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Emergency Medicine and Critical Care

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Central Venous Catheter Insertion: Internal Jugular

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The placement of a central venous catheter, or CVC, is an invasive technique necessary in a multitude of clinical situations including vascular access, central venous pressure monitoring, and hemodialysis; and internal jugular, or IJ vein is one of the frequently used sites for this procedure.

To perform this procedure successfully, it is imperative to understand the anatomical relationship between the internal jugular vein and the carotid artery and their appearance on ultrasound. It is also necessary to develop the psychomotor skills to perform vessel cannulation under ultrasound guidance.

In this video, we will first briefly review the Seldinger technique, which is used in all the CVC placement procedures. Then, we will demonstrate the IJ CVC placement method using anatomical illustrations and animations, AND ultrasound clips, to provide an in-depth understanding of this procedure.

This technique of introducing a device into the body was first presented back in 1953 by Dr. Sven-Ivar Seldinger, a Swedish radiologist in his publication in the journal Acta Radiologica.

To perform this technique, you need a thin walled introducer needle, a guidewire, a dilator and a catheter. First, the target vessel is cannulated with the thin walled introducer needle. A guide wire is then passed through the needle until it is appropriately positioned within the vessel. Then the needle is removed and a dilator is passed over the wire to dilate the skin and soft tissue to the level of the vessel. Next, the dilator is removed and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, after confirming that the catheter is in the vessel, the guide wire is removed and the catheter is secured in place to provide access to the target vessel.

The first step is to gather the necessary supplies including: a CVC kit, sterile gloves and a sterile bundle that contains mask, bonnet, gown, full body drape, sterile ultrasound probe cover and sterile ultrasound gel, and sterile syringes with sterile saline. Most commercially available CVC kits contain: a catheter, a J-tip guide wire, a dilator, a #11 scalpel, an introducer needle, 1% Lidocaine, several syringes and smaller needles, a suture needle with suture, a CVC clamp, sterile dressing, gauze, and chlorhexidine. The contents of the kit are enclosed in a sterile tray wrapped with a sterile cover.

With the supplies in place, position the patient supine with their feet elevated - the Trendelenburg position. This positioning helps prevent an air embolus and also allows for maximal engorgement of the target vessel. The right IJ is most commonly utilized because the straight route to the Superior Vena Cava makes malposition of the catheter less likely. Stand at the head of the bed, facing the patient's feet and rotate the patient's head away from the target vessel. Identify the anatomical landmarks to help localize the cervical vasculature. The two heads of the sternocleidomastoid (Ster-no-CLY-do-mastoid) muscle muscle and the clavicle form a triangle, through which the IJ passes. The carotid artery lies medial and deep to the IJ vein.

Next, apply acoustic gel to the linear transducer probe, and place it in the triangle with the indicator on the transducer oriented to the patient's left side. This is the transverse view in which the ultrasound probe is parallel to the patient's clavicle and it gives a cross-sectional view of the deep neck vessels, which will appear dark - or hypoechoic - due to the fluid within. Applying slight pressure with the transducer will help distinguish the compressible IJ from the pulsatile carotid artery. In the longitudinal view the ultrasound probe is oriented parallel to the length of the patient's body. The indicator is pointing toward the practitioner, standing at the head of the bed. Again, the vessel appears as a hypoechoic structure and in this plane we will see the IJ in its length.

Next, clean the skin with chlorhexidine -- scrub vigorously for 30 seconds, and then allow it to dry for 60 seconds. Now, open the CVC kit by grasping the non-sterile outside surfaces and unfold the wrap outward. As a result, the inner surface of the wrap will remain sterile along with the contents of the kit. Next open the sterile bundle and first put on the bonnet and mask. Then, open the portion containing gown, full body drape, sterile ultrasound probe cover, and sterile saline. Also, lay out sterile gloves. If your institution does not use the sterile bundle, these items may need to be gathered separately and dropped onto your sterile field. Once all of the equipment is opened, put on the sterile gown and gloves and drape the patient's neck area with the sterile drapes.

