B-mode image of oval internal jugular vein (IJV) and round carotid artery (CA). (Courtesy of Srikar Adhikari, MD)
Indications
Providing medications that are caustic to smaller vessels, i.e., vasopressors, certain antibiotics, and long-term electrolyte replacement
Large volume resuscitation (Cordis line)
Hemodynamic monitoring
Transvenous cardiac pacing
Hemodialysis/plasmapheresis
Difficult venous access
Contraindications
A CVC should not be placed in an area with overlying cellulitis or where it will be difficult to maintain site sterility. A CVC should not be placed in a clotted or stenotic vein or if there is known or suspected venous injury. Coagulopathic and obese patients should be approached with great care as there is an increased risk of complications. If a patient is in need of dialysis or is to have an arteriovenous (AV) fistula placed, the central line should not be placed in the vein that the AV fistula or temporary catheter will be placed.
Equipment and Probe Selection
Probe Selection
Equipment
Antiseptic (chlorhexidine gluconate, betadine, etc.)
Local anesthetic (1% lidocaine)
Gauze
25 gauge needle for anesthetic infiltration
18 gauge introducer needle
Syringes (3 cc, 10 cc)
Needles for anesthetic (18 gauge, 25 gauge)
Sterile drapes, gown, gloves, mask, and hat
Sterile ultrasound probe cover
J-shaped guidewire
Dilator
11 blade scalpel
Large Tegaderm
Biopatch
Catheter
Preparation and Preprocedure Evaluation
Prior to setup, anatomic landmarks should be assessed by ultrasound. First note the location of the target vein and its corresponding artery. Veins will appear to have thin walls versus the thicker walled and pulsatile artery. Note that the artery should not be easily compressible, while the vein should compress with gentle probe pressure. The use of color Doppler may also demonstrate the pulsatile flow of the artery and the steady flow of the vein. Scan up and down to visualize the course of the vein, while also taking note of surrounding structures. It is important to identify surrounding vessels, nerves, lymphatics, or evidence of lung tissue as these structures should be avoided while placing the line.
There are two ways that ultrasound can be utilized to guide the placement of CVCs. The static approach describes when ultrasound is used to confirm the location of the target vein and its trajectory and to assess the surrounding anatomy, but is not used during the procedure itself. The site of needle insertion over the vein must be marked on the skin prior to sterilization. The dynamic approach is when ultrasound is used to provide real-time visualization during needle insertion and help guide needle advancement into the target vessel. It has been found that the static approach has superior first-attempt success rates than the landmark technique (also known as the “blind” technique) alone. It can be done quickly if the practitioner is unable to place the line with the ultrasound probe remaining stable or if a sterile cover is not available. However, the same study found the dynamic approach to be superior to both static and landmark techniques [4]. The dynamic approach is strongly recommended as there is potential for the alignment and orientation of vessels to change with movement (particularly for the internal jugular vein with head and neck movements).
After scanning the vessel, the room should be set up appropriately with ultrasound machine and equipment in locations that permit the operator to easily access equipment and visualize the screen. The patient should be prepared and draped in normal sterile fashion. Clean the patient’s skin with chlorhexidine gluconate or a comparable antiseptic solution. The operator should gown and then drape the patient. It is important to have an assistant to aid the operator in handling equipment and the ultrasound probe.
All equipment should be inventoried and inspected prior to starting the procedure. When using a multilumen CVC, the lumens should be instilled with normal saline to assess for integrity and/or malfunction.
Procedure
Advantages and disadvantages of the in-plane, out-of-plane, and oblique needle visualization techniques for dynamic ultrasound-guided central venous catheter placement
Advantages | Disadvantages | |
---|---|---|
In-plane | Constant needle tip and vessel visualization without any need to move the probe | Potential for cylinder tangential effect May be difficult to keep the vessel and needle within the plane of the beam Cannot see adjacent structures |
Out-of-plane | Able to simultaneously view the vessel, and surrounding structures | The probe must be moved with the needle tip to keep it in view Loss of needle tip visualization can result in complications |
Oblique | Hybrid approach allowing partial view of vessel and surrounding anatomy with constant needle visualization | May be conceptually more difficult Potential for needle to travel out of plane |
Out-of-Plane Approach
An advantage of the out-of-plane approach is it allows for simultaneous visualization of the vessel and surrounding structures (artery, nerves, etc.). A common drawback is for the operator to mistake the shaft of the needle for the needle tip, which can result in advancing the needle too far and potentially puncturing the posterior wall of the vein or other nearby structures.