1. Ultrasound Central Line

3.  Most providers no longer use landmarks for central line placement except for with subclavian lines and occasionally femoral lines  Increased accuracy  Increased efficiency  Ability to confirm placement in real time

7.  Trendelenburg positioning  Phythagorean theorem

8.  Order in EPIC the “ultrasound ED bedside” prior to the procedure.  At the ultrasound machine click the new patient button and click on the worklist at the bottom of the screen.  Select the pt from the list. Enter your name under operator and press exit.  Now you will be able to save images for your central line.

9.  The Site Rite or the Zonare US machines  Sterile US probe Cover  Sterile Gloves  Betadine/Chlorhexidine  Sterile saline/ Blue caps  Central Line Kit  Should have everything else you need  A nurse/tech ready to help if you need anything else

10.  Still use the Seldinger technique  Needle  Wire  remove needle  Small incision at skin  dilator  back thread the wire through the triple lumen  Remove wire  suture in place  Never let go of the wire  Difference is you can use the US to see the vein and vein puncture  http://www.youtube.com/watch?v=cYzVPMQc3aY&feature= related http://www.youtube.com/watch?v=cYzVPMQc3aY&feature= related

12.  Please type.procdoc under the procedure section of your note. Click on the blue hyperlink for your ultrasound order.  You do not have to fill out the information, just write “see note” in the comments section.  Then go to your note and use the.EDUS smartphrases to document your findings. Using the central line documentation under procdoc will work. Self made ones may not if they do not include the line “Wire seen in vein and images saved to patients permanent record.”

15.  Failure to identify the needle in the tissue.  Failure to distinguish between vein and artery.  Angling the transducer towards the entry site of the needle on the skin may help visualize the needle earlier.  Avoid advancing the catheter if the needle tip is not visualized.  Trendelenburg position, Valsalva Maneuver,  Use caution when utilizing a long axis approach to central venous cannulation due to the inability to maintain visualization of the carotid artery at all times.  Sterile US gel  Failure to document with.procdoc and.edus smartphrases