critical care medicine
How To Do Internal Jugular Vein Cannulation, Ultrasound Guided
Step by Step Description of Procedure
Check that the ultrasound machine is configured and functioning correctly: Ensure that the screen image you are seeing correlates to the spatial orientation of the probe as you are holding and moving it. The side mark on the probe tip corresponds to the teal blue marker dot on the ultrasound screen. Adjust the screen settings and probe position if needed to attain an accurate left-right orientation. Do a nonsterile ultrasound inspection (ie, using an uncovered probe and nonsterile gel) and determine whether the vein is suitable for cannulation. Use a short-axis (cross-sectional) view. Begin at the apex of the anterior cervical triangle, and slowly slide the probe proximally (toward the clavicle) along the lateral border of the sternal head of the sternocleidomastoid. Blood vessels are hypoechoic (appear black on the ultrasound screen). Veins are generally larger, thin-walled, and ovoid (rather than thick-walled and round) and are more easily compressed (by gentle pressure on overlying skin) than their paired arteries. The size of the internal jugular vein varies with respiration and is increased by the Trendelenburg position and the Valsalva maneuver. Venous thrombosis may appear as an echogenicity (gray irregularity) in the lumen but often is diagnosed because the thrombosed vein is incompressible. Thrombosis disqualifies the vein as a suitable cannulation site. Cannulate a central vein at a site of optimal short-axis imaging (ie, large-diameter cross section of the vein, with no overlying artery). Attach the cardiac monitor to the patient and turn it on. Place sterile equipment on sterilely covered equipment trays. Dress in sterile garb and use barrier protection. Draw the local anesthetic into a syringe. Attach the introducer needle to a 5-mL syringe with 1 to 2 mL of sterile saline in it. Align the bevel of the needle with the volume markings on the syringe. Pre-flush all lines of the CVC with 3 to 5 mL of sterile saline and then close the ports with caps or syringes. When flushing a central line, use a 10-mL syringe (or one of equal or greater diameter) and do not push too hard to avoid rupturing the line. Swab a broad area of skin with antiseptic solution, encompassing the side of the neck, clavicle, and anterior chest to below the ipsilateral nipple. Creating this broad sterile area permits immediately switching to How To Do Infraclavicular Subclavian Vein Cannulation or unassisted (“blind”) Allow the antiseptic solution to dry for at least 1 minute. Place sterile towels around the site. Place large sterile drapes (eg, a full-body drape) to establish a large sterile field. Direct your assistant (nonsterile) to coat the probe tip with nonsterile ultrasound gel and then hold the probe, with the tip pointing up, just outside the sterile field. Insert your gloved dominant hand into the sterile probe cover. Grasp the tip of the probe with your dominant hand (now covered by the probe cover). Use your gloved nondominant hand to unroll the sterile cover over the probe and completely down the cord.Do not touch the uncovered cord nor allow it to touch the sterile field as you unroll the cover. Pull the cover tightly over the probe tip to eliminate all air bubbles. Wrap sterile rubber bands around the probe to secure the cover in place. The covered probe may now rest on the sterile drapes. Apply sterile ultrasound gel to the covered probe tip. Use short-axis ultrasound guidance: Attain an optimal cross-sectional image of the internal jugular vein (near the apex of the anterior cervical triangle, if possible).Press lightly with the probe tip to avoid distorting the image size and shape of the vein. Slide the probe transversely as needed to place the imaged vein at the center of the ultrasound screen. When the vein is centered on the ultrasound screen, the midpoint of the probe becomes a surface marker designating the luminal center of the underlying vein. Keep the probe in this spot. On the ultrasound screen, measure the depth to the center of the vein. When using short-axis ultrasound guidance, insert procedural needles (local anesthetic and introducer needles) into the skin at a point distal and perpendicular to the midpoint of the probe by the same distance as the vein depth. Then, initially advance the needle into the skin at a 45° angle directed toward the midpoint of the probe. Keep gentle negative pressure on the syringe plunger as you advance. Place a wheal of anesthetic at the needle entry point and then inject anesthetic into the skin and soft tissues along the 45° path leading toward the vein. Slightly tilt the probe fore and aft as you advance the anesthetic needle to continually identify the needle tip and keep it safely distant from the vein and artery. Continue to use short-axis ultrasound guidance (as described above for the local anesthetic injection). Insert the introducer needle. Maintain ultrasound visualization of the needle tip as you advance by continually tilting the probe slightly fore and aft (the needle tip appears and disappears as the ultrasound plane sweeps back and forth over it). If the needle tip strays from the vein,adjust the lateral direction of the needle to keep the needle tip above the center of the vein.If the needle tip is approaching the vein too slowly,withdraw the needle a bit, increase the angle of insertion, and readvance. As the needle tip approaches the vein, temper your speed and angle of insertion so the needle enters with as much control as possible.The superficial wall of the vein will indent when the needle tip encounters it. The needle then pops through the wall to enter the lumen, accompanied by a flash of dark red blood in the barrel of the syringe. Hold the syringe motionless