Internal jugular central venous catheter : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Apr 07, 2014

Complications, Contraindications

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The simplest, most practical and resources poor technique to distinguish artery from venous puncture is to use manometry.
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Jan 01, 2013

Angling the ultrasound (handle medially, tip laterally), when placing an IJ line may provide a view that shows the IJ lateral to the carotid, rather than directly above it. Following this lateral angle with the needle reduces the chance that inadvertant through and through puncture of the IJ results in puncture of the carotid artery.
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Jan 01, 2013

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Consider avoiding a central line in the neck of patients heading down the fontan pathway and asking the surgeon to place a direct atrial line instead.

Anything to avoid repeated trauma to the internal jugular vein may help reduce the risk of IJ thrombosis.

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Apr 07, 2014

In infants with fat rolls on the neck be careful not to puncture across a fat roll which would cause the line to pass into the skin, out of the skin, and into the skin again.

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Jun 06, 2013

Insertion of a left IJ CVC inadvertantly into a patient with persistent left superior-vena-cava may be mistaken for arterial insertion, extravascular placement, or placement outside the central venous system.
Image from Br. J. Anaesth. 1998; 81: 260-261 bja.oxfordjournals.org/co...
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Nov 23, 2012

The arrow 8cm 4fr triple lumen CVC has proximal lumen that is quite proximal. Consider that in small babies this leads to the risk that the proximal lumen not be sufficiently intravascular and should be thoroughly checked.

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Preoperative Optimisation

Nov 29, 2015

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Coordinating

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Medication management, Premed

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Equipment, Preparation

If placing adhesive draping over a prepped neck, placing a gauze over the endotracheal tube taping will help avoid the drape from sticking and inadvertantly extubating the patient.

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Oct 04, 2012

#pic

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For IJ lines in adults, I tend to use the catheter/introducer needle rather than the plain introducer needle. It seems more reliable for me in this region, although I'm not entirely sure why. It may be that the dynamic change in size of the IJ during respiration may mean the tip of the plain introducer needle occasionally withdraws from the vein lumen on inspiration, which the cannulation technique may avoid. #improve

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Apr 11, 2012

It also makes using manometry easier and less risky. The manometer can be connected directly to the cannula rather than an intemediate step of wiring the needle.

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Duration

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Anatomy

Persistent left-superior-vena-cava is present in 0.3% - 0.5% of the general population and up to 3-10% of those with congenital heart-disease.
If a left IJ CVC is inserted in this group the line will usually pass through the coronary sinus into the right atrium.
This is an undesirable passage as the diameter is too narrow and flow is too low putting the patient at risk of coronary sinus thrombosis.
#ref #IS
1. dx.doi.org/10.4061/2009/1...
2. bja.oxfordjournals.org/co...

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Dec 31, 2012

"...the pericardium generally crosses over the SVC below the carina level and duplicated pericardium strengthens just the medial side of the SVC in both adults and paediatrics.
Therefore, if the target position of the CVC tip is the carina, the CVC tip will be always positioned outside the pericardial sac and have little chance of perforating the intrapericardial SVC or RA causing cardiac tamponade."
dx.doi.org/10.1093/bja/ae...

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Nov 21, 2012

Anatomical landmarks for determining the depth of CVC insertion in paediatric patients <5 yo.
From dx.doi.org/10.1093/bja/ae...

"...in practice, the insertion depth can be determined by placing the graduated CVC over the sterilized skin from the insertion point to the midpoint of the perpendicular line joining the sternal head of the right clavicle and the line connecting both nipples. However, one should be cautious not to touch the skin with the graduated CVC, if possible, to minimize the risk of contamination, despite having sterilized the skin. This method is useful in children of <5 yr of age regardless of the puncture site, weight, and height."
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Nov 23, 2012

For insertion of paediatric right IJ lines this study demonstrated that the most reliable way to achieve optimal depth of insertion was to measure the distance from the insertion site to the second infercostal space.
doi.org/10.1053/j.jvca.20...

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Jun 25, 2020

Relevant anatomy.
Image from dx.doi.org/10.1056/NEJMra...

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Positioning, Surgical access

Nov 28, 2012

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Head down position ~10 degrees will increase the size of the internal jugular vein.

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Feb 28, 2012

Head-down positioning of upto 30' has been shown to increase upper vein diameter.

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This study of ninety children demonstrated that in infants with left to right shunt undergoing cardiac surgery, the trendelenberg plus passive leg raise results in a clinically significant increase of >25% cross sectional area of the internal jugular vein.

A clinically significant increase (>25%) in the cross sectional area is not seen with each manoeuvre in isolation nor in patients with a right to left shunt.

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Mar 01, 2013

Anesthesia, Analgesia, Antiemesis

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Procedure technique

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Cardiovascular, Renal, Fluids

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Blood loss, blood products

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Temperature

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Endocrine, Nutrition

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Emergence, Recovery

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Documentation, Handover

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Ward Disposition

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Guidelines, Protocols

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Full recipe

- Internal jugular vein, blind anatomical technique. -
Position head down to increase size of internal jugular and minimise risk of air embolus.
O2 mask for patient to breath under drape.
ECG monitoring plus intravenous access.
Rotate head 45 degrees.
Gown, glove, mask & eyewear.
Prep & drape.
Palpate carotid with finger.
Insert 23g seeker needle at apex of triangle formed by heads of sternocleidomastoid, lateral to carotid, aiming for ipsilateral nipple. Aspirate whilst advancing.
Leave 23g needle in place & use as guide for introducer needle. Use a seldinger technique whilst watching out for ECG changes suggestive of ventricular irritation

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Nov 28, 2012

This seeker needle technique is described here
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Misc tips

When inserting a left sided IJ line in a very small child and using a catheter to pass the guidewire, consider using a shorter catheter (22g) rather than the one that comes with the kit,. This shorter catheter is less likely to get caught up or kinked on the left subclavian junction.
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Apr 07, 2014

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Video

Educational video from SonoSite demonstrating how to map the jugular vein with surface anatomy and ultrasound on a live patient, and guiding the needle with ultrasound on a blue phantom.
Click on link below to watch.
cx1.sonosite.com/ST_Inter...

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Nov 23, 2012

#spanzacvad

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Educational video tutorial from SonoSite on ultrasound guided insertion of the internal jugular central venous catheter using the longitudinal axis technique.
Click on the link below to watch.
cx1.sonosite.com/CentralV...

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Nov 18, 2012

#spanza

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