The patient is placed in Tranverse position and then chlorhexidine swab is used to prep the left anterior chest wall all the way up, half way up the neck and then also broadly to cover the left shoulder. The chlorhexidine has to be allowed at least two minutes to fully dry for good antisepsis. Now a sterile wide drape is being applied with the hole centered on the insertion site. This sterile drape should cover the head and almost all of the bed.
Now we’re drawing up 1 percent lidocaine which we’ll use for local anesthesia. Since all of the fluid in a sterile field must be labeled after the syringe is full of the lidocaine, a sterile label with 1 percent lidocaine will be added onto the syringe. The normal saline syringes are already pre-labeled and therefore do not need an extra sterile label to be applied to them. Now we’re applying a sterile sheath onto the linear array probe so we can do real time ultrasound guidance for this ultrasound guided Subclavian line. The sterile sheath should cover the entire sterile drape.
Now we will apply some sterile rubber bands to keep the sterile sheath in place. Here we’re using sterile saline to flush out all the ports of the catheter. As we are doing this we’re also exchanging the classic needle caps for needle-less caps and these are applied to the blue and the white port of this triple lumen catheter. The brown port of the triple lumen catheter is the distal port and will be left without a cap because the wire will eventually be threaded back through this brown port. After you flush the brown port the port has to be clipped before the syringe is removed.
Now we’re using local anesthesia to numb up the skin and underlying subcutaneous tissue at the insertion site. We’re using a linear array probe with an enplane technique so that we can visual the needle from the skin all the way down to the axillary vein which is visualized in a longitudinal plane. At this moment you can see that the needle is almost popping into the vein. At this moment it just popped through right now so you can have aspiration of purple blood as is seen right here. The needle hub is then grasped and the syringe is removed and then the J-tipped wire is threaded through the needle hub with the curve directed towards the heart. You can see that the needle – the wire is visualized going through the vein as we gradually introduce the wire through the needle. And the wire is threaded to a 20 centimeter depth at the skin.
Now the sheath is removed and then the needle is then removed over the wire. A scalpel nick is then created over the wire at the insertion site and we guarantee that the wire can move freely within that stab wound. Now a dilator is being introduced over the wire and then the dilator will be gradually advanced with a twisting motion to dilate up a subcutaneous tract all the way into the axillary vein. The dilator is now removed, care being taken not to pull out the wire inadvertently. And now the catheter is being introduced over the wire and gradually pulled back until the wire can be grasped beyond the distal brown port.
Once the wire can be grasped beyond the brown port then you can introduce the catheter to the appropriate depth of insertion which in a left Subclavian vein is normally 16 to 17 centimeters. However, with ultrasound guidance you would add an additional 3 centimeters on top of that. And so we introduce this catheter all the way to 19 centimeters at the skin. We’re now flushing out all three ports, the blue port, the white port and finally the brown port with sterile saline.
Now an antimicrobial impregnated patch or bio-patch is applied to the insertion site to minimize the risk of catheter related bloodstream infection. We’re applying some more 1 percent lidocaine for local anesthesia and then we’re using some suture to secure the catheter in place in two locations. An instrument tie can be used to suture the catheter in place. Now we’re applying a sterile occlusive dressing with the bio-patch and the entire insertion site visualized in the open window, and then wings will be applied at the bottom to minimize the opening through which the three ports come through. And the procedure is complete.