Central Venous Catheterization: Internal Jugular Approach




  1. Indications
  2. Contraindications
  3. Technique
  4. Post-procedure Care
  5. Ultrasound Guidance
  6. Central Line Checklist
  7. Line Depth
  8. Compare Line Sites



Indications:
  1. Administration of vasoactive or inotropic agents
  2. Measurement of central venous filling pressure
  3. Quantification of mixed venous O2 saturation
  4. Introduction of a Swan-Ganz Catheter
  5. Transvenous pacing
  6. Total Parenteral Nutrition
  7. Hemodialysis
  8. Plasmapheresis
  9. Venous access during cardiopulmonary resucitation


Contraindications:

Absolute:
  1. Adequate peripheral IV access
  2. Operator Inexperience
  3. Uncooperative patient
  4. Thrombosis of the internal jugular vein

Relative
  1. Coagulopathy
  2. Thrombocytopenia
  3. Injury or previous surgery to the superior vena cava
  4. Inability to tolerate a pneumothorax


Technique

Anatomy:
internal_jugular.jpg
The internal jugular vein courses inferiorly between the two heads of the sternocleidomastoid (SCM) muscle and joins the subclavian vein medial to the head of the clavicle. The internal jugular lies anterior and lateral to the carotid artery and courses under the medial portion of the upper part of the SCM muscle and travels under the apex of the triangle formed by the sternal and clavicular heads of the SCM muscle and the clavicle. The right internal jugular is preferable to the left because it lies almost directly above the SVC and provides direct access to the heart should transvenous pacing or pulmonary artery catheterization be required.



Equipment (standard):
  1. Introducer needle (typically 18 gauge, 5-7cm)
  2. Guidewire (typically 0.32" x 60cm)
  3. Dilator (typically 8.5 Fr x 11cm)
  4. Multilumen catheter (~20cm is ideal)
  5. Sterile fenestrated drape
  6. Sterile gown & gloves
  7. Scalpel
  8. Lidocaine or xylocaine
  9. Anesthetizing needle (usually 25 gauge)
  10. Sterile gauze
  11. Suture, suturing needle, needle driver
  12. "Finder" needle (usually 22 or 25 gauge)

