What is the protocol for venous sheath placement?

From the Guidelines

Venous sheath placement should be performed using ultrasound guidance to minimize complications and ensure accurate placement. The procedure involves several key steps, including:

• Selecting an appropriate site, commonly the femoral, jugular, or subclavian vein, based on clinical indication and patient anatomy 1
• Preparing the site with chlorhexidine or povidone-iodine solution and draping the area
• Administering local anesthesia using 1-2% lidocaine
• Using ultrasound guidance to locate the target vein and insert the introducer needle at a 30-45 degree angle while applying negative pressure
• Inserting a guidewire through the needle, removing the needle, and making a small skin nick with a scalpel at the entry site
• Advancing the dilator and sheath assembly over the guidewire, then removing both the dilator and guidewire, leaving only the sheath in place
• Securing the sheath to the skin with suture and applying a sterile dressing The most recent and highest quality study recommends a systematic approach to ultrasound-guided central venous catheter placement, including identifying anatomy, confirming patency, and using real-time US guidance for puncture, needle, wire, and catheter placement 1. Additionally, the use of chlorhexidine solutions with alcohol for skin preparation is recommended 1. It is also important to note that the femoral vein should be avoided unless there is a contraindication to the other sites, due to the increased risk of infection and concerns about thrombosis 1.

From the Research

Venous Sheath Protocol

The protocol for venous sheath placement involves several steps to minimize the risk of infection and ensure proper placement. Some key considerations include:

• Skin antisepsis: Using 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin disinfection during central catheter insertion, as recommended by epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England 2
• Dressing: Applying a chlorhexidine gluconate-impregnated dressing to reduce the risk of central venous catheter colonization and catheter-associated bloodstream infections 3, 4
• Insertion site preparation: Preparing the skin with a 2% chlorhexidine gluconate/70% isopropyl alcohol antiseptic to reduce bacterial colonization 5
• Catheter placement: Inserting the catheter under sterile conditions and securing it properly to prevent movement and minimize the risk of infection

Key Considerations

Some key considerations for venous sheath placement include:

• Patient population: The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin disinfection during central catheter insertion may be safe for preterm neonates over 24 weeks gestational age 6
• Infection risk: The incidence of catheter-related infections can be reduced with the use of chlorhexidine-impregnated wound dressings 4
• Skin toxicity: The risk of skin lesions and toxicity should be evaluated when using 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin disinfection in preterm neonates 6

Best Practices

Best practices for venous sheath placement include:

• Following established guidelines for skin antisepsis and dressing application
• Ensuring proper insertion site preparation and catheter placement
• Monitoring for signs of infection and catheter-related complications
• Evaluating the effectiveness of chlorhexidine-impregnated dressings in reducing catheter-related infections 3, 4