Internal Jugular Vein—Central Venous Access

imagesEmergency venous access for fluid resuscitation and drug infusion

imagesInfusions requiring central venous administration (vasopressors, hyperosmolar solutions, hyperalimentation)

imagesCentral venous pressure and oxygen monitoring

imagesRoutine venous access due to inadequate peripheral IV sites

imagesIntroduction of pulmonary artery catheter

imagesIntroduction of transvenous pacing wire


imagesNo absolute contraindications

imagesRelative Contraindications

   imagesCoagulopathic patients (femoral approach preferred)

   imagesCombative or uncooperative patients

   imagesOverlying infection, burn, or skin damage at puncture site

   imagesTrauma at the cannulation site

   imagesPenetrating trauma with suspected proximal vascular injury

   imagesSuspected cervical spine fracture


imagesPain (local anesthesia will be given)

imagesLocal bleeding and hematoma

imagesInfection (sterile technique will be utilized)

imagesPneumothorax or hemothorax and the need for thoracostomy tube

imagesGeneral Basic Steps

   imagesPreprocedure ultrasound (if using ultrasound guidance)

   imagesVessel localization



   imagesSeldinger technique


   imagesCatheter insertion


   imagesFlush and secure


Site of insertion is the apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle. This point is lateral to the carotid pulse. The needle is pointed toward the ipsilateral nipple (FIGURE 23.1).


FIGURE 23.1 Landmarks for internal jugular vein central venous catheter placement.


Real-time ultrasound-guided internal jugular vein (IJV) catheterization has been shown to:

imagesIncrease success rates

imagesDecrease the number of attempts

imagesDecrease skin to blood flash time

imagesDecrease complications

imagesHelp achieve successful cannulation when landmark attempts have failed

The use of ultrasound to guide the procedure also allows detection of anatomical variants:

imagesCarotid artery (CA) directly below the IJV instead of lateral

imagesSmall IJV diameter

imagesNoncompressible IJV, indicating the presence of thrombus

If ultrasound is available for use, placement of the IJV catheter using ultrasound guidance is highly recommended.


imagesCentral Venous Catheter (CVC) Kit

   imagesDrapes, chlorhexidine prep (2), gauze

   imagesCatheter (multiport, cordis, or hemodialysis)

   imagesGuidewire within plastic sheath

   imagesLidocaine, anesthesia syringe, and a small-gauge needle

   imagesThree-inch introducer needle and syringe




imagesSterile gloves, sterile gown, sterile cap, eye protection, and mask

imagesSterile drapes

imagesSterile saline flushes

imagesSterile port caps

imagesUltrasound machine (optional)

imagesSterile ultrasound probe cover with sterile ultrasound gel (optional)


imagesPatient Preparation

   imagesCardiac monitoring to detect dysrhythmias triggered by the wire being advanced into the right ventricle

   imagesSupplemental oxygen and continuous pulse oximetry monitoring

   imagesRotate the patient’s head 30 to 45 degrees away from the side of cannulation

   imagesLower the head of the bed to 15 to 30 degrees in Trendelenburg position

   imagesIf using ultrasound guidance, evaluate the right and left IJVs for ideal size and position

   imagesSterilize the neck and clavicle area with chlorhexidine or povidone–iodine solution

   imagesWear surgical cap, eye protection, mask, sterile gown and gloves

   imagesDrape with sterile sheets to cover the patient’s head and legs

   imagesIf using ultrasound guidance, have an assistant place the probe (with gel applied) inside the sterile probe sheath

Note: Unless immediate emergent access is warranted, the physicians attempting the procedure must wear cap, eye shields, and mask, along with sterile gown and gloves.

imagesVessel Localization

   imagesIf attempting localization of right IJV, use the right hand to hold the syringe and introducer needle. With the left hand, palpate the CA to avoid arterial puncture while guiding needle insertion. If attempting the left IJV, reverse hands.


   imagesUse a small-gauge needle to anesthetize skin and subcutaneous tissue with 1% lidocaine


   imagesUsing the above landmarks, insert the introducer needle at 30- to 60-degree angle to the skin just lateral to the apex of the triangle just lateral to the carotid pulse (Figure 23.1)

   imagesApply negative pressure to the syringe plunger while advancing the needle 3 to 5 cm or until a flash of blood is seen in the syringe

   imagesIf no flash is obtained, withdraw the needle slowly while continuing to aspirate

   imagesIf redirecting the needle, always withdraw the needle to the level of skin before advancing again

   imagesOnce the needle enters the vessel, blood will flow freely into the syringe

   imagesStabilize and hold the introducer needle with the nondominant hand

   imagesRemove the syringe and ensure that venous blood continues to flow easily

   imagesUse a finger to occlude the needle hub to prevent air embolism

imagesSeldinger Technique

   imagesAdvance the guidewire through the introducer needle. The wire should pass easily. Do not force the guidewire.

   imagesIf resistance is met, withdraw the wire and rotate it, adjust the angle of needle entry, or remove the wire and reaspirate with the syringe to ensure the needle is still in the vessel.

   imagesWhen at least half of the guidewire is advanced through the needle, remove the needle over the wire. Keep one hand holding the wire at all times. Never let go of the guidewire.

   imagesMake a superficial skin incision with the bevel of the scalpel blade angled away from wire

   imagesEnsure the incision is large enough to allow easy passage of the dilator


   imagesThread the dilator over the guidewire, always holding onto the wire

   imagesWhile holding the guidewire with the nondominant hand, advance the dilator through the skin into the vessel with a firm, twisting motion

   imagesRemove the dilator, leaving the guidewire in place

imagesCatheter Insertion

   imagesThread the catheter over the wire and retract the wire until it emerges from the catheter’s port

   imagesWhile holding the guidewire, advance the catheter through the skin into the vessel to the desired depth. Optimal depth depends on patient size and is typically 12 to 18 cm for the right IJV and 15 to 20 cm for the left IJV.

   imagesWithdraw the guidewire through the catheter

   imagesUse a syringe to aspirate blood from the catheter to confirm placement in the vein



   imagesBlood gas analysis

   imagesSonographic confirmation of the catheter in the vein

   imagesPost procedure chest x-ray (CXR)

      imagesConfirm the catheter tip in the superior vena cava just proximal to the right atrium

      imagesRule out pneumothorax

imagesFlush and Secure

   imagesAspirate, flush, and heplock each central line lumen

   imagesSuture the catheter to the skin using silk or nylon sutures

   imagesCover the skin insertion site with a sterile dressing (bacteriostatic if available)

imagesUltrasound-guided Technique

   imagesUse a high-frequency linear probe (5–10 MHz)

   imagesProbe marker on the ultrasound probe should point toward the operator’s left so that it corresponds with the marker on left side of the ultrasound screen (FIGURE 23.2)

   imagesIdentify the IJV and CA (FIGURE 23.3)


FIGURE 23.2 Correct positioning of the ultrasound machine in line with the operator’s sight and procedure site with the probe marker facing the operator’s left. (Image courtesy of Mount Sinai Emergency Medicine site,

Only gold members can continue reading. Log In or Register to continue

Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Internal Jugular Vein—Central Venous Access
Premium Wordpress Themes by UFO Themes