Procedure:
  1. Obtain consent from the patient and/or representative as is appropriate and place in the chart
  2. You will need to obtain the appropriate central line kit, sterile gloves, sterile gown, and cap and place them in the patient room; open the outside packaging and place the items on a table such that the contents can be opened and accessed in a sterile manner
  3. Clean the side of the neck to be accessed using chlorhexidine solution
  4. Wash your hands and don the sterile gown and gloves
  5. Organize the equipment contained in the kit: obtain the appropriate caps for the the catheter access ports and place them on the multilumen catheter except for the distal port, remove covers and caps from the multilumen catheters and introducers, place syringes on the needles etc. At this point you may want to also arrange the equipment in the order that they will be accessed.
  6. Positioning: place the patient supine with Trendelenberg positioning to 20 to 30 degrees, the height of the bed should be adjusted so that the head is at a height which is comfortable for the operator (generally waist level or higher). The patient's head should be slightly turned to the side so that the area of the neck to be accessed is readily exposed. It is important for the operator to be at a position where he/she will be able to advance the guide-wire with the most ease. This will most likely be with the operator standing at the head of the bed. This will give the operator the best angle to advance the wire.
  7. Place the sterile drape on the patient such that the side of the neck that has been prepped is exposed through the fenestrated area
  8. Anesthetize the neck with lidocaine by making a small wheal
  9. Approach:
    • Anterior approach: insert the needle at the medial edge of the sternocleidomastoid muscle at about the level of the thyroid cartilage. Insert the needle at about 45 degrees. Aim for the ipsilateral nipple.
    • Central approach: insert the needle at the superior aspect of the sternocleidomastoid triangle. Insert the needle at about 45 - 60 degrees. Aim for the ipsilateral nipple.
    • Posterior approach: insert the needle at the lateral edge of the sternocleidomastoid muscle at about the level that is 1/3 the distance from the clavicle to the mastoid. Insert the needle at about 45 - 60 degrees. Aim for the sternal notch.
  10. Using your free hand, palpate the carotid artery; the internal jugular vein is located approximately 1-2 cm lateral of the carotid artery pulse. While maintaining palpation of the carotid artery pulse with your freehand, using one of the approaches above, insert the needle while simultaneously drawing back on the syringe until return of blood is obtained.
  11. Once blood is returned into the syringe, disconnect the syringe from the needle while maintaining position of the needle as much as is possible.
  12. Obtain the guidewire and advance it through the needle for about 15 cm; this should leave about 5 cm of free guidewire outside of the patient. In general enough guidewire length should be available to maintain adequate control of this device during the rest of the procedure. Advancement should be smooth and without resistance. If resistance is encountered the needle may need to be repositioned at a different angle. If this does not work, the needle may need to be reinserted at a different area or approach. Be sure to watch for ventricular tachycardia on the monitor. If ventricular tachycardia is induced, withdraw the guidewire 3 - 4 cm at a time until the arrhythmia is terminated.
  13. Once the guidewire has been advanced to the desired depth, withdraw the needle over the guidewire while maintaining the guidewire in place.
  14. Take the scalpel and nick the skin at the base of the guidewire.
  15. Place the dilator over the guidewire and dilate the skin at the base of the guidewire. Always maintain adequate control of the guidewire with one hand. Be prepared with sterile gauze as there will be brisk bleeding at the insertion site once the dilator is removed from the skin. This is especially the case when inserting larger catheters such as VasCaths for hemodialysis that require 2 sequentially larger dilations.
  16. The multilumen catheter should have been previously prepared by placing the caps on all access ports except for the distal port. Thread the guidewire through the proximal end of the catheter all the while maintaining proximal control of the guidewire. Once enough of the guidewire was been passed through the distal port to maintain distal control, grasp the distal end of the guidewire and thread the catheter over the guidewire into the skin to the desired depth (usually about 15-18 cm in an average height person - see references below).
  17. Remove the guidewire though the distal port and place a cap on it.
  18. Using sterile flush, connect the syringe to the distal port and draw back until blood is drawn into the syringe. Once blood has been drawn into the syringe, flush the port and lock it with the attached clip. Repeat for all ports.
  19. Place the suture anchors on the catheter line at the depth of desired insertion. The bottom edge on the anchor should be a the tick mark which designates the desired depth of insertion.
  20. Suture the anchors to the skin. Suture the attached suture flanges that are physically on the catheter itself.
Line Depth
cvc-depth.jpg
References:
Kim et al. Optimal insertion depth of central venous catheters-Is a formula required? A prospective cohort study. Injury (2011) pp.2160
Of the 1238 patients who were CVC-cannulated over 10 months, 106 underwent chest CT. Based on the mean distance from the CVC insertion point to the distal SVC, we determined that the recommended depth of insertion should be 14cm for the right subclavian vein, 15cm for the right internal jugular vein, 17cm for the left subclavian vein and 18cm for left internal jugular vein. Using these guidelines, initial placement of a CVC in the distal SVC was more accurate than when the Peres formula was used (91.5% vs. 77.4%, p<0.05).

McGee et al. Safe Placement of Central Venous Catheters: A Measured Approach. Journal of intensive care medicine (2011) pp.2163
Using a 15-cm insertion depth via the internal jugular or subclavian vein results in safe catheter tip location in the majority of procedures consistent with FDA and manufacturer guidelines.

Peres. Positioning central venous catheters--a prospective survey. Anaesth Intensive Care (1990) vol. 18 (4) pp. 536-9
To avoid right atrial placement with its well documented risk of cardiac tamponade, it is recommended that right infraclavicular subclavian catheters are inserted to H/10-2 cm, right internal or external jugular catheters to H/10 cm and left external jugular catheters to H/10 + 4 cm.


