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


CONTRAINDICATIONS



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


RISKS/CONSENT ISSUES



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


   imagesAnalgesia


   imagesInsertion


   imagesSeldinger technique


   imagesDilation


   imagesCatheter insertion


   imagesConfirmation


   imagesFlush and secure


LANDMARK TECHNIQUE



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).



images


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


ULTRASOUND-GUIDED TECHNIQUE



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.


SUPPLIES



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


   imagesDilator


   imagesScalpel


   imagesSuture


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)


TECHNIQUE



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.


imagesAnalgesia


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


imagesInsertion


   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


imagesDilation


   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


imagesConfirmation


   imagesManometry


   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)



images


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, sinaiem.us/tutorials/peripheral-iv-access)

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