Yap Wai Liam

Mentor : Dr Syauqi

 Central Venous Line Insertion

Chest Tube Insertion

Suprapubic Catheter insertion

Paracentesis

 Indications

Equipments
Procedure
Complications

- Monitoring of Central venous pressure (CVP) in

critically ill patient to quantify fluid balance
(Normal Value 5-10 cmH2o, 3-8 mmHg)
- for long term IV antibiotics
- for long term Parenteral nutrition
- Chemotherapy
- Plasmapheresis
- Need IV access when peripheral venous access is
impossible
- Renal Dialysis

 Central line dressing pack

Sterile gloves/gown
Iodine or chlorhexidine for cleaning
1% or 2% lidocaine
Central line (preferably at least a triple-lumen line)
Saline or heparin saline to flush line
Suture (silk- non absorble)
Scalpel blade

21-gauge (green) and 27-gauge (orange) needles

2 10-ml syringes

 Choose the site of insertion:

-> Long line : Peripherally inserted central

cathether
-> Short line: Internal Jugular Vein / Subclavian
Vein

 A tourniquet is applied to the arm and the area is cleaned and

draped;
Local anaesthetic is injected into the skin near the vein;
A cannula is then inserted into the vein, the needle is removed, and
the tourniquet is released;
A wire is inserted through the cannula and further into the vein;
The central line is then passed over the wire into the vein and the
wire is removed
Clean the skin around the line once more, dry, and cover with
occlusive dressings.
Ensure that you can aspirate blood from each lumen of the line, then
flush each lumen with saline or heparin saline.

- Prepare the patient, put in pulse oximeter and position

the patient on Trendelenburd position (15 - 30).

Identify the landmark (1-2cm below the clavicle where
the lateral 1/3 and medial 2/3 of the clavicle meet.
- Sterilize the field and prepare the equipment, make
sure all the ports in the central line is flushed and
draped the patient.
- Use 25G needle to anesthetized the skin at the desired
spot. Make sure to anesthetize the inferior portion of
clavicle as this is the most sensitive area.

 Using the finder needle and small syringe with

heparinized saline in it, enter the skin at 30 45

degree angle, aiming towards the sternal notch, always
pull back gently on the plunger to create a negative
pressure.
When you see a flash and easy withdrawal of dark
blood, this indicates entrance into the vein. Steady the
needle and remove the syringe, insert J-tipped guide
wire into the needle; if resistance is felt do not force it

 Watch the monitor (if there is cardiac monitor in

placed). Ventricular ectopic indicated placement in

RV, guide wire should pull back. Hold the guide wire,
remove the needle from the skin. Advance the dilator
over the guide wire with twisting motion. Make a small
nick with blade provided to accommodate dilator.
Remove the dilator and place catheter over the guide
wire. Removed the guide wire and flush the line.
Suture catheter in place via flange with holes.
Order the CXR stat to evaluate the line placement and
complication.

- Landmark approach most widely used is between the

medical and lateral heads of the SCM muscle and lateral
to carotid artery. Needle point towards ipsilateral nipple
at 30 45 degree.
- IJV is a readily compressible vessel. Position the patient
in Trendelenburg will increase the size of IJV. Mild
rotation of the neck away from the side of IJ insertion
will aid
- Over rotation and over extension can cause the SCM
to compress the IJ vein.

- Palpate the carotid artery, covering the artery

with your fingers. Insert the needle 0.51 cm

laterally to the artery, aiming at a 45angle to
the vertical. In men, aim for the right nipple; in
women, aim for the iliac crest. Advance slowly,
aspirating all the time, until enter the vein.
- When the needle is in the vein, ensure that you
can reliably aspirate blood. Remove the syringe,
keeping the needle very still.

 Insert the wire into the end of the needle, and advance

the wire until at least 30 cm are inserted. The wire should

advance very easily do not force it.
Keeping one hand on the wire at all times, remove the
needle, keeping the wire in place. Make a insertion over
the skin where the wire enters the skin. Insert the dilator
over the wire and push into the skin as far as it will go.
Remove the dilator.

 Insert the central line over the wire. Leave a few

centimeters of the line outside the skin. Withdraw

the wire and immediately clip off the remaining
port.
Attach the line to the skin with sutures.
Clean the skin around the line once more, dry,
and cover with occlusive dressings.
Ensure that you can aspirate blood from each
lumen of the line, then flush each lumen with
saline or heparin saline.

 Local site or systemic infection

Arterial puncture
Hematoma
Hemothorax / Pneumothorax

Catheter related thrombosis

Air embolism
Catheter tip too deep

Catheter in the wrong vessel

 Indication

Equipments
Procedure
Complications

- Pneumothorax

- Haemothorax
- Massive pleural effusion
- Empyema

- Traumatic Haemapneumothorax
- Post operative procedure

 Sterile gloves and gown

Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol
Sterile drapes
Gauze swabs
A selection of syringes and needles (2125 gauge)
Local anaesthetic, e.g. lignocaine (lidocaine) 1% or 2%
Scalpel and blade
Suture
Instrument for blunt dissection (e.g. curved clamp)

Chest tube
Connecting tubing
Closed drainage system (including sterile water if underwater seal

being used)

How to position the patient?

Prop up patient to 45
the arm of the affected side behind the patients head to
expose the axillary area.
Insertion should be in the safety triangle.
anteriorly: lateral border of pectoralis major muscle,
inferior: horizontal level of the nipple/ 4th or 5th ICS
posteriorly: mid axillary line

 Chest tube of appropriate size

- Man : 28 32F
- Woman : 28F
- Child : 12 28 F

- Infant : 12 16F
- Neonate : 10 12 F

 The arm on the affected side should be abducted and

externally rotated, and place behind the patients head.

