Venous Access Procedures:

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PORT-A-CATH insertion

AKA Port, Chest Port, Mediport, Infusion Port, Tunneled Implantable Subcutaneous Venous Access Device

 

Pt. Setup:

Supine on fluoroscopy table.

Head turned to the left side (if going into R IJ)

uncover the Right neck, right upper chest

Acc. to VS, to decrease risk of infection, consider giving patient scrub in the right neck and right upper chest region with warm soap and water to decrease risk of port pocket infection, a devastating complication

Ancef 1 G IV going in or 600 mg of Clinda if PCNA

 

Procedure:

Scrub up

Sterile skin of patient with wide prep area, use chlorehexidine, R neck to Right upper chest, make area quite broad

Drape patient with blue towels, cut hole in the large drape and place on patient with help of CT tech

Use blue plastic clamp to create small window for patient

Place I.I. cover

Place ultrasound probe cover and secure probe somewhere sterile

Should have mark on Right lower neck, right at clavicle where you will access the RIJ

Can check mark with ultrasound to ensure accuracy

Provide generous anesthesia with lidocaine to venotomy site and also to project port pocket site and tunnel area

Use Lidocaine with epi to numb deeper subcut tissues, according to SS do not inject lido with epi into skin to avoid necrosis

If mark ok, make small blade incision with scalpel

Open this up with kelly clamp

Grab the micropuncture needle (thin green needle)

Under direct ultrasound guidance, access the RIJ with the micropuncture

Very gently direct needle caudal to facilitate microwire passage

Grab 0.018 microwire and insert through needle, floppy tip leading

Watch under fluoro, wire to follow venous course into the SVC region

If satisfied with wire position, remove needle, keeping hand on wire at all times

Grab 4F transitional sheath/dilator combo and advance over microwire

Remove inner sheath and wire and then place working wire through 4F sheath (typically 0.038 Amplatz)

Under fluoro track wire down to the IVC to obtain solid purchase into the venous system

 

Now can focus on making port pocket

Ensure port pocket site is numb as above, basic site is approx 2 finger breadths under clavicle with gentle curve towards venotomy

Use skin knife to make single small incision for port

Use other scalpel to open up this dermotomy into the subcu

Then start using kelly clamp to open this up caudally and start using blunt dissection with kelly and finger to make a small pocket appopriate for the size of a single lumen port

Check size with the port, use kelly to hold port at the metal portion where catheter is affixed to

 

Now can tunnel catheter through.  
Affix catheter to tunneling device, make sure end is appropriate

Tunnel from port pocket to the venotomy site, pop thru venotomy incision carefully

Pull catheter through.  Now can size catheter through peel away sheath

Advance 8 F peal away sheath over Amplatz, watching with fluoro to ensure sheath follows wire

Remove wire, make sure to pinch sheath to avoid air embolism

Advance catheter through sheath and then use fluoro to measure catheter

Peel sheath about halfway and seat it into the venotomy site

Measure the catheter at the port site and cut the catheter where feel appropriate that the catheter will affix to the port

Now Affix catheter to port, make sure locking mechanism on port is placed properly

Once port and catheter are together, place port into pocket

check with fluro the overall length of catheter

if everything looks good, then peel sheath away and save fluoro image of final placement

Check port to make sure flushes and aspirates well

 

Closure:
Close skin and subcu in layers

Use 3 stiches for subcu

Use subcuticular stich to close dermis

Use Glue to close port site and venotomy site

When glue dries, place steri strips, prefer to place steri strips at port site using KR method to outline port 

Place nice big teg or other sterile tape on top

 

For heparinizing the port: 100 U of Heparin / 1 ML.  Put 10 ml and lock

 

 

TUNNELED DIALYSIS CATHETER PLACEMENT:
Tunneled Dialysis Catheter (TDC) aka HD catheter aka Permacath

Pt should be supine on fluoro table.  Image pt. R neck prior to starting procedure and mark spot for IJ access.

Basic Overview:
1.  Get RIJ access with micropuncture needle.  Upsize to working wire using a 4 F dilator+sheaht
2.  Numb up a subcu tunnel from the cath exit site to the RIJ access site.  Tunnel catheter through.
3.  After sequential dilatation of the subcu tissues at the venotomy site, place a 16 F peel-away-sheath at the RIJ over the wire
4.  Remove wire, place catheter through sheath.  Confirm position with fluoro.  Secure catheter.

