# CVC insertion note
# CVC放置技巧
# 中央靜脈導管放置技巧
###### 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)

---
#### 要跟護理師說的備物
1. 5cc空針for local(接25號針頭)：抽local用
2. 10cc空針for blind try(接23號針頭)，也可以兩隻，一隻針頭丟了留針筒來rinse
3. 超音波最好是有軟組織探頭，若只有腹超探頭也勉強可用
4. 超音波無菌包(內有雨傘套跟無菌jelly)
#### CVC Kit 裡的東西
3. 18號粗針接5cc的藍色 syringe (有屁眼)
1. 小技巧：套軟針，這樣pun到時，送軟針，syringe跟硬針直接一起退
5. 紗布(不要搞得像NEJM示範影片的命案現場)，多的血都打在紗布上
6. Guidewire：
1. 一格為十公分
2. 送入到兩格20cm多一點，看到一格表示線快掉啦，趕緊塞一點回去
3. 有Syringe的話要自己加10cm，送到3格
7. 鋼針/刀片，切開皮膚用，記得鋼針要選針頭有斜面的
8. Dilator
9. Catheter：都沖過，白頭lock，紅頭open；送15cm
10. clamp一對
11. Suture Kit
12. Tegaderm

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
> 血流若朝探頭而來影像會呈現紅色，離探頭則影像會呈現藍色
> 

### 穿衣、第一次消毒、鋪單、消毒
### 把所有東西擺開來
1. 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
2. 抽Local、抽Normal Saline
3. 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
4. Rinse一下管路
5. 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

### Echo-guided insertion: 速率決定步驟
1. 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垂直多遠，也是就入針點到porbe水平多遠 (大概2~3公分)
3. 入針位置跟角度的小建議：
* 常常會遇到明明看到針在畫面中，卻是怎樣都沒中，是因為入針的位置離探頭太近，導致一入針就過頭，畫面中的亮點不是針尖而是針的中段(situation1)
* 因此需要退一點，同時角度不要太大，先抓個30度，看畫面中，原本沒有針，變成有針，這樣表示那個白點就是你的針尖。接著再回抽一點，調整一下，角度大一點，再送，你應該就會看到針尖在血管理，這樣還不中就…嗯
* 

5. 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
6. 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.

4. 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
5. 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.

# Ref
https://proceduralist.org/cvc-cannulation/