[Music] central lines first so let's put one in i'm not going to talk about acid technique
today so i am cleaned some aseptic technique here i've scrubbed air below the elbows there
below the elbows the patient if they can before these procedures you've explained to the problem
you've consented them you've talked about different options and never agreed they're signed
um that's all good okay so um i'm going to presume that this is all set up in a sterile fashion and
i've got help if i need it okay so without talking about it anymore i've pre-set myself up here which
you can see i haven't because it's after the last session so first thing i'd say is i've got
a central i've got an ultrasound okay so i'm going to try to find what vessel do we typically use in
brim anyway what vessel we're going to aim for for cvc i j cool internal jugular awesome so does it
matter where i'm going here's my ultrasound i'm going up and down my internal jugular can i just
go anywhere in the neck or can i in relation to the carotid is there a little trick i might use so
if the carotid sits right behind the ivc there's a risk that you can you can puncture through your
internal jugular and go into your crotted okay so you're trying to type them down a little bit
where your eye j sits a little bit to the side of your carotid so you don't go accidentally through
and back wall your ij into your crotted a couple of tricks to yeah if you're finding it difficult
you can put them head down a little bit you're going to do a vowel salva and what will happen
with if you do a vowel sound what happened to there okay you'll blow exactly it'll blow open um
uh and you can push down just gently on it and you'll see that your credible really
if it's a weak pulse you'll you'll be able to see the crawler very clearly over your
internal jugular so you found the spot and what i would say is you do everything um when you're when
you're advancing your needle you'll always see a needle tip so don't do anything without seeing
your needle tip so once again i'm going to say one way there's so many different ways of doing it
i've firstly got some like this person's awake so after doing all the stuff we talked about i've now
got a helper the help is monitoring the patient so full monitoring i'm now concentrating solely on
this if the patient's sick and the blood pressure is low then um yeah i want to know about it uh so
basically my i'm focusing on this and i first need to put some local anesthetic in so i've got
my local anesthetic needle in and i do what they call a field block what i call field block anyway
so you put it under the skin where you're gonna go and then you really could give a
good 5-10 mils so i'll put it in with a small little 25 gauge needle and i'll fan it this way
so a good blend of skin this way and then turn it around and fan it this way too
so i've got a big bulge of inner thighs skin there okay so then after i've done that you have
to go too deep but just around the skin surface once i've done that i've got i'm just going to
assume i've got my ultrasound on so ultrasound's in cross-section i'm going to do just a straight
needle we can do this with a cannula but i'll show you this way first in fact let's get this ready
last session
okay so
in fact that's good okay um what i've got is my ultrasound here i've gone in through the skin
it's really neat sized skin i just know that that's where this hole is and that's so what
i'm now doing everyone's a bit different is i will pull back on the plunger okay
so i'm pulling back on the plunger this needle this syringe comes in the pack
and i should say it's got a little hole in the back but you can see that it's got a
little hole in the back that's where your wire is going to go down so i go in through the skin
ultrasound's on i can see the point of my needle and i've now got a problem because i'm looking
up at my my ultrasound screen and forced us to be really easy because it's a big black hole
but there's a problem it's he's a bit dehydrated and every time i push on it that stupid veins
collapsing now how annoying is that what happened i don't know it's what happens it's a big thick
vein it's big big vein for sure but it can be quite easy to close on itself if they're a bit
dry and getting that needle through this so any tricks how would i blow the vein up into so you
can bow several you can do when the ventilator is pushing the air in whichever one but yeah getting
the vowel sour so i get in a good position i'm pulling back on the on the syringe and i'm it's
squeezing down and i say okay i'm bound i tend to bounce it down so bounce bounce on the surface of
it bounce bounce bounce bounce and then four seven pop okay okay and now pulling back and
all this blood coming back okay so there's blood coming okay cool there's blood coming back awesome
so good there's blood there so i stop and i feed my wire with a little introduced to the
tip actually comes in the hole all rounded up but that goes in the end of this syringe
and i feed my wire down is it ever hard to feed your wire did you ever hit resistance
so if you hit resistance it means something's not right so stop and start again i would say clearly
if you're like oh actually i hit resistance i can't go any further you're probably in the
wrong spot it should be really easy to pass and when you're doing that what you have to watch on
the screen heart rate and heart rhythm yeah you can tickle up the heart a little bit by putting
a wire into it cause low rhythm is and if you do it's okay it just means you're definitely in a
hot place you're doing a little bit far probably but yeah so cool so stop that 15 about the three
little marks on the on the on this on the wire there i've stopped there okay i'm now going to
pull my needle out okay so here we go i'm holding my wire always it won't get sucked in but i might
accidentally push it in or pull it out so i hold my wire on this side as i pull my needle out
and stabilize my mannequin and now i can see my wire on this side of the skin hold that there
and that goes away the sharp container will you know somewhere safe
so now it's got a wire inside the vessel do i definitely know i'm inside the right place 100
sure life on it that this is in the vein not the artery so i get the ultrasound and i go down again
on the vein and make sure i see the i see the why inside interesting cross section then cross
