ultrasound guided internal jugular central venous catheter insertion

IJ vein landmarks

1. Position patient in trendelenburg position (head angled down toward floor)
   1. Lower risk of air embolism
   2. Engorges vessels and allows for easier visualization
2. Preparation of the catheter
   1. Flush all three central venous catheter lumens with Normal Saline
   2. Flushing lines is preferred to aspirating as low volume may result in line collapse on aspiration
3. Preparation of skin
   1. Perform Ultrasound machine preparation and pre-scanning as above
   2. Position head extended and turned away from the insertion site
   3. Apply hibiclens to a wide area over the anterior-lateral neck
   4. Drape the neck to shield all but the prepped skin
4. Local anesthetic
   1. Clear any air bubbles in a syringe of Lidocaine 1% without Epinephrine
      1. Air bubbles will markedly decrease quality of Ultrasound image
   2. Inject Lidocaine 1% without Epinephrine at the entry site
      1. Raise a skin wheal at insertion site
      2. Infiltrate along expected needle insertion tract
         1. Aspirate prior to injecting to prevent intravascular injection
5. Needle insertion site
   1. Use Ultrasound localization technique described above
   2. Insertion site
      1. Insertion site will be lateral to palpated carotid pulsation
      2. Approximately at top of triangle formed by sternocleidomastoid muscles bodies and clavicle
      3. Caution
         1. Internal Jugular Vein positioning is variable
         2. Ultrasound guidance is far preferred as landmarks are unreliable
         3. Avoid inserting needle through the sternocleidomastoid muscle (hematoma risk)
      4. Landmark triangle (insertion is at the apex of triangle, where two bodies of SCM meet)
         1. Anterior sternocleidomastoid muscle (SCM) body
         2. Posterior sternocleidomastoid muscle (SCM) body
         3. Clavicle (base of triangle)
      5. Landmarks by finger breadths
         1. Three fingers lateral to midline trachea
         2. Three fingers superior to clavicle (approximate level of cricoid ring)
   3. Needle insertion
      1. Needle types (either is attached to a 10 cc syringe)
         1. Steel Needle 18g (standard, more rigid)
         2. Angiocatheter 18g - long (alternative to steel needle)
            1. Angiocatheter (18 gauge) is typically included in the Central Line kit
            2. Once in lumen, remove needle and thread wire through catheter
            3. May be easier to maintain catheter within vessel lumen while threading guide wire
            4. In large patients, angiocatheter may be too short to access the vessel lumen
      2. Needle is directed toward nipple on side of insertion
      3. Insert needle at 45 degrees to the skin plane (when using Ultrasound guidance)
         1. Landmark insertion (without Ultrasound) is typically at a 30 degree angle to the skin plane
      4. Advance needle as described above under technique of Ultrasound-guided needle insertion
         1. Internal jugular is typically superficial (2-3 cm depth from skin surface)
         2. Aspirate while inserting needle
         3. Advance the needle another 0.5 cm past the time blood is first aspirated (to ensure in lumen)
6. Guide-wire insertion
   1. Remove syringe from needle
   2. Occlude the open needle base to prevent bleeding and air embolism
   3. Insert guidewire
      1. Some recommend observing guidewire enter vessel on Ultrasound
   4. Typically insert guidewire until free end is approximately at the level of the patient's head
      1. Withdraw guidewire a short distance if ectopy seen on telemetry monitor
7. Withdraw needle
   1. Firmly grasp guide wire
   2. Back out over the wire
   3. Adjust grasp on wire to be at skin entry site once needle is withdrawn
8. Make skin nick
   1. Nick skin with #11 blade along the edge of the wire insertion site
   2. Confirm that the nick is contiguous with the space the wire lies within
9. Dilator insertion
   1. Insert dilator over the wire and into the skin
      1. Do not fully insert dilator
      2. Only insert dilator far enough to dilate skin and soft tissue, but not vessel
   2. Twist the dilator to assist in advancing past resistance
   3. Withdraw the dilator
10. Central catheter insertion
    1. Always have hold of guidewire throughout this process
    2. Insert catheter over the guide wire via the longest, most distal port (remove brown cap)
       1. As catheter approaches skin, if guidewire does not emerge through port
          1. Withdraw the guidewire from skin until it emerges via port
       2. Grasp the guidewire at the distal port prior to letting go of guidewire at skin
    3. Advance catheter through skin to estimated depth
       1. Err on the side of caution by inserting further than estimate (e.g. 15 cm right, 20 cm left)
          1. Line may be withdrawn if inserted too far
          2. Line may not be inserted deeper after initial placement
             1. Deeper insertion requires replacement of line over another guidewire
       2. Typical final insertion depths (as above, insert further than these depths initially)
          1. Right side: Men 12-13 cm, Women: 11-12 cm
          2. Left side: Add 5 cm to right side length
    4. Remove guidewire
    5. Flush all 3 lines (all three lines should have been filled with saline in preparation)
11. Confirm catheter placement
    1. Secure Central Line
    2. Portable Chest XRay
       1. Central Line tip should be at superior vena cava junction with right atrium
       2. Approximate tip position is 2 cm below the superior right heart sillhouette
       3. Tip will be 4-5 cm below the carina, just below the hilum
    3. Adjust Central Line based on Chest XRay (may withdraw, but may not insert further due to infection risk)
    4. Suture the Central Line in place