Detailed Procedure:
1.  Clean skin with chlorhexidine.  Clean the area of the lower R neck and make wide prep area down to nipple and up to jawline.
2.  Drape patient with large drape.  Use blue towels for extra coverage.  Make sure to cover image intensifier (with help of technologist).  Hand tech a blue clip so they can make window for patient.
3.  Place sterile cover on ultrasound probe.
4.  Draw up lidocaine and start numbing to obtain access. Numb up area of the access site (spot marked as above)
5.  Make a skin nick using a scalpel.  Open up the fascia using the kelly clamp.
6.  Use the 21 gauge echo tip micropunture needle to access the RIJ using ultrasound.  Scan in the transverse plane of the RIJ, place probe at the level of the clavicle.  The RIJ should be a large venous structure just lateral to the carotid.  
7.  Under strict ultrasound guidance, and with full visulization of the needle tip at all times, guide the needle into the vein.  You will have to "pop through" the vein wall.  Clearly visualize tip of the needle within the vessel and save image.  
8.  At this point you should see blood return at the needle hub.  Gently straighten the needle, making it closer in orientation to the long access of the vessel, to facilitate the wire entry into the RIJ.  
9.  Advance the microwire (.018 inch) make sure floppy tip is leading. Gently advance the wire, there should be slight tension but the wire should slide freely into the vessel.  If there is resistance, stop immediately and take a look with fluoro.
10.  If wire is advancing freely, check position with flurio.  The wire should advance caudal and be within the region of the SVC.  It should NOT follow the orientation of the aortic arch or carotid artery.   
11. Now have to switch microwire for working wire.  In order to do this, take needle off wire.  Don't let go of wire and don't let the wire float into the vessel.  Advance the 4 french sheath + dilater over the microwire.
12.  The inner dilator and wire come out.  Now you have a 4 french access to the RIJ.  
13.  0.035 or 0.038 amplatz wire goes in the sheath.  Watch this fluoroscopically and ensure the wire goes into the IVC.  **If having trouble getting wire to go into the IVC, can use a 4-5 French berenstein angled angiographic catheter to help guide wire.  
14.  At this point you have durable working wire access to the RIJ / right side of the heart.  Now you can focus on placing the catheter.
15.  Numb the tunnel exit site and numb a track in the subcu from the tunnel exit site to the venotomy site.  The tunnel exit site should be approx 2 finger breadths below the clavicle and form a gentle curve to the venotomy.
16.  Use scalpel to make a skin nick for the tunnel exit site.  Open this up a little bit with the Kelly clamp to open fascia.
17.  Now grab the dialysis catheter.  Flush both ports with heparizined saline ( big tub) and lock the ports (click closed).  Attach the tunneler to the catheter.  
18.  Tunnel the catheter through.  Start at the exit site and gently dissect subcu with the tunneler to exit at the venotomy site.  Pull the catheter all the way through.  This might hang up at the cuff.  Wet the cuff with heparizined saline to help it advance.  Use gentle steady pressure to being the catheter through the tunnel.  
19.  Now the distal aspect of the catheter should be in good position with the cuff in the tunnel.  At this point, need to advance the peel away sheath onto the 0.038 working wire.
20.  Use the sequential dilators.  Advance the dilators over the wire, keeping the wire straight and ensuring under fluoro that the dilators don't bend the wire.  Advance the dilator to the level of the vein and then back out.  There may be significant bleeding from the venotomty site and use the sponges to tamponade bleeding.

IMPORTANT NOTE.  DO NOT BEND THE WIRE WHEN USING THE DILATORS OR PEEL AWAY SHEATH.  IF THE WIRE BENDS, THE SHEATH COULD GO TRANSVERSE TO THE PLANE OF THE SVC AND TRAUMATIZE/LACERATE THE VESSEL.  WATCH THE ADVANCEMENT OF THESE DILATORS AND SHEATHS WITH FLUORO AT ALL TIMES

21.  Finally, advance the 16 french peel away sheath using fluoro guidance and have the tip in the CAJ.
22.  Now have to advance catheter through sheath and then peel sheath away.  First take out the working wire, leaving the sheath in place.  The peel away sheath is valved, meaning that air cannot go into the vessel, therefore avoiding air embolism, another major complication.  
23.  Now take distal aspect of catheter and quickly but carefully insert the catheter through the sheath.  Crack the pell away and continue to advance the catheter through the sheath.  Peel the sheath all he way to the end.  Check position of the catheter under fluoro.
24.  There may be a knuckle at the venotomty site, as the catheter curves around from the tunnel into the vessel.  Using your finger, massage the area to get a nice gentle curve, confirm this on fluoro.
25.  Save shots of the catheter in place.  
26.  Flush the catheter to ensure its working correctly.  Nice way to do this:  take  50 cc syringe, attach to the port while still locked.  Aspirate the syringe to maximum and then unlock the port.  It should fill in milliseconds.  Give the blood back and flush small amt of heparizned saline to clear the port and prevent clotting.  
27.  Same thing with the venous ports.
28.  Can instill heparin in the  ports using the volume listed on the catheter.  Typically about 2 ml per port.
29.  Secure the catheter proximal end using sutures.  Make sure to place BIOPATCH.  If minimal bleeding, just place Tegaderm over tunnel exit site.  At the venotomy site, can either use suture or glue.  Plce steristrip and then tegaderm on top.
30.  Make sure to place blue caps on the catheter tips.  These caps prevent air from being aspirated into the catheter.  
31.  Procedure complete.