Ultrasound Guidance:

Ultrasound guidance should be used for placement of internal jugular venous catheters whenever possible. When using ultrasound guidance, the "blind" procedure described above is modified in the following way:

  1. Prior to performing sterile prep on the patient place the ultrasound probe on the side of the neck in which the procedure is planned; this can be helpful in the planning process in that it may lend to anatomic or mechanical considerations which suggest performing the procedure at a different location.ultra.jpg
  2. Use the linear array probe. The is a small tactile dot on the side of the probe; when holding the probe in the transverse plane, the dot should always be placed to the patient's right. When holding the probe in the horizontal plane, the dot should be facing upwards.
  3. Place the probe in the general area of the SCM triangle. Vessels will appear as round anechoic structures.Fan the probe superior and inferior or medial to lateral until the carotid artery and internal jugular vein are found.
  4. The carotid artery and vein will appear as two overlapping anechoic structures. The internal jugular vein is often found directly anterior or anterolateral to the carotid artery. The internal jugular vein most often larger in diameter to the carotid artery.1224672059_7304.jpg
  5. Confirmation that the vessel being visualized is venous in origin can be done in one of the following ways. Compression of the neck using the probe will cause collapse of the internal jugular vein but not of the carotid artery. Also, you can press the color button on the ultrasound console and use trackpad to center the pointer over the vessel in question. This will apply color doppler analysis to the vessel. A blue color form indicates flow moving away from the probe which will indicate venous flow. Red color indicates blood moving away from probe which should indicate the carotid artery. compression technique is likely more accurate in identifying venous vs arterial structures as color doppler can be confusing to the novice operator and in the typical ICU patient with low perfusion
  6. After the patient has been prepped and draped the ultrasound probe will need to be sterilely draped as well. Once you are ready to perform the procedure, use the technique described above to localize the internal jugular vein.
  7. Once the vein has been identified center it on the screen; the vein, as it appears on the screen, is now directly under the probe.
  8. When ready for needle insertion, insert the needle at a 45 degree angle to the skin approximately 1 cm proximal to the probe
  9. Watch the screen and attempt to identify the needle as it protrudes through the subcutaneous tissue. The tip will often appear as a white dot on the screen. Many times the tip cannot be identified and fanning of the probe may be able allow for better visualization. In most cases, however, tenting of the skin and soft tissue can be seen and the needle tip can be identified is this manner. Very short, under-exagerrated, pulsating or "stabbing" motions with the needle can be used to better accentuate the appearance of tenting.
  10. Using the technique described above, visualize the needle entering the internal jugular vein until blood is returned in the syringe. At this point the remainder of the procedure can be carried out in a standard fashion.



Complications
  1. Pneumothorax
  2. Arterial puncture
  3. Air embolization
  4. Arrhythmia
  5. Thrombosis
  6. Embolization of clot or equipment
  7. Infection

Post-procedure Care:

  1. A post procedure chest-xray will need to be ordered in order to confirm line placement
  2. The area of insertion will need to be covered with a sterile dressing, usually sterile gauze or a clear sterile dressing such as tegaderm. If gauze is used, it may be useful to impregnate it with chlorhexidine or iodine.
  3. Dressings should be changed at a minimum of every 72 hours, though hospitals specific guidelines may modify how often dressing changes may be necessary
  4. The necessity of central lines should be evaluate daily and removed once it is determined that it is no longer required.

A word about catheter related blood stream infections (CLABSI):

Infections resulting from central line placements remains a major contributor to inpatient morbidity and mortality as well as a substantial financial burden to the healthcare provision. The CDC published a guideline in 2002 outlining the provisions that should be observed when placing central lines. Some of the major guideline points include the following:
  1. Educate health-care workers regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection-control measures to prevent intravascular catheter-related infections
  2. Do not routinely culture catheter tips
  3. Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter
  4. Maintain aseptic technique for the insertion and care of intravascular catheters
  5. Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changes. Although a 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor, or 70% alcohol can be used
  6. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter sit
  7. Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy
  8. Promptly remove any intravascular catheter that is no longer essential
  9. Clean injection ports with 70% alcohol or an iodophor before accessing the system

Central Line Checklist: