Download Central Venus Line Placement: Internal Jugular Vein Access Kevin

Central Venus Line Placement: Internal Jugular Vein Access
Kevin Ergle, MD; Rohit Patel, MD
Keywords: central venous line, hypotension, heart failure, sepsis, internal jugular central venous line
Indications:
• Volume replacement
• Emergent venous access
• Administration of caustic medications: vasopressors, calcium chloride, hypertonic saline, high dose of
potassium
• Central venous pressure monitoring
• Transvenous pacing wire introduction
• Dialysis catheter placement (hemodialysis)
• Pulmonary artery catheterization
• Nutritional support (TPN)
• Long term antibiotics
• Chemotherapy
• Plasmapheresis
• Frequent or persistent blood draws or intravenous therapy when unable to establish peripheral access due to
edema or other causes
Contraindications:
Absolute:
• Infection at site of insertion
• Distorted anatomy/landmarks (prior surgery, radiation, or history of thrombus in the specified vein)
Relative:
• Morbid obesity
• Agitated or moving patient
• COPD
• Inability to tolerate potential pneumothorax of the ipsilateral thoracic cage
• Pneumothorax or Hemothorax of the contralateral thorax
• Patients receiving ventilatory support with high end expiratory pressures (temporarily reduce the pressures)
• Children less than 2 years (higher complication rates)
• Coagulopathy (although ultrasound guided internal jugular can be done in this situation)
• Trauma to the ipsilateral clavicle, anterior proximal rib, subclavian or superior vena cava vessels
Materials and Medications (some of these items may be located in tray or bundle):
• Central Venous Catheter tray or bundle (single/double/triple/quad lumen, dialysis catheter, large bore
introducer (for transvenous pacing or pulmonary artery catheter kit)
• Sterile gloves
• Sterile drapes or towels
• Sterile gown
• Hat/hair cap and mask with eye protection
• Antiseptic solution with skin swabs (ie chlorhexidine)
•
•
•
•
•
•
•
•
•
Sterile saline flushes (30ml or x3 10ml syringes)
Lidocaine 1%
Sterile gauze
No. 11 blade scalpel
Dressing (sterile waterproof transparent dressing or sterile 4x4 gauze with tape)
Sterile biopatch
Suture material with needle driver if needed
Transducing line (optional)
Sterile probe cover (if using ultrasound guidance)
Internal jugular vein access:
Procedure:
1. Obtain informed consent if not emergently indicated procedure.
2. Obtain supplies and prepare the room, ensuring that all supplies are within operator reach, prior to placing
gown and commencing the procedure. Include a sterile ultrasound sheath on the sterile field if ultrasound is
being used.
3. Raise bed to a comfortable height for the operator.
4. Place patient with head facing away from side of central line site (if using ultrasound, other positions may
be more optimal). Place patient in 15-20º Trendelenburg position, as this helps with filling the upper central
veins and reduces the risk of air embolism.
5. Identify the anatomy. Palpate triangle made by the clavicle and sternal and clavicular heads of the
sternocleidomastoid muscle to identify the location for the internal jugular vein. If using ultrasound
guidance, identify optimal anatomical arrangement (see Figure 1)
6. Wash your hands and wear sterile gloves.
7. Prepare the site from clavicle to the ear and across the trachea with antiseptic solution. Make sure to allow
the antiseptic (chlorhexidine or iodine) to fully dry.
8. Wear sterile attire using aseptic technique, including cap, mask, gown, and sterile gloves.
9. Drape the site and patient with sterile towels and drapes included in most CVL bundles. Make sure to cover
the whole area and bed.
10. Cover the ultrasound probe with a sterile sheath. This can be done solo or by holding the sterile ultrasound
sheath and having an unsterile assistant hold the probe so that the probe can be covered by the sheath.
11. Prepare the kit by checking the guidewire and flushing the tubing and lines with saline included in the kit.
12. With a 25-gauge needle, use 1% lidocaine to anesthetize the skin at the apex of the triangle made by the
SCM and clavicle. Aspirate to make sure the operator is not in a vessel and make a superficial wheel for the
insertion site.
13. Preferred method is with ultrasound guidance (steps 15-18, and see below for more technical description of
ultrasound guidance), but if performing without ultrasound, palpate the carotid artery and insert needle
lateral to the artery at the apex of the triangle formed by the SCM, aiming toward the ipsilateral nipple at an
angle 30-45 degrees above the horizontal plane (see Figure 1). Once blood returned go to step 19.
14. Place sterile ultrasound gel over the insertion site. Use the ultrasound to identify vessel anatomy including
internal jugular vein and carotid artery. Use the ultrasound probe to compress the vein, which is
compressible as opposed to the carotid artery which is not compressible (see Figure 2)
15. Prepare the insertion needle and syringe (if long and short needles are available, a short needle may be used
to reduce posterior vein perforation) and prime the syringe by pulling back on the plunger prior to making
the puncture.
16. Use the ultrasound probe to re-identify the patient’s anatomy.
17. Ultrasound can be used in short axis or long axis (see Figure 3). Short axis is usually easier for novice
operators due to the ability to see the artery and vein but has higher risk of posterior perforation especially if
the needle tip is not visualized well. Once short axis of the vein is found, turning the probe 90 degrees
clockwise will allow you to see the vein in long axis. The needle is better visualized in this view but
technically more difficult, and has less chance to penetrate the posterior wall. Also some patients with short
necks may be difficult to obtain long axis view and needle insertion in the limited space.
18. Insert the needle using the ultrasound guidance (see ultrasound section below for specifics). Make sure to
aspirate while inserting the needle to identify when the venous access is obtained.
If using the static approach (read in ultrasound section below), insert needle lateral to carotid pulsation
as this is where the vein anatomically is located.
If inserting the needle ~3cm does not achieve access, gently withdraw the needle towards the surface of
the skin while aspirating. Avoid withdrawal of the needle completely from the skin and if needed, redirect the needle and advance until blood is aspirated. Cannulation of the vein often takes place while
withdrawing the needle.
19. Hold the needle steady with your non-dominant hand and remove the syringe, careful not to advance or
withdraw the needle. You can place the base of your hand on the patient’s chest to make your hand more
stable during this part of the procedure. Occlude the hub of the needle to prevent air embolus.
20. You may verify that you are in the vein by transducing pressure with a fluid column. The fluid should flow
easily into the vein.
If the aspirated blood is pulsatile and moves up the column withdraw the needle completely and apply
pressure for 10-20 minutes while taking the patient out of Trendelenburg position (if non-emergent
procedure).
21. Once it is verified that you are in the vein, insert the J tip of the guidewire into the needle hub and advance
into the vein. The J-tip can be straightened with a pinching motion (see Figure 6). Always keep one hand on
the guidewire until it is removed from the patient. Monitor for arrhythmias as the guidewire is advanced
towards the right atrium.
If the guidewire does not flow easily, remove the guidewire and re-attach the syringe, checking for
blood flow.
If arrhythmia occurs, slowly withdraw the guidewire until the patients native rhythm returns.
Alternatively, one can use the catheter/syringe found in most kits to use as a bridge to guidewire
placement. For the author this has improved success when there is difficulty in wire placement. Use the
same steps above with the catheter (see Figure 4) and when you have return of blood advance the
angiocath into the vein followed by insertion of the guidewire through the angiocath. This is especially
useful in moving/agitated patients, patients who have collapsible veins due to hypovolema, and patients
who have abnormal anatomy and may have veins that take an abnormal angle shortly past the needle tip.
22. Remove the needle over the guidewire, making sure to always keep control of the guidewire. You can also
leave the needle in place and proceed to step 23 before taking the needle out.
23. Make an incision contiguous with the guidewire using a straight (No. 11) blade with the scalpel blade facing
upward (away from the wire).
24. Advance the dilator over the guidewire in a twisting motion, keeping control of the guidewire.
The dilator only needs to go slightly beyond the anticipated depth of the patient’s jugular vein. Do not
advance the entire length of the dilator.
25. Withdraw the dilator and hold pressure over the wound site.
26. Advance the catheter over the guidewire while keeping control of the guidewire.
27. With the catheter inserted 10-12 inches from the skin insertion site, retract the guidewire until it comes out
of the distal port. Maintain control of the guidewire and advance the catheter to the appropriate length.
Usually catheters are inserted 15-16 cm from the right side and 18-20 cm from the left side (see Figure 5)
28. Flush each port of the catheter and check aspiration. If difficulty with aspiration or flushing, then concern is
raised for catheter malposition. You can change the depth slightly or twist the catheter and recheck.
29. At this time an antibiotic ointment or biopatch may be applied to skin around the intersection with the lumen
of the catheter. This step is based on local institutional guidelines.
30. Suture the line in place.
31. Enclose central venous line site with sterile waterproof transparent dressing.
32. Chest X-ray: Confirm placement using CXR. The tip of the catheter should be in the lower third of the SVC
at the insertion of the SVC into the right atrium.
Complications:
1. Pneumothroax/Hemothorax:
• Prevention: Remove patient from ventilator before advancing the needle, choose the right side rather than
left, avoid multiple attempts when possible.
• Management: Check postprocedure x-ray, if pneumothorax, arrange for thoracostomy depending on the
size of the hemo/pneumothorax
2. Catheter embolization:
• Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter.
• Management: x-ray the patient and contact specialist who can remove the embolized catheter
3. Arterial puncture: hold compression if this occurs
4. Hematoma: usually requires monitoring only
5. Thrombosis: this complication may lead to pulmonary embolism
6. Local site or systemic infection: using maximal sterile precautions has been shown to greatly decrease rate
of infection
7. Air embolism: may be caused by negative intrathoracic pressure, with inspiration by the patient drawing air
into an open line hub. Be sure the line hubs are always occluded. Placing the patient in the Trendelenburg
position lowers the risk of this complication. If air embolism occurs, the patient should be placed in
Trendelenburg position with a left lateral decubitus tilt, which may prevent the movement of air into the right
ventricle and onward into the left side of the heart. One hundred percent oxygen should be administered to
speed the resorption of the air. If a catheter is located in the heart, aspiration of the air should be attempted
8. Dysrhythmias: due to cardiac irritation by the wire or catheter tip. This can usually be terminated by simply
withdrawing the line into the superior vena cava. One should always place a central venous catheter with
cardiac monitoring.
9. Lost guide wire. If the operator is not careful about maintaining control of the guide wire, it may be lost into
the vein. This requires retrieval by interventional radiology or surgery and is an emergency.
10. Catheter tip too deep. Check the postprocedure chest xray for this complication, and pull the line back if
the tip disappears into the cardiac silhouette
11. Catheter in the wrong vessel. Check the postprocedure chest xray for this complication; Remove catheter
and try again.
Ultrasound guided cannulation (general tips for each approach)
·
·
Venous anatomy is best visualized using high frequency (5-10 MHz) linear probe. Higher frequencies
generate less penetration but better resolution.
You can use the ultrasound to identify the location of the vessel prior to the procedure and utilize external
landmarks during the procedure itself (static technique), or you can use the ultrasound to visualize
cannulation of the vessel during the procedure (dynamic technique).
·
·
·
·
·
·
·
Static view is advantageous is that the ultrasound transducer is not needed during the sterile portion of the
procedure, but it does not allow for direct visualization of cannulation and guidance during the procedure.
Dynamic view (preferred) allows for direct visualization during the procedure, but requires more technique
and requires use of transducer during the sterile portion of the procedure.
The dynamic technique can be used in either a short axis view, where a cross sectional view of the vessel
and needle is used, or a long axis view, where a longitudinal view of vessel and needle is used (see Figure
3).
The long axis view allows for full visualization of the needle throughout the procedure and allows for better
visualization and adjustment of needle depth. It is more difficult for lateral changes in positioning and tends
to be technically more difficult.
Key in this view is that once a good section of vein is obtained, do not move probe to visualize the
needle, move the needle into the ultrasound view by slightly adjusting trajectory.
The short axis view allows for lateral changes in position but is not as good at visualizing depth throughout
the procedure, as visualization of the needle is in cross-sectional imaging. Perforation of the posterior wall
is more common in this view.
When using the short axis view, remember to position the ultrasound probe such that the field of the
ultrasound intersects the vessel (IJ, femoral, subclavian) at the anticipated site of insertion of the needle into
the vein. Remember that the needle is only visualized as it intersects the plane of the ultrasound.
When using the long axis view, make sure to visualize the vessel with the ultrasound such that you can see
the greatest diameter of the vessel along the entire length of the ultrasound probe. Keep the ultrasound
steady during the procedure and insert the needle at an angle at the lateral edge of the ultrasound probe.
Using this technique, one can visualize the entire length of the needle
Removing a Central Line:
1. Place patient in supine or Trendelenburg position.
2. Remove suturing and dressing.
3. Have patient exhale and pull the line during the exhalation.
Exhalation increases intrathoracic pressure as compared to atmospheric pressure, thereby
reducing the risk of air thromboembolism.
4. Hold pressure for approximately one minute to stop bleeding.
5. Dress with a sterile dressing.
6. If central line-related infection is suspected, cut off the tip with sterile scissors and send for culture.
References
Internal Jugular
1. Noble, V., et al. Manual of Emergency and Critical Care Ultrasound. Cambridge University Press. 2007.
Pages 196-204.
2. Parry, G. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein
diameter. Can J Anaesth. 2004;51(4):379.
3. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. Mar 20
2003;348(12):1123-33.
4. Mimoz, O., et al. Chlorhexidine-based antiseptic solution vs alcohol-based providone-iodine for central
venous catheter care. Arch Intern Med. 2007 Oct 22;167(19):2066-72.
5. Vesely, T. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol.
2003;14(5):527.
Figure 1: Internal jugular blind approach. This would be the same location for probe placement if doing
ultrasound guided.
Figure 2: Ultrasound showing vein and artery with and without compression
Figure 3: Long and Short axis views of the internal jugular vein
Figure 4: Angiocath that can be used in difficult to cannulate/wire patients
Figure 5: Length: marking seen on typical central venous catheters, number indicates in centimeters
from distal tip
Figure 6: J tip straightening using the pinching motion