infection control practices can significantly reduce the rate of CRBSI and their associated morbidity and mortality. A recent study showed that CRBSI rates could be decreased by up to 66% using the following evidence based interventions: 1) Appropriate hand hygiene before CVC insertion and line dressing changes 2) Use of chlorhexidine for site preparation 3) Use of full barrier precautions during central line insertion (hat, mask, gown, gloves, bed drape) 4) Subclavian site insertion unless contraindicated 5) Early removal of CVCs when no longer necessary The incidence of CRBSI increases with the length of time that the CVC remains in place. Typically the risk of infection starts to increase on approximately day 4, and reaches 20% at 1 week. Current guidelines recommend that catheters may be left in place unless there is interval development of fever, leukocytosis, and / or local erythema or purulence at the catheter site. Catheter changes over a guide wire either routinely or in the setting of possible CRBSI have been associated with increased risk of infection, and should generally not be performed. Catheters impregnated with silver sulfadiazine, chlorhexidine or minocycline may reduce the risk of CRBSIs, and should be considered in locations where the CRBSI rate is high or it is anticipated that the CVC will be in place for an extended period, especially in an immunocompromised host. References: 1. Taylor, RW, Palagiri AV. Central venous catheterization. Crit Care Med 2007; 35: Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: McGee D.C., Gould M.K. Current Concepts: Preventing Complications of Central Venous Catheterization. N Engl J Med 2003;348(12): SCCM. Fundamentals of Critical Care Support Course, Appendix. 5. Raad I. Intravascular catheter-related infections. Lancet 1998; 351: Xaio Y, Seagull J, Bochicchio GV et al. Video-based training increases sterile technique compliance during central venous catheter insertion. Crit Care Med 2007; 35:

15 Student Handout Central Venous Catheter (CVC) Insertion 1. Obtain informed consent and prepare equipment 2. Position patient and identify anatomic landmarks b. Internal Jugular i. Position patient in a 15 degree head down (Trendelenberg) position ii. Stand at head of bed and turn patient s head away from the side to be cannulated iii. Identify medial (sternal) and lateral (clavicular) bellies of sternocleidomastoid and clavicle (triangle) iv. Palpate the carotid pulse and gently displace medially with hand v. Using ultrasound, identify internal jugular vein and carotid artery just beneath the apex of this triangle. c. Subclavian i. Position patient in a 15 degree head down (Trendelenberg) position ii. Stand at the side of the bed, turn the patient s head away from the side to be cannulated, and place a rolled towel vertically between the scapulae iii. Identify medial and middle thirds, bend of clavicle iv. Using ultrasound, identify subclavian vein and artery lateral to bend in clavicle. d. Femoral i. Position patient in a supine position with the legs slightly abducted ii. Stand at the side of the bed iii. Identify the anterior superior iliac spine (ASIS), pubic tubercle, and course of the inguinal ligament iv. Palpate the femoral pulse (place base of palm against ASIS, pulse should be at junction of middle and medial thirds of the inguinal ligament). Femoral vein is 1 cm medial and parallel to femoral artery v. Using ultrasound, identify the femoral vein and artery below the inguinal ligament 3. Prepare operating area a. Chlorhexidine scrub in two directions for 30 seconds each 7. Don cap, mask, and eye protection 8. Wash hands 9. Don sterile gown and gloves 10. Create a sterile field a. Sterile bed drape b. Sterile towels around area of interest (optional) c. Local sterile drape over area of interest 11. Assemble equipment a. Organize equipment in the order that you will use it b. Flush catheter and insert needleless caps c. Estimate the length of CVC necessary to rest just above the junction of SVC and right atrium (second intercostal space) 12. Reconfirm anatomic landmarks and vessel location using ultrasound and identify needle entry site, angle, and depth of insertion a. Internal Jugular i. The skin is punctured at the apex of the triangle (usually 2 fingers above clavicle); the needle tip is directed caudally at a 45 to 60 degree angle to the 15

16 frontal (horizontal) plane and laterally towards the ipsilateral nipple. The needle is advanced to a depth of 3-5 cm, depending on the size of the patient b. Subclavian i. The skin is punctured at the junction of the lateral and middle thirds of the clavicle, just inferior and medial to the bend; the needle tip is advanced beneath the clavicle parallel to the frontal (horizontal) plane and directed towards the sternal notch. The needle is advanced to a depth of 3-5 cm, depending on the size of the patient c. Femoral i. The skin is punctured 1-2 cm below the inguinal ligament; the needle tip is advanced at a 45 degree angle directed cephalad. The needle is advanced until blood is aspirated 13. Infiltrate local anesthetic a. Raise subcutaneous wheal with 22G needle (blue) b. Infiltrate subcutaneous tissue with local, 22G then 19G (brown), using a stepwise approach (advance aspirate (no blood) inject) 14. Advance 18G needle (bevel up) at the specified angle, direction, and depth while applying suction to the syringe (consider use of 19G finder needle first, especially with high risk patients and/or difficult anatomy) a. Entry to vein signified by a rapid flush of blood into the syringe b. If a rapid flush of blood does not occur, continue to apply suction to the needle and withdraw slowly along the same needle path c. If no vein is encountered, withdraw the needle to a subcutaneous position and redirect the tip 15. Rotate the needle 90 degrees once in the central vein and immobilize needle with your free hand 16. Advance guide wire through needle or needle/catheter system. Minimal to no resistance should be met. a. Monitor for ectopy while passing guide wire 17. Withdraw needle from insertion site over wire, leaving the guide wire in place a. Maintain control of the guide wire during this and all further steps 18. Use scalpel to open the skin along the path of the guide wire (NOTE: when using ultrasound, doing this before insertion of the 18G needle may improve initial ultrasound images) 19. Use dilator to open the subcutaneous tissue along the path of the guide wire. 20. Advance the central venous catheter over the guide wire using a rotating motion, holding the catheter close to the skin a. Insert the dilator through introducer (cordis) prior to catheter insertion; advance triple lumen without dilator 21. Remove guidewire (and dilator if present) and aspirate free flow of venous blood to confirm that catheter tip is within the vessel lumen 22. Secure the catheter with suture and apply sterile dressing 23. Obtain chest radiograph to confirm correct position (internal jugular and subclavian catheters) 16

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