W19 Jugular Venous and Brain Tissue Oxygen Tension Monitoring
Ultrasound-Guided Internal Jugular Vein Oxygen Saturation (Sjvo2) Catheter Placement: Before Procedure
Anatomy
Procedure
• Place the patient in Trendelenburg position to increase jugular filling and reduce possibility of air embolism.
• Perform an ultrasound survey to assess the location and patency of the jugular vein and to determine whether one side has dominant flow. Catheter placement is easier, and continuous oxygen saturation measurements will usually be better on the side with the greatest blood flow.
• The common carotid artery and the internal jugular vein should be easily identifiable. You will see the common carotid artery as a pulsating image, and it will be difficult to compress. The internal jugular vein is larger, easily compressible, and nonpulsating. Make sure the internal jugular vein is patent by gently compressing the vein with the transducer; slight pressure is sufficient to collapse the lumen of the internal jugular vein. Placing the transducer in a cross-sectional position during the ultrasound examination facilitates interpretation of the resulting images. Many probes have a marker on one side that corresponds to the same side of the image on the screen. This helps the operator identify the correct orientation of the image.
• Prepare skin using chlorhexidine-based antiseptic, and cover the area with a sterile fenestrated drape.
• To prepare the ultrasound probe, have the assistant dispense enough acoustic nonsterile gel into a sterile transducer sheath to cover the transducer surface inside the sheath.
• Have the assistant carefully feed the probe into the sheath and through the gel while extending the sterile sheath away from you over the length of the probe wire. Eliminate any wrinkles in the sheath and any air bubbles between the transducer and sheath. Place the rubber bands to secure the cover sheath in place. To complete acoustic coupling, apply a small amount of sterile ultrasound gel to the covered ultrasound probe or the patient’s skin.
• Position the transducer perpendicular to the skin so that the internal jugular vein is centered in the resulting ultrasound image and between the two heads of the sternocleidomastoid muscle. The ultrasound probe should be held in your nondominant hand.
• Gently palpate the skin to confirm that the puncture will be between the muscle heads and not through one of the heads.
• Using an 18-gauge needle, puncture the skin just below the transducer, being careful not to damage the sterile sheath.
• Slowly advance the needle at a 45-degree angle in an upward direction while watching the ultrasound screen. As you advance the needle, maintain negative pressure in the syringe until the vein is punctured. The needle will appear as a hyperechogenic shadow.
• If you do not aspirate blood as the needle is advanced, slowly withdraw the needle while maintaining negative pressure. Venous puncture may become evident as you withdraw the needle. Occasionally, pressure from the ultrasound probe may compress the vein, making it difficult to enter the vessel.
• As soon as the blood is freely aspirated, place the probe in the predetermined sterile area, stabilize the needle, and disconnect the syringe.
Introducer Insertion
• Using the Seldinger technique, introduce a flexible guidewire through the needle and into the internal jugular vein. Direct the guidewire in an upward direction toward the jugular bulb.
• While holding the guidewire in place, remove the needle. The guidewire can be visualized in both cross-sectional and longitudinal views within the lumen of the internal jugular vein in the ultrasound screen.
• Thread the guidewire thorough the distal opening of the dilator until it exits through the proximal end of the dilator.
• Confirm that it has reached the proximal end of the dilator, hold the wire in place, and advance the dilator through the skin and into the vessel.
• Hold the proximal end of the guidewire at all times when advancing the dilator or catheter. This avoids complications from unintended advancement of the guidewire.
Opticath Intravascular Catheter Insertion
• Pass the optical connector to the assistant, who will connect it to the optical module and proceed with the preinsertion calibration. PLEASE NOTE that only after verifying with your assistant that the preinsertion calibration was successful should you proceed to the next step. Failure to do so will result in inaccurate readings.
• After successful preinsertion calibration, the oximetry system is now ready for use. Prepare for catheter insertion.
• Grasp catheter near the entrance of the black reference assembly and gently pull straight out. Care should be taken in removing the catheter, as the fiberoptics may be damaged if the catheter is withdrawn improperly.
• The catheter should then be advanced until resistance is felt; this distance is usually about 13 to 15 cm and indicates positioning in the jugular bulb.
• The catheter is then pulled back 0.5 to 1 cm to minimize cephalic vascular impact with head movement.
• When the catheter is in position and blood is flowing, the system will immediately provide SO2 readings.
• Verify the position of the catheter tip, and secure the catheter to the patient. The optical module should be secured to the patient or in close proximity to avoid strain or tension on the catheter.
After Procedure
Postprocedure Care
• Lateral cervical spine x-ray should be used to confirm adequate catheter tip placement, which should be above the C1-C2 level in order to minimize contamination with blood coming from the facial vein.
• The Opticath intravascular catheter is removed by a physician. It is generally removed when ICP has been normal for 24 hours without specific treatment.
Outcomes and Evidence