squash squash squash and you'll see the bright spark of a piece of metal inside the vein on the
ultrasound and you think okay cool if you stuck this into artery it's okay i've not done it yet
but it it's okay if you put little wire a little wire into it into a crowded it's not going to hurt
the patient realistically pressure on go the other side but if you dilate the artery that's where
you're starting your problems okay so you don't want to dilate the arteries so this if you're in
an artery this is where you want to stop and start again okay so i now know i'm definitely inside the
um definitely inside the um the vessel the the ij so now what do i do next the skin's there
scalpel's got two sides so the blunts are the scalpel on the wire not the sharp and
push push oh okay i've still got pushed through so it pushed through the um the
skin so differently into the skin the trick here what somebody just do a little tiny little nick
and that's not probably enough you actually go through the whole skin level skin layer come out
and get you you get your y and actually rotate it around a bit and actually make sure that you
it has frick and you can move and like because that's the next problem you're going to have
so make sure you can move that that y around and you'll find this is the same triggers you use
in other places not in other other procedures now are you drunk or not i don't know
this here has already been um flushed i should've done it straight off that
was flushed with saline or with it but the satellite's been flushed and then
what are these bungs why use these bungs
yeah what does it do like that nothing crazy but if you had to explain yeah perfect stops you don't
want blood still coming back here and blocking off and clotting off so yeah it stops the backflow so
here we go put them all on i'm a bit thinny i will also clamp off them as well but i'll leave this
brown one open it says distal on it what does that mean just do a hole there's three three
little injecting ports there's a hole it's the distal hole where the wire is going to go through
but there's also another one and another hole okay it's where the mid is going to go through
everything while i'm injecting in but when i'm going to fit this over the wire the wire's going
to come out the brown hole the distal wall so i'll go leave that open so i'll leave that open that's
all ready to go so once again holding my wire if i let go of my wire does it get sucked down
it won't go it won't automatically get sucked down so that's exactly i've heard one person go oh if
you look over your wife it's going to get stuck in it doesn't get sucked in but what will happen is
is as i'm pushing it in i'm just going to start pushing the wire and pushing the wire in and
then something gets in and go with my wire and potentially i won't get it back and then i have
to go to get that fixed or taken out so hold my wire until it comes out oh there the brown hole
so wires come out there and now i just feed this in gently twizzled about a little a couple of
centimeters up and just twizzle as you go down this isn't total this is going into plastic pvc
pipe so just bear with me a little bit because i get that little little sweet one right through the
pvc pipe it has yeah anyway it's gone through it's gone in as it's going in this is probably
not an ultrasound but anyway it's in there we go it's now in about five to about 10 centimeters
okay so i put it down to 10 centimeters there it is there's 15. and when i've done that
i can now pull my wire out as i put my wire out i might see a bit of blood coming out the back
of it here and what i tend to do is i tend to as it comes out fold it over and just kink it
off as it comes out why air embolism so you can suck air in it can go into here and cause near
embolism as well so you really don't want open ports to open there so i i'm a bit over careful
with it because i've heard some horror stories whether that be true or not i've never seen it
but as soon as that was coming out i can't get over put my bung on and i'm done
i'm a bit naughty now there's this thing being honest what i'll then do is i'll get a syringe
i'll pull back some blood because i like to see dark blood come out of it and then as soon as i
see a dark blood come out i'm happy i then get a sail line and i flush all three ports
with the pressure bungs on i doubt it's going to clog the next in 10 seconds and be doing that
and then securing it um i'll tend to wrap it up in a little little loop
and i'll suture these in i'll just turn on the suture i'll get one of these little bio patches
once again there's a thousand ways of doing this i'm sure but by a patch um which side goes towards
the sky blue towards the sky so blue towards the sky that goes we're inserting like that okay and
then i'll put a couple of just a proline suture we run through our four kind of protein switches
through each side here some local anesthetic in there if you haven't put local through your fill
block there because that will sting otherwise um but switch to that once that's sutured
i then will do i'll ask help from the nurses but i'll then do for me a sandwich um so like that
now i'm the worst person else about dressing is i'll put a sandwich dressing on like that
and then i'll put tegadem around the outside also fix them all around the outside
so they can always see the insertion can i just use it now x-ray perfect everything's just being
really careful i am where i think i am i've been really careful at any time the kind of places
you're going to know you're wrong would be if you can't feed something so i can't feed it gets stuck
just stop you know if i can't feed the wife i can't feed the catheter just stop you know and
start it again because it's probably not the right place it was too hard to feed
if you pull back and bright red blood comes out it's not good and if you ultrasound it and you
can't see in your vein it's probably not in the right place either okay so that's the three things
there's anything which just smells if you just stop and start again there's no
harm in stuff something's starting again you can give vasopresses peripherally while you
do all that stuff we can come back to it in a couple of hours when the patient's more stable
for us there's no great reason to have to do it quickly [Music] you