 

 

Additional Comments:

 

- when doing a leg permacath (Common Femoral Veni approach). go R CFV and access using ultrasound similiar to a picc line.  Want to place catheter in IVC just below renals.  Alternatively, just use the longest catheter (typically 27 cm tip to cuff)

-when changing from quinton to permacath, use the quinton to perserve access and place wires through.  According to AM, he prefers to use the following sequence:  stiff glidewire down the venous hub, then remove catheter, change over for Kumpe catheter, then change out to amplatz, then place sheath.  

 

-IF placing from the left IJ, according to KR, rember that the catheter has tendency to retract and you have to place it depper int he svc / RA so it doesn't malfunction

 

-for securing the catheter, try this stich instead of using the two holes at the split portion:  use 2.0 prolene, come transverse to the plane of the tunnel exit site, come under over and unver out the oopp site, then do a cross stich (drain stich AM style) upp the cath, then tie a few knots to secure.

 

-use 4.0 vicryl at venotomy site coming subcu to cutis, then cutis to subcu on the other side, tie knot, then go down and out of incision to bury the knot

 

link

 

Pneumothorax calculator:

 

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PICC LINE :

 

• For right arm vein access:

• First image the patient veins on the R upper arm using ultrasound.

• Image both short and long axis orientations.  Goal is place in basilic, then deep brachial veins.

Procedure:
Pt. should be supine with arm board and Right arm extended. 
1.  Clean patient upper arm with chlorehexidine.  
2.  Drape patient using sterile blue towels for additional coverage.  
3.  Prep ultrasound probe with cover, set aside
4.  Draw up 1% lidocaine and start to numb vein access site.
5.  Use ultrasound to numb tissue deep and in the perivenous tissues.  Ensure that no lidocaine goes intravascular by intermittent aspiration
6.  Grab the green needle (21 gauge micropuncture needle).  
7.  Using the ultrasound to image in both transverse and longitudinal planes, access the vein using the needle.  This can be quite tricky initially.  Try to estimate the depth of the vessel.  Alternatively can use the longitudinal view to watch needle entry to the vein.  This is a skill which takes time.
8.  If feel you are in the vessel, attempt to pass microwire through the needle.  Make sure floppy tip is leading.  If encounter resistance, stop immediately.  
9.  Sometimes you can be through and through the vessel.  In this case, attach a 20 cc syringe with small amount of flush inside and aspirate on the needle as you pull back.  If aspirate blood, needle tip is now intravenous and can try again with the wire. 
10.  May have to repeat steps 7-9 in order to gain access.  This is a difficult process initially but gets easier with time.
11.  Once you have wire in the vein need to track wire with fluoro.
12.  under fluoro guidance, advance wire til the tip is in the region of the SVC.  The wire should stay to the right of midline and not be in the position of the aorta.  If suspect arterial access, will have to d/c the wire and start again
13.  Get wire to the right position at the SVC/ CAJ region.  Remove the access needle.
14.  Take the peel away sheath+dilator combo and advance over wire.  Make a skin nick at the vein access site to allow dilator to pass through.  Make sure not to cut the wire, keep scalpel blade away from the wire.
15.  When the dilator peel away sheath is fully advanced over the wire, you now have a stable access to the vein.  Clamp the wire at the insertion and remove wire.  
16.  Now measure the wire so know the length of the Picc catheter.  
17.  Grab Picc line.  Flush all ports with heparinized saline.  Measure out the picc to the correct length and cut catheter. Measurement help:  when measuring the wire, ensure that you can clearly visualize the wire tip where you want the catheter tip to be.  Clamp the wire at this level, and this should be the length of the cathteter from hub to tip.
18.  Now remove inner dilator of the peel away sheath.  Blood will come rushing out.  Advance picc line quickly through the sheath, watching fluoroscopically to position catheter in the cavo-atrial junction.
19.  Peel the sheath away, leaving the catheter in place.  The white plastic hub of the catheter should be nudged up under the vein access site dermotomy, tamponading the bleeding
20.  Secure the catheter using the STAT lock deveice.  MAKE SURE TO PLACE BIOPATCH DRESSING
21.  Test catheter flushing and aspirate all ports.
22.  Place sterile tegaderm over catheter access site.  Catheter is ready for current use.  

