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| Central Venous Access Procedures Question |
CV CATHETER PLACEMENT-EXT
P/T age--65
History: The patient needs temporary dialysis. Please place temporary
dialysis catheter.
Reference: None
Right internal jugular non-tunneled temporary dialysis catheter
placement using fluoroscopic and ultrasound guidance:
Procedure: The patient was placed on the angiographic
table in the supine position and the right neck
was an ultrasound to ascertain the size and patency of the right internal
jugular vein. This was deemed to be adequate in size and widely
patent. The right neck, therefore, was prepped and draped in the usual
sterile fashion. After 1% lidocaine was used for local anesthesia, a
the micropuncture needle was advanced into the right internal jugular vein
using ultrasound guidance. Ultrasound image was saved in PACs. A .018
a wire was advanced through the needle and utilized to place a 5 French
dilator. Through this, a .035 Amplatz wire was advanced and utilized to
place 8 and 10 French dilators followed by the placement of an 11.5 French
13.5 cm non-tunneled temporary Mahurkar dialysis catheter tip in the
SVC using fluoroscopic guidance. The good flow was obtained through both
ports. The catheter was sutured in place using a 2-0 nylon suture. The
patient tolerated the procedure well and suffered no immediate
complications.
Impression:
1. Placement of a right internal jugular non-tunneled temporary
dialysis catheter tip in the SVC using both fluoroscopic and
ultrasound guidance without complication.
2. Sample Report for Picc line placement:
Age-43
PICC LINE PLACE
HISTORY:
Dehydration, need for long-term IV access
PROCEDURE:
Full written informed consent was obtained. Ultrasound evaluation
was performed on the right upper arm. Images were obtained and
placed in PACS. A patent brachial vein was identified. The right
upper arm was prepped and draped in a standard sterile fashion. A
sterile tourniquet was applied. Using direct ultrasound guidance,
the vein was punctured with a 21 gauge needle. A .018 wire was
inserted. The needle was removed. A 5.5 French introducer sheath
was inserted. The wire was used to measure an appropriate length for
the PICC line. A Morpheus double lumen PICC line was obtained and
cut to the appropriate length. The device was advanced through the
sheath. The peel-away sheath was removed. The device was secured to
the skin with a monofilament suture. The PICC line flushed and
aspirated well following the procedure. The patient tolerated
the procedure. The distal tip of the right upper extremity PICC line overlies the expected location of the SVC.
IMPRESSION:
Successful right upper extremity PICC line placement with ultrasound.
3. Sample report for Port placement:
Age-71
PORT PLACEMENT UNDER ULTRASOUND AND FLUOROSCOPIC GUIDANCE
FINDINGS- Risks and benefits of the procedure were explained to the
patient and informed consent was obtained. The patient was placed on the
angiographic table in the supine position and prepped and draped in the
usual sterile manner. Lidocaine was used to anesthetize the skin.
Ultrasound confirmed the patency of the right IJ. A stored image was
obtained and sent to PACS.
Under ultrasound guidance, the right IJ was punctured using a
micropuncture needle. An 0.018 guidewire was advanced through the needle
and the needle was exchanged for a transition dilator. The 0.018
the guidewire was exchanged for an Amplatz guidewire which was advanced into
the IVC. The transition dilator was exchanged for a peel-away sheath.
Attention was then turned to the creation of a pocket and tunnel along the
right chest wall. The skin was anesthetized with lidocaine with
epinephrine. A skin incision was made and the subcutaneous tunnel was
created using blunt dissection. An 8-French PowerPort catheter was
brought through the tunnel and advanced through the peel-away sheath so
that its tip rested near the atriocaval junction. The catheter was
connected to the reservoir which was placed within the pocket. The
subcutaneous tissues were closed using multiple interrupted 3-0 Vicryl
stitches. The skin was closed using Dermabond glue. The skin over the
right IJ puncture site was closed using an interrupted 3-0 Vicryl
stitch. The patient received Versed and fentanyl for conscious sedation under my
supervision for 30 minutes. There were no complications.
