TCVC insertion in Starship Operating Rooms

Preparation and planning

Choice of central vein

Site of insertion of CVC include the internal jugular, brachiocephalic, subclavian, axillary and femoral veins. Each of these sites has relative advantages and unique disadvantages.

Choice of patients: risk factors for complications

• Small venous diameter in neonates and infants

• Large bore venous catheters

• Coagulopathy – Platelet count < 50x10⁶/L, INR >1.5. Note: Proceduralist may adjust these limits in some cases, such as potential bleeding from venipuncture site that cannot be controlled with external pressure e.g. brachiocephalic and subclavian vein.

• Congenital cardiac disease

• Abnormal vasculature – congenital and iatrogenic

• Catheters with multiple lumens

Pre-scanning: Rapid assessment of central vein protocol (RACEVA)

Ultrasound offers trained practitioners real time venous assessment and visualisation of needle tip during venepuncture. The rapid assessment of central vein protocols (RACEVA) provides a systematic framework to evaluate the upper body venous system.

Note the following vessel characteristics:

1. Path

2. Size (catheter to vein ratio of 1:3 reduces endothelial damage)

3. Depth

4. Patency

5. Flow (colour Doppler to identify artery and vein)

6. Proximity to other structures (pleura, nerve and artery)

7. Collapsibility during inspiration

Central ZIM zone: Choice of exit site by tunnelling

Tunnelling of CVC offers several advantages:

1. Optimising catheter fixation reduces catheter migration and dislodgement by avoiding exit site in the mid-neck (red) zone. Choosing mid-neck as exit site may increase risk of central catheter related bloodstream infection and thrombosis. Choosing the yellow and green exit sites reduces the constant movement of catheter against skin associated with neck movement.

2. Facilitates relocation of exit site to more favourable locations for catheter securement and dressing change:
   Supraclavicular (yellow) and Infraclavicular (green) region for upper body venous catheter.
   Mid thigh or lower abdomen for femoral venous catheter.

Ergonomics and equipment

1. Position patient, ultrasound machine and image intensifier to ensure optimal ergonomics.

2. Place shoulder roll under forced air warming blanket so it can be removed for X-Ray imaging.

3. Ultrasound assessment to identify anatomy of insertion site, localisation and patency of vein.

4. Wear appropriate X ray protection gear

5. Ensure the optimal size catheter for the patient is available. As a general guide for internal jugular catheters:
   3Fr: <3kg
   4Fr: 3-10 kg
   5Fr: 10-25kg
   6.6Fr: >25kg

Diameter of central vein and artery in children (Souza et al 2014)

Catheter vs venous diameter guide (Moureau N 2019. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer)

Antisepsis and maximum barrier precaution as per ADHB CLAB care bundle

1. Hand hygiene

2. Skin preparation
   Appropriate skin antiseptic solution applied in a back-and-forth scrub for at least 30 seconds.
   Recommended for all including neonates ≥ 1 kg and over 3 weeks of age: chlorhexidine 0.5% in 70% ethanol.
   Alternatives if there is a contraindication to one or other component: Povidone iodine 10%, alcoholic tinctures of iodine, ethanol 70% alone or chlorhexidine 2%.
   Neonates < 1 kg and neonates ≥ 1kg but under 3 weeks of age: Chlorhexidine 0.1% (NICU should send this skin prep with patient).
   Allow antiseptic solution to air dry completely before venepuncture. Allow at least 2 minutes for povidone iodine to dry.

3. Draping
   Cover the entire body of the patient with large sterile fenestrated drape.
   Leaving only a small opening (including supraclavicular region, ipsilateral shoulder and nipple) around the insertion site.
   The wide arc of the guide wire and the subsequent need to control its free end requires adequate draping well beyond its radius.

Accessing central vein

1. Ultrasound guided venepuncture is used to visualise needle path and confirm location of needle tip before advancing guidewire into the vessel. This improves success rate, avoids repeated puncture and damages to vein, nerve and artery.

2. Trendelenburg position to reduce risk of air embolus during CVC insertion.

3. When using Seldinger technique, verification of tip of guidewire in the distal SVC (or IVC for femoral catheter) with fluoroscopy should be done before the peel-away sheath-dilator is advanced into the vessel.

4. Techniques that are complementary to fluoroscopy in confirming position of guidewire placement in venous system prior to dilatation:
   IV contrast
   Blood gas measurement
   Venous pressure waveform with pressure transducer
   
   Note: Venous laceration usually occurs when the peel-away sheath-dilator combination is advanced over a malpositioned guidewire or over a relatively floppy guide wire. The wire-dilator tandem then punctures the wall of the vein.

Dilatation and tunnelling

Use blunt dissection with artery forceps to create a small pocket just lateral to the venepuncture site.

Infiltrate along the expected course of tunnel with local anaesthetic. A gentle curve will form a smooth track for catheter to reduce the risk of pinch off syndrome.

A small incision is made (#11 blade) at the final exit site for catheter so a blunt tunnelling probe can be introduced to create a track.

Tunnelling trajectory directed cephalic from the upper chest wall over the sterno-clavicular joint, finishing just lateral to the venepuncture site, before across to exit with the venous catheter.