 

PICC TRICCS (READ THIS BEFORE EVERY PRESUMED TECHNICALLY DIFFICULT PICC):

-often even after obtaining access and inserting a peel away sheath, the picc line will not slide through the sheath and into the svc...

-First trick from KR:  use the wire from the picc kit through the picc line hub (use dilator from peel away sheath to get through valve and then use both to jimmy the picc into the SVC

-Ask for contrast on the table (make sure GFR ok).  Inject through picc if inserted, or through the dilator of the micropuncture/ministick kit.  Shoot venogram, consider making roadmap or shooting DSA to prove central occlusion

-Ask for GT wire (.018 glidewire Terumo).  Use this to navigate into SVC.  Can change orientation of table to help hold length of wire

-Cut the end of the picc so its tapered /beveled.  I’ve seen this make a difference and it works

-Put both wires down both lumens of the picc when sliding it in.  Makes picc stiffer so it tracks better through the vessels.  Ask for nitrix wire or try the green wire from the PICC kit.

-consider putting a long 5.5 F sheath (sheath has to be bigger than 4-5 French PICC).  The long sheath allows for better control of picc through sheath

-if not sure:  ask for contrast and a GT

-for extra torque on the wire, use kelly clamp or ask for torque device

-ask for berenstein catheter /angled catheter to direct wire into SVC

-if all fails, consider leaving midline.  “perfect is the enemy of good”- Voltaire

-THING TO WATCH OUT FOR:  can inadvertently form a loop of the wire inside the vein which wont reduce internally.  if so place peal away sheath, DO NOT attempt to remove through dilator.  remove dilator and attempt removal through sheath.  if the knot is too big, consider upsizing the sheath, but be careufl of bleeding through the sheath. do not put too much tension on wire or the tip can unwind and potentially be lost in patient.

-can use nitrix wire and shape tip using kelly to help guide into SVC, did this once with good success

-Don’t forget to decrease depth to increase visualization of needle tip in difficult cases of small veins

Make sure to use tourniquet

-sometimes are perivenous and wire will advance for short length and then stop.

-sometmies the mandril from the bioflo kit is better than the nitrix wire.  Also try the GT glide (018 100cm glide) if all else fails

-if catheter is flipping up into the IJ, cut the cath longer and place in to deep SVC or mid RA.  have to learn to cut the catheters a little deeper in the SVC or even RA

-also i forgot to angle the tip of the wire

 

Port a Cath Check:

 

How to access a Portacath:

Need:

Huber needle

Chloroprep (1)

Steriles Latex Free

Flush 10 ml

Sterile Towels

Blue caps

 

Procedure:

1. Palpate the port on the chest wall. 

2. Sterilize skin.  

3. Hold port with thumb and forefinger.

4. With other hand, push needle directly into septum of port

5. Using flush, aspirate off the tubing from the Huber needle.  (If port previously Hep-locked, aspirate 10 mls and discard)

6. If aspirate, check for flushing.

7. Click tubing closed.  Place little blue cap (prevents air embo)

8. When finished, simply remove needle. 

9. If not accessing the port for some time, lock with 100 U / ml of heparin solution.  Infuse 10 ml to lock catheter.  (To make 100 u / ml heparin solution, take 10 ml of flush, kill 1 ml, aspirate 1 ml of heparin 1000u / ml solution, therefore giving you 1000U in 10 ml or 100 U / ML

 

how to do a port a cath check:

Need:

10 ml flushes

10 ml syringes filled with contrast

alcohol wipes

steriles

10 ml heplock (heparin 100 u / ml solution)

 

access port as above

loc the port

under fluoro, infuse contrast and see it filling port resevoir

see it filling the catheter

check for extrav

save images of each step as above

 

Do a run:

Hit the upper left button on the pedal:  

Tell patient:  Hold your breath dont move:

hit button and then infuse about 5-10 ml of contrast quickly

when done, flush saline through

then lock with hep, 100 U / ML for port a cath, 10 ml totes

 

Have seen problems mostly with surgically placed ports which are hairpin looped in the axilla and accessed through subclavian