DR. MILLINGTON'S DYI INTERNAL JUGULAR AND FEMORAL LINES

Back in the days when dinosaurs roamed the earth we put central lines in using only our landmarks and our knowledge of anatomy

It is essential that you still landmark even if using ultrasound in order to ensure you are putting your needle in the safest position.  It is tempting to poke low because the vessel is wider but it increases the risk of pneumothorax and arterial puncture/insertions.

Your best insertion site is at the apex of the sternal and clavicular head of the sternocleidomastoid muscle and aimed towards the ipsilateral nipple

That said, we all know you often cannot see or feel this on patients with thick necks. and so another way is to palpate the sternal notch and the mastoid process and go half way between the two (try it on the picture above.  It works. 

The deeper the Trendelenberg the fatter the vein.  Period.  

The fatter the vein, the easier it is to cannulate.  Period

The fatter the vein, the less likely you are to puncture the artery.  Period.

The lines have to be secured in 4 places because the patients are constantly being moved and lines can snag and come out

This is risky.  Some of those lines will have life support running through them (pressors and inotropes) and/or sedatives to keep the patient asleep and keep them from extubating themselves.

The blue and white caps in the kit work as follows:

• Wrap the white cap around the line and suture it down.  It will not secure the line until the blue cap is snaapped on top and so it will pop off while you are suturing it but that's ok.  do not suture the blue cap

• The blue cap is designed to snap over top of the white cap that is sutured down securely in place and tightens it around the central line

• The reason you do not suture the blue cap is because it was designed so that you can pop it off and pull your line back if its too deep, then simply pop it back on and redress the line (ie no sutures have to be cut to adjust your line and you do not have re-suture when you're finished

This catheter can help you if you are unsure as to whether or not you are in an artery.

The diagnosis of an arterial puncture happens when you take the syringe off  your needle and see bright red pulsatile flow.  

If you manage to diagnose an arterial insertion of a central line on an xray , something more than just the arterial insertion has gone terribly wrong

In fact, the syringe will often fill by itself when you are in an artery due to the pressures

Do not aim for "bloodless" procedures.  It is IMPORTANT that you see the blood color (bright red versus dark red), and flow of the blood (pulsatile versus non-pulsatile)