Following this, ask an assistant to place acoustic gel on the ultrasound probe. Then hold the sterile probe cover open so that the assistant can carefully drop the probe inside, maintaining the sterility of the outside of the cover. Now grasp the probe firmly within the cover, while the assistant unfurls the sheath over approximately four feet of the cord.

Next, separate the contents of the kit for easy accessibility and draw the lidocaine into a syringe. Retract the guidewire slightly within the sheath to straighten out the J curve so that it feeds easily into the introducer needle and flush the lumens of the catheter with saline, leaving the distal lumen unlocked, as this is where the wire will pass through.

Using the ultrasound probe within the sterile sleeve, again identify the target vessel, verifying the location with reference to the external anatomy. Inject lidocaine at the insertion site, 2 centimeters cephalad to the position of the ultrasound probe. While injecting, create a wheal and penetrate deeper to anesthetize the soft tissues. Also, aspirate each time before injecting so that you can be certain you are not injecting into a vessel.

Next, attach an empty syringe to the introducer needle and insert the needle into the insertion site at a 45° angle to the skin.Aim the needle toward the ipsilateral nipple, holding the ultrasound probe perpendicular to the needle, which makes following the needle tip easier. Fan the ultrasound probe to follow the tip of the needle as it advances, while simultaneously redirecting the needle as needed and gently pulling back on the plunger. Observe the needle tip as it enters the vessel and confirm the location in the IJ by drawing blood easily into the syringe. Then, put down the ultrasound probe and remove the syringe from the introducer needle, bracing the hand holding the needle against the patient to avoid changing the position of the needle. Blood return should be dark and non-pulsatile. At this point, reduce the angle of the needle to 30° as this allows the needle to more easily stay within the vessel and will facilitate passage of the guidewire.

The next step is to feed the guidewire through the introducer needle into the vessel to a depth of 20 cm, which is marked by 2 black lines on the guidewire. If resistance is met, confirm that the angle of the needle is not too steep and re-try. Once the wire is in the desired location, nick the skin at the insertion site with the scalpel and remove the introducer needle. Then pass the dilator over the guidewire to a depth of 2 to 3 centimeters, gently rotating it to dilate the skin and soft tissues. Next, remove the dilator and feed the catheter over the guidewire to approximately 15 cm for a right IJ and 20 cm for a left IJ in most adults. Once the catheter is inserted, remove the guidewire.

Attach a sterile syringe to the distal port and aspirate to verify blood return. Then flush the lumen with sterile saline. Repeat this step for each lumen on double or triple lumen catheters and cap the ports of each lumen.

Now using a two-part clamp, hold the catheter in place. First place the soft rubber part over the catheter where it enters the skin, followed by the hard piece, which secures the catheter in place. Then anesthetize the skin and suture the clamp through the eyelets. Finally, apply a sterile dressing in accordance with the practices of the medical facility and dispose of all sharps. Then obtain a chest X-ray to confirm proper placement and depth of the catheter and to rule-out a pneumothorax.

"Central venous access is necessary in a multitude of clinical situations including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, and hemodialysis, to name a few. The internal jugular vein is one of the frequently used sites for this procedure. Other common sites are the sub-clavian and femoral veins."

"Formerly this procedure was done using exterior neck anatomical landmarks only, but the use of ultrasound guidance has significantly improved the safety profile of this technique. In addition, IJ CVC's have a lower infection rate than femoral vein catheters and if there is an accidental arterial puncture, it is readily compressible, unlike the subclavian location."

"However, similar to other sites for central vein access, IJ CVC's carry the risk of: local and systemic infection, arterial puncture with bleeding, and thrombosis. IJ catheterization also carries the risk of pneumothorax and tracheal puncture. However, all of these risks are minimized with the use of sterile precautions and ultrasound guidance."

You have just a JoVE video on Central Venous Catheter insertion into the Internal Jugular vein under ultrasound guidance. You should now have a better understanding of the essential preparatory and procedure steps of this technique, as well as the benefits and risks of establishing central venous access at this anatomical location. As always, thanks for watching!

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