Identify the 4th or 5th intercostal space just anterior to
midaxillary line.
Cleaned and draped the area.
Administer analgesia over the skin, subcutaneous tissue,
intercostal muscle and pleura.
Approximately 4 cm long incision made parallel to the
upper border of the rib below the chosen intercostal space.
using blade no. 11 or 10
Use a Kelly clamp to bluntly dissect a tract in the
subcutaneous tissue, intercostal muscle and parietal pleura
and enter into pleural space by intermittently advancing
the closed instrument and opening it.

 Palpate the tract with a finger, make sure the tract ends at the

upper border of the rib above the skin incision, to minimized the
risks of injury to the nerve and blood vessels of the lower border
of each rib.
Upon entry into the pleural space, a rush of air or fluid should
occur. Use a sterile, gloved finger to appreciate the size of the
tract and feel for the lung tissue and possible adhesion.
Grasp the proximal end of the chest tube with Kelly clamp and
introduce it through the tract. The distal end of the chest tube
should always be clamped until it is connected to the drainage
device.
Release the Kelly clamp and continue to advance the chest tube
posteriorly and superiorly up to 8 10cm. Make sure all the
fenestrated holes in the chest tube are inside the thoracic cavity.

 Connect the distal end of the chest tube to the drainage

system and release the clamp. Look for a respirationrelated swing in the fluid level of the water seal device to
confirm intrathoracic placement.
Secure the chest tube to the skin with silk 1-0 using
mattress method or just across the incision site. Fix the
drain with second suture and wrapped tightly around the
tube several time to cause slight indentation to prevent
dislodging the chest tube.
Place petrolatum (Vaseline) gauze over the skin if available.
Dressing over the site and provide enough of padding
between the chest tube and chest wall.
CXR post insertion of chest tube.

 Improper placement

Bleeding
Hemoperitoneum
Organ penetration

Empyema
Injury to the neurovascular bundle in the ICS
Injury to the lung parenchyma

 Indication

Equipments
Procedure
Complications

 SPC is indicated (when transurethral catheterization is contraindicated

or technically not possible) to relieve urinary retention due to following

conditions:
Urethral injuries
Urethral obstruction / stricture
Bladder neck masses
Benign prostate hyperplasia (BPH)
Failed urethral catheter

Contraindication:
- Lower abdominal incision with likelihood of adhesion
- Pelvic fractures
- Need to rule out bladder cancer in case of clot retention

 Sterile set
Anesthetic solution
Syringe, (10 mL, 60mL)
Needles
Scalpel blade
Percutaneous suprapubic catheter set (Pediatric: 8F,

10F; Adult: 12F, 14F, 16F)Needle obturator

Malecot catheter
Connecting tube
Sterile urine bag
Skin tape or nylon suture (3-0)

 Provide adequate parenteral analgesia with or without

sedation.
Clean and shave if patient is hirsute.
Palpate the distended bladder and mark the insertion site
at the midline and 2 fingers above pubic symphysis.
Apply an antiseptic solution from pubis to umbilicus and
apply drapes.
Filled 10 cc syringe with LA and use 25G needle to raise a
skin wheal at the insertion site.
Using the Blade no 11 make 4mm stab incision at the
insertion site with blade facing inferiorly

 Advance the needle while alternating injection and

aspiration, until urine enter the syringe. Remove the

syringe and insert the guidewire.
Remove the needle and insert the introducer. Once
introducer is entered, remove the guidewire and the
trochar.
Insert the catheter till the urine flow out and split the
introducer.
Inflate the balloon with 5 cc of sterile water for injection.
Connect the catheter to the urine bag. And gently withdraw
the catheter to lodge the balloon against the bladder wall.
Undrape the patient and clean the skin. Apply dressing
over it.

 Complication :

- Gross hematuria is typically a transient condition.

- Postobstruction diuresis monitor i/o and electrolytes
- Bowel perforation and intra abdominal visceral

injuries

 Indication

Equipment
Procedure
Complications

Diagnostic tap is used for the following:

New-onset ascites: Fluid evaluation helps to determine
etiology, differentiate transudate versus exudate, detect
the presence of cancerous cells, or address other
considerations
Suspected spontaneous or secondary bacterial peritonitis
Therapeutic tap is used for the following:
Respiratory compromise secondary to ascites
Abdominal pain or pressure secondary to ascites
(including abdominal compartment syndrome)

 Paracentesis kit:
Lidocaine 1%, 5-mL ampule
Syringe, 10 mL and 60mL
Needles,
Blade
Catheter, 8F, over 18 ga 7 1/2" needle with 3-way

stopcock, self-sealing valve, and a 5-mL Luer-Lock

syringe
Introducer needle, 20 ga
Tubing set with
Drainage bag or vacuum container
Specimen vials or collection bottles

Landmark:
2 cm below the umbilicus in the midline (through the
linea alba)
5 cm superior and medial to the anterior superior
iliac spines on either side

 Position, clean and drape

Apply local analgesia
Insert the needle directly perpendicular to the selected

skin entry point.

Continuously apply negative pressure to the syringe as
the needle is advanced. Upon entry to the peritoneal
cavity, loss of resistance is felt and ascitic fluid can be
seen filling the syringe

 Advanced the catheter and remove the needle

Connect the catheter to the drainage bag

 Persistent leak from the puncture site

Abdominal wall hematoma
Perforation of bowel
Introduction of infection
Hypotension after a large-volume paracentesis
Dilutional hyponatremia
Hepatorenal syndrome
Major blood vessel laceration

Catheter fragment left in the abdominal wall or cavity