in this spot and visualize the tip of the needle at all times. Displacement is common, and even a slight movement may displace the needle tip from the vein. Optional: If the accessible vein segment is long enough to accommodate the long axis of the probe, you may prefer to use the short-axis (cross-section) view first to aim the needle at the vein, and then rotate the probe 90° to attain the long-axis (in-plane, longitudinal) view of the needle and vein, which provides better imaging of the venipuncture. Move the probe as needed to keep both the needle and the vein in sight (in-plane). Press lightly with the probe tip so the vein remains under the tip and does not roll to the side. Continue to hold the syringe motionless. Securely grasp the needle hub and also hold it motionless. Remove the syringe from the needle hub and briefly let blood flow out to confirm that the blood is venous (ie, dark red and flowing, but not pulsatile). Then immediately cover the hub with your thumb to stop the blood flow and prevent air embolism. However, if the blood is bright red and pulsatile (arterial),terminate the procedure. Remove the needle and use 4 × 4 squares for 10 minutes to hold external pressure on the area and to help prevent bleeding and hematoma. Carefully rotate the introducer syringe such that the bevel of the needle now faces medially (ie, toward the heart and away from the subclavian vein). Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing medially (ie, in the same direction as the needle bevel). Advance the guidewire through the needle and into the vein. You may use ultrasound guidance (either short- or long-axis) to verify the guidewire entering the vein. Do not force the wire; it should slide smoothly. Advance the wire 10 to 15 cm for a right-sided internal jugular insertion, 15 to 20 cm for a left-sided insertion, or until ectopic heartbeats occur (withdraw from this point until ectopy stops). If you feel any resistance as you advance the guidewire,stop advancing it. Try to gently withdraw the wire slightly, rotate it slightly, and then readvance it, or try to gently withdraw the wire entirely, reestablish the needle tip within the vein (confirmed by venous blood return), and then reinsert the wire. However, if you feel any resistance as you withdraw the wire,terminate the procedure and withdraw the needle and guidewire together as a unit (to prevent the needle tip from shearing through the guidewire within the patient). Then use 4 × 4 gauze squares for 10 minutes to hold external pressure on the area and to help prevent bleeding and hematoma. Once the guidewire has been inserted, continue to hold it securely in place with one hand and maintain control of it throughout the remainder of the procedure. First, securely hold the guidewire distal to the needle and pull the needle from the skin. Then, securely hold the guidewire at the skin surface and slide the needle down the remaining length of the guidewire to remove the needle. Extend the skin insertion site: Using the scalpel, make a small stab incision (about 4 mm) into the skin insertion site, avoiding contact with the guidewire, to enlarge the site and allow it to accommodate the larger diameters of the tissue dilator and the catheter. Advance the tissue dilator over the guidewire: First, grasp the guidewire at the skin and slide the dilator down the length of the wire to the skin. Then grasp the wire just distal to the dilator, hold the dilator near the skin surface, and use a corkscrew motion as needed to stepwise insert the entire length of the dilator. Maintain your grasp on the wire at all times during the insertion. Remove the dilator: First, securely hold the guidewire distal to the dilator and pull the dilator from the skin. When the guidewire is visible at the skin surface, completely remove the dilator by sliding it down the remaining length of the guidewire. Maintain your grasp on the guidewire at the skin surface. Advance the catheter over the guidewire to the skin surface: Hold the guidewire fixed at the skin surface, thread the catheter tip over the distal end of the guidewire, and slide the catheter down to the skin surface. The distal end of the guidewire should now be protruding from the port hub. If the distal end of the guidewire is not protruding from the port hub,inch the guidewire outward from the skin surface while holding the catheter tip close to the surface until the guidewire protrudes. Continue to advance the catheter into the vein: Grasp and control the guidewire where it protrudes from the hub. Hold the catheter near its tip and insert the tip through the skin. Then, in increments of several centimeters and using a corkscrew motion as necessary, stepwise advance the entire length of the internal jugular catheter. If ectopic heartbeats occur, slowly withdraw the catheter until ectopy stops. Use ultrasonography to verify intravenous placement of the catheter. Maintain your grasp on both the guidewire and the catheter. Remove the guidewire: Withdraw the guidewire while holding the catheter securely in place at the skin surface. Flush each catheter port with saline: First, draw any air from the line and confirm venous blood flow into the hub. Then, using a 10-mL syringe (or one of equal or greater diameter) and nonexcessive force, push 20 mL of saline into the line to clear it. If the patient is awake or minimally sedated, use 1%lidocaineto numb the skin at the planned suture locations. Place achlorhexidine-impregnated disk on the skin at the catheter insertion point. Suture the skin to the mounting clip on the catheter. To prevent pulling on the insertion site, suture the catheter at a second site so that a curved or looped segment of catheter lies between the two sites. Apply a sterile occlusive dressing. Transparent membrane dressings are commonly used. 