IMPRESSION-
Placement of a right IJ port under ultrasound and fluoroscopic guidance,
as described
4. TUNNELED CATH REMOVAL W/O FL
Right tunneled dialysis catheter removal
History sepsis, right tunneled dialysis catheter, working and left
upper extremity fistula
Removal of tunneled dialysis catheter was requested by Dr. Wilkowski.
Written informed consent was obtained. The skin was prepped in a routine
manner. Local anesthesia was administered. Without difficulty, the
dialysis catheter was dissected bluntly from the tunnel. The catheter
is withdrawn. Hemostasis was obtained using local pressure.
The patient tolerated the procedure well and there were no complications.
Impression:
1. Removal of a tunneled dialysis catheter from a right Subclavian
approach as described.
5. TUNNELED CATH REMOVAL W/O FL
History: Line infection
Following local anesthetic and using sterile technique and blunt
dissection, an existing tunneled dialysis catheter was removed. The
tip was sent for culture.] Hemostasis was achieved at the neck with 10
minutes of direct pressure. No immediate complications.
Impression:
1. Removal of a tunneled dialysis catheter
6. SP REMOVE TUN CV ACC DEV WPORT
CHEMOTHERAPY PORT REMOVAL
DATE OF PROCEDURE: 8/24/2012
COMMENTS: Informed consent was obtained. Time outperformed. Maximal
sterile barrier technique was used (cap, mask, sterile gown, sterile
gloves, large sterile sheet, proper hand hygiene, and 2% chlorhexidine
for cutaneous antisepsis). 1% lidocaine utilizing local anesthesia,
divided doses of intravenous Versed and fentanyl were utilized for
conscious sedation. Patient cardiovascular status was monitored.
Procedure time less than 30 minutes.
Utilizing the aseptic technique, the port was cut down on, isolated, and
removed. The pocket irrigated with antibiotic solution and skin sites
closed with 4-0 Vicryl suture material. The patient tolerated the procedure well
with no immediate complications. The procedure was performed under the
direction and supervision of Dr. Sanjay Patel.
IMPRESSION: Successful removal of implanted port.
7. CV CATHETER PATENCY CHECK
History: No blood return, right chest port.
Exam: Fluoroscopic patency checks right chest port.
Technique: The port was evaluated using fluoroscopy. The port and
catheter are intact. The tip is in the proximal SVC.
The contrast was injected using a sterile technique. This shows a large
fibrin sheath at the tip of the catheter with the retrograde flow of
contrast along the fibrin sheath to the entrance site into the vein
with a small number of extravasations into the adjacent soft tissues.
The majority of the contrast did empty into the SVC.
Impression:
1. There is a large fibrin sheath along the intravascular aspect of
the right chest port. The majority of the contrast did empty into the
SVC though there was retrograde flow within the fibrin sheath with
extravasations of a small amount of contrast at the insertion site into
the vein. TPA infusion may be helpful to improve function. This will
be performed.
8. Reposition of the right arm PICC catheter
Indication: Nurses are unable to flush recently placed right arm PICC catheter
Discussion:
A 0.018 guidewire was placed through the patients indwelling right arm PICC
catheter without significant difficulty. The tip of the catheter was
repositioned in the SVC. This was confirmed radiographically. Both ports were
flushed easily with heparinized saline. There was an easy return of blood through
both ports. The catheter was secured to the skin.
Impression:
Reposition of the patient's right arm PICC catheter as described
There was easy blood return and easy flushing of both ports following
Repositioning
9. REPLACEMENT OF RIGHT ARM PICC CATHETER
PROCEDURE PERFORMED:
FLUOROSCOPIC GUIDED REPLACEMENT OF RIGHT ARM PICC CATHETER
Indications:
PICC catheter was placed yesterday. Subsequently, nurses were unable to
aspirate or flush the catheter. This was repositioned that evening. Apparently,
the catheter is still not functioning well.
Discussion:
The skin entry site of the patients existing right arm PICC catheter was
scrubbed with Betadine. 0.018 guidewire was advanced centrally to the SVC. The
catheter was removed. A new 5 French dual-lumen PICC catheter was placed over
the wire without difficulty and trimmed at 40 cm. This was advanced to the
region of the SVC/right atrial junction. There was good, easy blood return from
both ports. Both ports were flushed with heparinized saline. This was secured
in place at the skin. IV therapy nurse was present during the flushing of the
catheter.
