Central venous catheter (CVC) placement is indicated in patients who need hemodynamic/fluid balance monitoring, rapid volume resuscitation, therapies such as vasoactive drugs, vasopressors and hypertonic saline and in patients with difficult venous access. A large bore catheter is placed into a large vein in the neck in which the unexposed portion lies in the superior vena cava (SVC). Complications of CVC placement include infection, hematoma, pneumothorax, hemothorax, thrombosis and inadvertent arterial puncture.
The basic concept is that a tube is placed below the skin and is connected to a primary vein. The exposed portion of the tube contains a valve that can open and close. When open, the valve provides medical personnel with direct access to the vein, allowing for a variety of medical procedures to be performed. When closed, the valve forms an airtight seal which prevents germs or dirt from entering the tube and causing infection or other complications.
With a procedure as invasive as a central line, infection is perhaps the most common complication likely to occur. Not only from germs entering through the tube itself, but also from around the point of insertion. As a result, the insertion area needs to be meticulously cleaned and cared for. Complications of CVC placement include infection, hematoma, pneumothorax, hemothorax and inadvertent arterial puncture.. This protocol covers the task of central line placement by a Nurse Practitioner (NP).
Learning Sequence Builds Confidence
The learner practices the procedure in the ‘guided mode’ (ghosted hints, narrative from tutor) as often as they like.
When the learner is confident that they can accurately demonstrate the procedure without error, the learner plays the level in the ‘expert mode’ (no hints or coaching narration) - which they can repeat as often as they wish.
Finally, when the learner is confident that they have mastered the procedure - they take a one-time ‘exam’ attempt which results in their grade for that procedure.
Features
Guided Mode - ghosted hints show step-by-step positions, learner can 'see through' the patient to verify placement.
Oculus Quest Hand Tracking - learner uses natural hand movements to interact (no need to memorize buttons & controls).
Oculus Quest Affordability & Ease of Use - next generation game development processes allow the untethered, mobile VR to present effective visual and interaction fidelity at 1/4 of the cost of desktop VR.
Physiology Engine - real-world patient & case data informs the simulation.
Feedback - Cloud-based enterprise incorporates real-time data acquisition that allows learner to track progress and mastery, and provides detailed insights for debrief with faculty.
Support - Enterprise incorporates Knowledge Base (with tutorial videos & FAQ) - combined with help desk support staff for learners and staff.
Central Line Checklist
-
Chart reviewed: INR, platelets checked
-
Consent verified
-
Allergies confirmed
-
EKG and SpO2 verified
-
Team introduction
-
Verify patient with 2 identifiers
-
Wash hands and don personal protective equipment.
-
Vein and artery identified with US (non-sterile)
-
Adequate sterile prep with chlorhexadine (wait 3 minutes)
-
Patient placed in Trendelenburg
-
Wide drape placed correctly
-
Ultrasound probe sheath applied correctly
-
All equipment verified, prepared, and placed (CVC kit)
-
Catheter flushed and capped
-
Location of IJ confirmed with US (sterile)
-
Needle placed at proper location, aiming at the ipsilateral nipple
-
Vein accessed: no more than 3 needle passes
-
Venous blood return verified
-
Wire advanced 12-17cm
-
Wire visualized with US in longitudinal view
-
Skin nick made with 11 blade
-
Dilater deployed and removed properly (2-3 cm, no kinking of wire)
-
Catheter advanced over wire, 12-17cm
-
Control of wire maintained at all times
-
Wire removed and stored without breaking sterility
-
Catheter checked for blood return and flushed (all ports)
-
Catheter secured in place with suture
-
Sterile dressing applied
-
Chest x-ray of correct placement confirmed