Emergency venous access for fluid resuscitation and drug infusion

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

 Central venous pressure and oxygen monitoring

 Routine venous access due to inadequate peripheral IV sites

 Introduction of pulmonary artery catheter

 Introduction of transvenous pacing wire

CONTRAINDICATIONS

 No absolute contraindications

 Relative Contraindications

    Coagulopathic patients (femoral approach preferred)

    Combative or uncooperative patients

    Overlying infection, burn, or skin damage at puncture site

    Trauma at the cannulation site

    Penetrating trauma with suspected proximal vascular injury

    Suspected cervical spine fracture

RISKS/CONSENT ISSUES

 Pain (local anesthesia will be given)

 Local bleeding and hematoma

 Infection (sterile technique will be utilized)

 Pneumothorax or hemothorax and the need for thoracostomy tube

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).

ULTRASOUND-GUIDED TECHNIQUE

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

 Increase success rates

 Decrease the number of attempts

 Decrease skin to blood flash time

 Decrease complications

 Help achieve successful cannulation when landmark attempts have failed

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

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

 Small IJV diameter

 Noncompressible IJV, indicating the presence of thrombus

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

SUPPLIES

 Central Venous Catheter (CVC) Kit

    Drapes, chlorhexidine prep (2), gauze

    Catheter (multiport, cordis, or hemodialysis)

    Guidewire within plastic sheath

    Lidocaine, anesthesia syringe, and a small-gauge needle

    Three-inch introducer needle and syringe

    Dilator

    Scalpel

    Suture

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

 Sterile drapes

 Sterile saline flushes

 Sterile port caps

 Ultrasound machine (optional)

 Sterile ultrasound probe cover with sterile ultrasound gel (optional)

TECHNIQUE

 Patient Preparation

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

    Supplemental oxygen and continuous pulse oximetry monitoring

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

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

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

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

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

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

    If 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.

 Vessel Localization

    If 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.

 Analgesia

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

 Insertion

    Using 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)

    Apply 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

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

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

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

    Stabilize and hold the introducer needle with the nondominant hand

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

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

 Seldinger Technique

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

    If 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.

    When 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.

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

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

 Dilation

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

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

    Remove the dilator, leaving the guidewire in place

 Catheter Insertion

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

    While 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.

    Withdraw the guidewire through the catheter

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

 Confirmation

    Manometry

    Blood gas analysis

    Sonographic confirmation of the catheter in the vein

    Post procedure chest x-ray (CXR)

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

       Rule out pneumothorax

 Flush and Secure

    Aspirate, flush, and heplock each central line lumen

    Suture the catheter to the skin using silk or nylon sutures

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

 Ultrasound-guided Technique

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

    Probe 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)

    Identify the IJV and CA (FIGURE 23.3)

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