Saturday February 20, 2010

Editors' note: This is not a pearl but may help people looking for generic templates

Sample Central Venous Catheter Placement Procedure Note

Date ________ Time ______

□ New central venous catheter □ Guide wire exchange

Indications: □ Hemodynamic monitor/instability

Diagnosis: ____________________

□ Medications require central venous access
□ Inability to get peripheral access ___________________
□ Acute short term hemodialysis/apheresis
□ Infusion of > 3 incompatible continuous infusions or 2 continuous infusions plus blood product



Consent:

□ Informed consent was obtained from _____________
□ This procedure was done emergently


Insertion Site: □ Right □ Left

□ Subclavian
□ Jugular
□ Femoral (indication required) _________
□ Other sites where placement attempted _________

Type of catheter:

□ Non-tunneled □1 □2 □3 □4 lumens
□ Introducer
□ Pulmonary artery

□ Antiseptic impregnated
□ Dialysis catheter

□ Other__________


Skin Prep:

□ Chlorhexidine (preferred)

□ Povidone iodine


Ultrasound guided: □ Yes □ No

Conditions:

□ Sterile barriers: Sterile gloves, sterile gown, cap, mask, large sterile drape
□ Anesthetized site with lidocaine
□ Patient in Trendelenberg position
□ Modified Seldinger technique
□ New sterile gloves used to insert catheter during guidewire exchange
□ Sterile field maintained throughout procedure
□ Emergent line placement (consider replacement in 24 hours)


Following Procedure:

□ Blood was aspirated from all lumens, ports were flushed, and a sterile dressing was placed
□ Chest x-ray was ordered for SC and IJ attempt(s)
□ Patient tolerated without immediate complications
□ Patient experienced complications:
□ Bleeding □ EBL _________
□ Hematoma
□ Pneumothorax
□ Arterial puncture
□ Air embolism
□ Neurologic changes
□ Other __________________________


Additional comments: ____________________________________________

Time spent performing the procedure _____________


Performed by (check one)

□ Attending □ Resident/Fellow

Signature ____________________
Print name_________


Attending physician present during critical portion(s) of procedure

Attending Signature _________________
Attending name_________________________