Pre‐procedure

ActionRationale

1. 1.Show
   Gain consent from medical team to carry out the procedure and assess the patient's medical and intravenous device history.
   To ensure the patient has no underlying medical problems and is suitable to undergo the procedure. E
2. 2.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
3. 3.Show
   Draw screens and assist the patient into a supine position.
   To ensure privacy. To aid insertion of the introducer and then advancement of the catheter (Gabriel [161], E).
4. 4.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   To minimize the risk of infection (Fraise and Bradley [156], E; NHS England and NHSI [348], C; RCN [381], C).
5. 5.Show
   Take the equipment required to the patient's bedside. Open the outer pack. Put on theatre cap and mask with visor.
   To ensure appropriate equipment is available for the procedure. E

   To prevent contamination (Loveday et al. [278], C).

Procedure

1. 6.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   To minimize the risk of infection (Fraise and Bradley [156], E; NHS England and NHSI [348], C; RCN [381], C).
2. 7.Show
   Put on sterile gown and powder‐free sterile gloves; open sterile tray, arranging and preparing the contents as required.
   To prevent contamination. Powder on gloves can increase the risk of mechanical phlebitis (Elliott [139], E; Loveday et al. [278], C).
3. 8.Show
   Pre‐fill a 10 mL syringe with 0.9% sodium chloride and flush each lumen of the catheter. Then slide the clamp across the lumens.
   To prevent blood loss and reduce risk of air entry. To ascertain that all lumens are patent. E
4. 9.Show
   Draw up lidocaine into a 5 mL syringe and apply identifying label to it.
   To ascertain which syringe contains the local anaesthetic. E
5. 10.Show
   Place a sterile towel under the intended site for insertion.
   To provide a sterile field to work on. E
6. 11.Show
   Clean the skin at the selected site with 2% chlorhexidine in 70% alcohol, with friction, and prepare an area of 15–25 cm².
   To ensure the removal of skin flora and to minimize the risk of infection (Loveday et al. [278], C).
7. 12.Show
   Allow the solution to dry thoroughly.
   To ensure coagulation of bacteria and disinfection (Loveday et al. [278], C).
8. 13.Show
   Drape the patient with a sterile full‐body fenestrated towel.
   To provide a sterile field (Loveday et al. [278], C).
9. 14.Show
   Ask assistant to tip the patient's head down into the Trendelenburg position.
   To encourage venous filling and reduce the risk of air embolism (Farrow et al. [144], E).
10. 15.Show
    Apply sterile ultrasound gel inside the ultrasound probe cover. Then cover the probe with the sterile ultrasound probe cover.
    To improve conductivity. E

    To maintain sterility during the procedure. E
11. 16.Show
    Apply ultrasound gel to the patient's neck and scan the side of the neck from below the ear lobe to the clavicle to locate the internal jugular vein and other vessels.
    To identify and select a suitable vein and vessels to avoid, for example thrombosed vessels or arteries (Kelly [241], E; Moureau [329], E; NICE [349], C).
12. 17.Show
    Inject local anaesthetic intradermally using a 25 G safety needle to the area over the selected vessel and wait for it to take effect.
    To ensure that the area is anaesthetized and reduce patient discomfort. E
13. 18.Show
    Attach an empty 5 mL syringe to the seeker needle.
    To prepare equipment. E
14. 19.Show
    While visualizing the vein on the ultrasound machine, insert the needle directly into the vein at a downward angle of 30–50° (or steeper, up to 60–70°, to get clear visualization on the screen), maintaining gentle suction with the syringe plunger.
    To gain venous access (Gabriel [161], E), reduce the risk of arterial puncture and to know when the needle is in the vein. Apposition of the anterior and posterior walls of the vein can occur so blood is often only aspirated on withdrawal rather than insertion (Farrow et al. [144], E).
15. 20.Show
    When blood is observed in the syringe, check that the blood is dark and non‐pulsatile.
    To ensure the needle is in the vein and not the artery as it would then be bright red and pulsatile, although the most reliable method of checking is to perform a blood gas analysis (Farrow et al. [144], E).
16. 21.Show
    Remove the syringe from the needle, apply a digit over the entry and thread the guidewire through the needle until the selected depth is reached (this will depend on the side used and the anatomy of the patient). Keep hold of the guidewire at all times.
    To prevent air entry and contamination of the area with blood, and to minimize the amount of blood loss from the patient (Gabriel [161], E). If the guidewire is placed too deeply, the patient will have arrhythmias (Farrow et al. [144], E).
17. 22.Show
    Advance the dilator over the wire up to the puncture site.
    To prepare for advancement of the dilator. E
18. 23.Show
    Make a small incision in the skin at the puncture site.
    To aid the advancement of the dilator through the skin. E
19. 24.Show
    Advance the dilator using a gentle corkscrew motion to dilate the soft tissues. Advance to about the same depth as the venepuncture and then remove.
    To facilitate the passage of the catheter (Farrow et al. [144], E).
20. 25.Show
    Remove the catheter from the plastic cover and advance it over the wire and into the vein via the puncture site.
    To maintain sterility until required. To commence insertion of the catheter. E
21. 26.Show
    As the catheter is advanced along the wire, keep hold of the guidewire from the end of the lumen and ensure it moves freely.
    To ensure that the wire is not kinked or stuck within the vessels (Farrow et al. [144], E).
22. 27.Show
    Continue slow advancement of the catheter to the desired length (15 cm on right or 17 cm on left) then remove the guidewire.
    To minimize damage to the intima of the vein (Gabriel [161], E). To check there is no obstruction and that the catheter advances into the correct location (Farrow et al. [144], E).
23. 28.Show
    Aspirate and flush all lumens with 0.9% sodium chloride. Clamp each lumen after flushing.
    To check for blood return or resistance. To check the patency of the device and ensure continued patency. To prevent air embolism (Gabriel [161], E; Loveday et al. [278], C).
24. 29.Show
    Return the patient to a supine position.
    To aid patient comfort. E
25. 30.Show
    Attach needle‐free connectors.
    To ensure a closed system. E
26. 31.Show
    Clean the insertion site and attach the wings of the catheter to the securing device.
    To ensure protection of the site. To prevent the tubing pressing into the patient's skin (Gabriel [161], E; RCN [381], C).
27. 32.Show
    Attach the wings to a securing device (preferably), or alternatively stitch them to the skin with polypropylene sutures. Cover with a semi‐permeable transparent IV film dressing.
    To ensure the stability of the device (Gabriel [161], E; RCN [381], C).

Post‐procedure

1. 33.Show
   Remove gloves, hat, mask and gown and dispose of equipment appropriately. Dispose of sharps and clinical waste.
   To prevent sharps injury. To ensure safe disposal in the correct containers and avoid laceration or injury of other staff. To prevent reuse of equipment (HSE [217], C; NHS Employers [346], [347], C).
2. 34.Show
   Send the patient for a chest X‐ray. Ensure the position of the catheter is assessed and documented by a doctor or qualified practitioner. The X‐ray should also be checked to ensure there is no pneumothorax.
   To ensure that the catheter tip is in the correct position and that there is no pneumothorax (Wise et al. [474], E).
3. 35.Show
   Document the procedure in the patient's notes:

   • type of catheter (number of lumens)
   • number of passes (times needle inserted)
   • vein used
   • any problems
   • ability to aspirate blood
   • how it was secured
   • confirmation tip
   • patient education
   • serial number of catheter and ultrasound machine used.
   To ensure adequate records are maintained and enable continued care of the patient and device (NMC [356], C).