Impression: Status post replacement of the patients existing right arm PICC
catheter. The new catheter was placed and trimmed at 40 cm. The catheter
extends to the region of the SVC/right atrial junction.
jugular vein. This was deemed to be adequate in size and widely
patent. The right neck, therefore, was prepped and draped in the usual
sterile fashion. After 1% lidocaine was used for local anesthesia, a
the micropuncture needle was advanced into the right internal jugular vein
using ultrasound guidance. Ultrasound image was saved in PACs. A .018
a wire was advanced through the needle and utilized to place a 5 French
dilator. Through this, a .035 Amplatz wire was advanced and utilized to
place 8 and 10 French dilators followed by the placement of an 11.5 French
13.5 cm non-tunneled temporary Mahurkar dialysis catheter tip in the
SVC using fluoroscopic guidance. The good flow was obtained through both
ports. The catheter was sutured in place using a 2-0 nylon suture. The
patient tolerated the procedure well and suffered no immediate
complications.
Impression:
1. Placement of a right internal jugular non-tunneled temporary
dialysis catheter tip in the SVC using both fluoroscopic and
ultrasound guidance without complication.
2. Sample Report for Picc line placement:
Age-43
PICC LINE PLACE
HISTORY:
Dehydration, need for long-term IV access
PROCEDURE:
Full written informed consent was obtained. Ultrasound evaluation
was performed on the right upper arm. Images were obtained and
placed in PACS. A patent brachial vein was identified. The right
upper arm was prepped and draped in a standard sterile fashion. A
sterile tourniquet was applied. Using direct ultrasound guidance,
the vein was punctured with a 21 gauge needle. A .018 wire was
inserted. The needle was removed. A 5.5 French introducer sheath
was inserted. The wire was used to measure an appropriate length for
the PICC line. A Morpheus double lumen PICC line was obtained and
cut to the appropriate length. The device was advanced through the
sheath. The peel-away sheath was removed. The device was secured to
the skin with a monofilament suture. The PICC line flushed and
aspirated well following the procedure. The patient tolerated
the procedure. The distal tip of the right upper extremity PICC line overlies the expected location of the SVC.
IMPRESSION:
Successful right upper extremity PICC line placement with ultrasound.
3. Sample report for Port placement:
Age-71
PORT PLACEMENT UNDER ULTRASOUND AND FLUOROSCOPIC GUIDANCE
FINDINGS- Risks and benefits of the procedure were explained to the
patient and informed consent was obtained. The patient was placed on the
angiographic table in the supine position and prepped and draped in the
usual sterile manner. Lidocaine was used to anesthetize the skin.
Ultrasound confirmed the patency of the right IJ. A stored image was
obtained and sent to PACS.
Under ultrasound guidance, the right IJ was punctured using a
micropuncture needle. An 0.018 guidewire was advanced through the needle
and the needle was exchanged for a transition dilator. The 0.018
the guidewire was exchanged for an Amplatz guidewire which was advanced into
the IVC. The transition dilator was exchanged for a peel-away sheath.
Attention was then turned to the creation of a pocket and tunnel along the
right chest wall. The skin was anesthetized with lidocaine with
epinephrine. A skin incision was made and the subcutaneous tunnel was
created using blunt dissection. An 8-French PowerPort catheter was
brought through the tunnel and advanced through the peel-away sheath so
that its tip rested near the atriocaval junction. The catheter was
connected to the reservoir which was placed within the pocket. The
subcutaneous tissues were closed using multiple interrupted 3-0 Vicryl
stitches. The skin was closed using Dermabond glue. The skin over the
right IJ puncture site was closed using an interrupted 3-0 Vicryl
stitch. The patient received Versed and fentanyl for conscious sedation under my
supervision for 30 minutes. There were no complications.
IMPRESSION-
Placement of a right IJ port under ultrasound and fluoroscopic guidance,
as described
4. TUNNELED CATH REMOVAL W/O FL
Right tunneled dialysis catheter removal
History sepsis, right tunneled dialysis catheter, working and left
upper extremity fistula
Removal of tunneled dialysis catheter was requested by Dr. Wilkowski.