Venepuncture wound

Venepuncture site wound should be closed with a 5-0 vicryl subcuticular continuous suture and tissue adhesive e.g. Dermabond TM to avoid exposure of catheter at the neck wound.

Central venous device tip location

Aim: Use intraoperative fluoroscopy to ensure catheter tip locate as close to cavo-atrial junction as possible.

Landmark: Upper limb TCVC – aim for T6 vertebral body. This usually correlates to 1.5 (not exceeding 1.7) vertebral body units from carina.

Lower limb TCVC e.g. tunnelled femoral venous catheters - aim for T10. Sometimes it is useful to have lateral X ray to ensure catheter tip is in IVC rather than its tributaries.

Avoid: poor image exposure, catheter tip projected over spine

How to achieve the above

Role of MRT (they have the expertise to obtain the best image):

1. Ensure the appropriate image intensifier is used. GE OEC Elite (SII6) is used for patients over 40kg.

2. Appropriate protocol is used (vascular peripheral).

3. Appropriate exposure setting.

4. Ensure image sent to PACS is a static image with full exposure and clearly defined catheter tip.

5. Adjust projection to avoid catheter tip overlapping spine.

Role of anaesthetist:

1. Bed is levelled

2. Patient’s neck in neutral position, avoiding extreme extension and rotation. Please remove shoulder roll if possible.

3. Reinsert stylet wire (put a bent in the wire to ensure the tip of wire lines up with tip of catheter) for final imaging may be useful.

4. Use live screening as fast moving catheter tip in the RA and RV may not been seen with static image in some cases. Please ensure a static image is used as final image sent to PACS for reporting and archiving.

5. Use of radiopaque dye (up to 2ml/kg Omipaque 300) would be useful in some cases e.g. metalware in the thoracic region or abnormal anatomy, abdominal pathology.

Flushing catheter

Guide wires: Ensure all guide wires are accounted for and out of the catheter before flushing the catheter.

Agent: Free flowing venous return via catheter should be verified at the end of each procedure.
Flush PICC with 0.9% saline using push-pause or turbulent flow technique and volume twice the priming volume of the catheter. If blood is aspirated, please flush with 10ml 0.9% saline to minimise drug or blood residue left inside the catheter.
Lock with 1-2ml 10u/ml heparinised saline solution.
Needleless connectors: Use a neutral displacement needleless connector e.g. Microclaveᵀᴹ.

Securement and Dressing

Tissue adhesive: Seal exit site with tissue adhesive e.g. Dermabondᵀᴹ to minimise ooze. This helps avoid dressing change in the first 24 hours and may reduce risk of dislodgement.

Skin barrier preparation (only use for neonates ≥ 48 weeks): e.g. Skin prepᵀᴹ or Cavilonᵀᴹ applied and allowed to dry prior to adhesive dressing. This improves dressing fixation and prevent medical adhesive related skin injury.

Securement: Secure TCVC with sutureless device eg Statlockᵀᴹ or Securacathᵀᴹ. Consider using drain suture to improve fixation if Statlockᵀᴹ is used.

Dressing: Semi-permeable transparent polyurethane dressing: Cover site with Tegaderm IV advanceᵀᴹ. Alternatives eg IV 3000TM/ Polyskinᵀᴹ or Meporeᵀᴹ can be used in patients with a history or at risk of medical adhesive related skin injuries.

Documentation

All TCVC should have the following documentation: CLAB form and IDAS record
IDAS record should include:

Proceduralist: Name
Indications: Antibiotics, TPN, Blood sampling, Chemotherapy, IV infusion requiring central venous access
Expected duration of treatment:
Ultrasound record of vessels diameter: mm
Skin antisepsis: 0.5% chlorhexidine in 70% ethanol, Povidone iodine 10%, Alcoholic tinctures of iodine, Ethanol 70% , Chlorhexidine 0.1%
Vein cannulated: Cephalic, Basilic, Median cubital, Internal jugular, Brachiocephalic, Subclavian, Axillary, Femoral
Number of attempts: 1,2, more than 3
Catheter brand: Medcompᵀᴹ, Bioflowᵀᴹ
Catheter gauge: 3Fr, 4Fr
Number of lumens: Single, Double
Length of trimmed catheter:
Length of internal catheter:
Length of exposed catheter:
Tunnelling distance:
Suture used for neck wound and securing: 5-0 Vicryl, tissue adhesive, N/A
Position of catheter tip: Subclavian, Proximal SVC, SVC/RA junction, RA
Method of determining catheter tip position: Fluoroscopy, CXR
Strength and volume of heparin solution used: 2ml 50u/ml heparinsed saline
Tissue adhesive application: None, Dermabondᵀᴹ, Glubran Tiss2ᵀᴹ
Use of skin barrier preparation: None, Skin preᵀᴹ, Cavilonᵀᴹ
Type of securement device: Suture, Statlockᵀᴹ, SecurAcathᵀᴹ
Type of dressing: 3M Tegaderm Advanceᵀᴹ, Chlorhexidine impregnated dressing, Sorbaviewᵀᴹ, Tegadermᵀᴹ, Polyskinᵀᴹ, IV3000ᵀᴹ, Meporeᵀᴹ