KEEPING CL STARTS STERILEThe ICU RN role in placing central lines at the bedside
Lori Ritter RN, BSN, CNRNVicki Beck RN, MN, CNS, CNOR, CNRN
Pre-planningAssure informed consent…Have patient or family
sign consent for procedure unless emergentDiscuss with proceduralist planned insertion site
and planned medicationsSedationPain managementPossible paralytic
If time, physician/PA to write med orders. If not meds may be over-ridden in Omnicell for emergent administration.Make sure orders are written by physician/PA prior
to leaving the unit
Patient ReadinessIf patient aware enough, explain what to
expectHead may be placed in trendelenberg and
covered with drapeNurse’s role
Provide comfort, communication, administration of meds
Position patient to top of bedPlace chux under and around area of
insertionPlace towel roll between shoulder blades for
SC site
Prepare for Emergency1000 mL normal saline in-line for fluid
resuscitation if orderedAmbu bag connected to O2 sourceNRB mask if not ventilatedYankaur connected to suction and turned onReversal agents for sedation and pain
medications ~especially if not intubated
Prepare the Room Area
Arrange bed with clearance for proceduralist to access pt
Clear the over bed table completely – wipe clean with Sani-Cloth
Position spotlight to shine on insertion sitePlace garbage can close for easy target
Prepare monitoring equipmentPatient attached to EKG, SaO2, BP cuff with frequency of BP
taken Q 5 mins once procedure is underwayBedside monitor readied with appropriate insertion screen
pulled up (esp with PA catheter insertion)Pressure modules and cables inserted
Prime pressure tubing using 500 mL NS. Place in pressure bagTransducer/s can be leveled and zeroed prior to insertion
Vigilance monitor set-up for ScVO2 TL catheter or CCO PA catheterAsk if physician plans for in-vitro or in-vivo calibration
Most lean toward the in-vivo calibration because of sterile field contamination with the in-vitro calibration
Utilize critical elements if unsure of procedure
Ultrasound equipmentSonosite ultrasound in room and ready to go
Sterile sleeve availabilityKnow how to navigate the screens the
proceduralist will need to get to. You will be pushing the buttons as they are sterile Power button Depth Transducer choice View change
Central Line CartCart should in room, opened, with expected
needed supplies pulled prior to procedureIf isolation room, cart will remain outside of
room Designate a helper to pass through any additional
items during procedure
Everyone in room during procedure will need to wear a mask and bouffant cap ~at minimumAssisting RN should be prepared to step into
sterile field Have ready sterile gown and properly sized sterile
gloves
Supplies to pullMaximum barrier PPE for proceduralistThis is included in the CVC triple lumen kitIf not utilizing the CVC TL kit, pull the
following for proceduralistBouffant capMask with eye guard OR mask and goggles (if
not wearing glasses)Sterile gown2 pairs appropriately sized sterile gloves
Supplies, cont.Catheter to be placed
CVC TL catheter kitScVO2 TL catheter kitIntroducer kit and correct PA catheterTransvenous pacing wire and temporary pacemaker if needed
Full body sterile drape
30 mL vial of NS along with syringe and needle for flushing catheter portsProceduralist may pull up, or RN may squirt into the well of
kit….taking care to not contaminate sterile field (i.e. do not reach across)
Stopcocks and caps for line
Replacing a CLIf procedure is to replace an old CL:
Need all new IV drips, tubings, and in-line filters Prepare prior to procedure
NEVER connect old IV’s to new central line
Prepare the PatientAssure informed consentProvide patient comfort with position, meds, face
shieldAssure “time out” and document
Hand Hygiene/Mask/Cap/Gown/Glove
Drape the PatientSurgeon will lay drape on pt chest and openAssist by touching only under side of drape to
openDrape is not to move once opened – so
balance weight of drape or anchorRespect sterile field – Avoid reaching over or
touching
Maintaining the sterile field:Place only sterile items within the sterile field. Open, dispense, and transfer items without contaminating
them.Do not allow unsterile personnel to reach across the sterile
field or to touch sterile items.Do not allow sterile personnel to reach across unsterile
areas or to touch unsterile items.Recognize and maintain the service provider's sterile area.If a sterile barrier has been wet, cut, or torn, consider it
contaminated.Do not place sterile items near open windows or doors.When in doubt about whether something is sterile, consider
it contaminated.
Defining the ICU RN’s rolePRIOR
Make sure all supplies needed are in room, and room set-up is conducive to the flow of the procedure. Know physician/PA’s expectations for specifics.
WASH HANDS and roll up your sleeves Don bouffant cap and mask to wear throughout
procedure Use sterile procedure when working close to sterile
field. Do not brush against, lean over, or touch, unless you are wearing sterile gloves. If you are the one placing the supplies on and preparing procedure sterile field, do not leave room after this has occurred to assure maintenance of sterility.
Defining the ICU RN’s roleDURING
Perform ‘Time Out’ at the start of procedure Provide comfort to patient throughout procedure through
communication, pain and sedation medication, and touch as able Assist physician in the placement of the full body sterile drape by
grabbing from underneath and pulling down completely over body Monitor patient’s O2 sats, HR, BP, sedation and pain levels and
intervene as needed. Provide ongoing communication of patient status with physician/PA as procedure is underway
Assist as required with procedure (i.e. Anticipate need for trendelenberg position, if requested make sure PA catheter calibrated prior to insertion, don sterile gloves if assistance needed in sterile field, assist with Sonosite manipulation). ScVO2
catheter will be calibrated after placement ( in-vivo)
AFTERDiscuss disposal of the sharps with physician/PA to
assure appropriately doneMonitor and recover patient from procedural sedationMonitor for all s/s of possible complications (i.e.
pneumo after central line placement, etc….)Follow up with physician regarding post procedure
CXR result and clearance to utilize placed linesComplete the Central Line Insertion QI form. Return
front page to Bill and second copy to GSRMC QI dept.Document in NUR and assign individualized
interventions Include notation about the “Time Out”
Defining the ICU RN’s role
Prevention of CLABSICentral Line Associated Blood Stream InfectionHand hygieneMaximal barrier precautions
Proceduralist to wear cap, mask, goggles, sterile gown and gloves
Sterile full body drapeChlorhexidine skin antisepsis
At insertion Daily CHG bath while patient in ICU
Optimal catheter site selection Avoidance of the femoral vein
Daily review of the line necessity; with prompt removal of unnecessary lines
Maximum barrierMaximum barrier PPE for
the proceduralist is a standard of care and required for all CL placements
SHS is tracking all CL placements for 100% compliance
RN is empowered to stop procedure if full sterile PPE is not being utilized. If full PPE declined, must fill out unusual occurrence report
Defining the ICU RN’s roleCelebrate your commitment to keeping our patients safe!