Written informed consent was obtained. The skin was prepped in a routine
manner. Local anesthesia was administered. Without difficulty, the
dialysis catheter was dissected bluntly from the tunnel. The catheter
is withdrawn. Hemostasis was obtained using local pressure.
The patient tolerated the procedure well and there were no complications.
Impression:
1. Removal of a tunneled dialysis catheter from a right Subclavian
approach as described.
5. TUNNELED CATH REMOVAL W/O FL
History: Line infection
Following local anesthetic and using sterile technique and blunt
dissection, an existing tunneled dialysis catheter was removed. The
tip was sent for culture.] Hemostasis was achieved at the neck with 10
minutes of direct pressure. No immediate complications.
Impression:
1. Removal of a tunneled dialysis catheter
6. SP REMOVE TUN CV ACC DEV WPORT
CHEMOTHERAPY PORT REMOVAL
DATE OF PROCEDURE: 8/24/2012
COMMENTS: Informed consent was obtained. Time outperformed. Maximal
sterile barrier technique was used (cap, mask, sterile gown, sterile
gloves, large sterile sheet, proper hand hygiene, and 2% chlorhexidine
for cutaneous antisepsis). 1% lidocaine utilizing local anesthesia,
divided doses of intravenous Versed and fentanyl were utilized for
conscious sedation. Patient cardiovascular status was monitored.
Procedure time less than 30 minutes.
Utilizing the aseptic technique, the port was cut down on, isolated, and
removed. The pocket irrigated with antibiotic solution and skin sites
closed with 4-0 Vicryl suture material. The patient tolerated the procedure well
with no immediate complications. The procedure was performed under the
direction and supervision of Dr. Sanjay Patel.
IMPRESSION: Successful removal of implanted port.
7. CV CATHETER PATENCY CHECK
History: No blood return, right chest port.
Exam: Fluoroscopic patency checks right chest port.
Technique: The port was evaluated using fluoroscopy. The port and
catheter are intact. The tip is in the proximal SVC.
The contrast was injected using a sterile technique. This shows a large
fibrin sheath at the tip of the catheter with the retrograde flow of
contrast along the fibrin sheath to the entrance site into the vein
with a small number of extravasations into the adjacent soft tissues.
The majority of the contrast did empty into the SVC.
Impression:
1. There is a large fibrin sheath along the intravascular aspect of
the right chest port. The majority of the contrast did empty into the
SVC though there was retrograde flow within the fibrin sheath with
extravasations of a small amount of contrast at the insertion site into
the vein. TPA infusion may be helpful to improve function. This will
be performed.
8. Reposition of the right arm PICC catheter
Indication: Nurses are unable to flush recently placed right arm PICC catheter
Discussion:
A 0.018 guidewire was placed through the patients indwelling right arm PICC
catheter without significant difficulty. The tip of the catheter was
repositioned in the SVC. This was confirmed radiographically. Both ports were
flushed easily with heparinized saline. There was an easy return of blood through
both ports. The catheter was secured to the skin.
Impression:
Reposition of the patient's right arm PICC catheter as described
There was easy blood return and easy flushing of both ports following
Repositioning
9. REPLACEMENT OF RIGHT ARM PICC CATHETER
PROCEDURE PERFORMED:
FLUOROSCOPIC GUIDED REPLACEMENT OF RIGHT ARM PICC CATHETER
Indications:
PICC catheter was placed yesterday. Subsequently, nurses were unable to
aspirate or flush the catheter. This was repositioned that evening. Apparently,
the catheter is still not functioning well.
Discussion:
The skin entry site of the patients existing right arm PICC catheter was
scrubbed with Betadine. 0.018 guidewire was advanced centrally to the SVC. The
catheter was removed. A new 5 French dual-lumen PICC catheter was placed over
the wire without difficulty and trimmed at 40 cm. This was advanced to the
region of the SVC/right atrial junction. There was good, easy blood return from
both ports. Both ports were flushed with heparinized saline. This was secured
in place at the skin. IV therapy nurse was present during the flushing of the
catheter.
Impression: Status post replacement of the patients existing right arm PICC
catheter. The new catheter was placed and trimmed at 40 cm. The catheter
extends to the region of the SVC/right atrial junction.
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