Central line: internal jugular

Indications

  • Central venous pressure monitoring
  • High volume/flow resuscitation
  • Emergency venous access
  • Inability to obtain peripheral venous access
  • Repetitive blood sampling
  • Administering hyperalimentation, caustic agents, or other concentrated fluids
  • Insertion of transvenous cardiac pacemakers
  • Hemodialysis or plasmapheresis
  • Insertion of pulmonary artery catheters

Contraindications

Absolute[1]

  • Infection over the placement site
  • Anatomic obstruction (thrombosis of target vein, other anatomic variance)
  • Site-specific
    • Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs

Relative

  • Coagulopathy (see below)
  • Distortion of landmarks by trauma or congenital anomalies
  • Prior vessel injury or procedures
  • Morbid obesity
  • Uncooperative/combative patient

Central line if coagulopathic

  • Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible)
  • No benefit to giving FFP unless artery is punctured[2]

Equipment Needed

  • CVC kit typically contains:
    • Chlorhexidine
    • Sterile drape
    • 1% lidocaine without epinephrine
    • 5 mL syringe (for lidocaine)
    • 22-ga and 25-ga needles (for lidocaine)
    • 5-10 mL syringe (for venipuncture)
    • 18-ga needle (for venipuncture)
    • Guidewire
    • Scalpel with 11-blade
    • Dilator
    • Triple-lumen catheter (or introducer catheter/Cordis)
    • Catheter clamp
    • Silk suture
  • Sterile gown, cap, mask, gloves
  • Biopatch
  • Tegaderm
  • Sterile saline flush
  • Sterile caps for lumen ports

Procedure

Ultrasound-guided

Right IJ CVC in place
  1. Obtain informed consent when possible
  2. Trendelenberg is ideal position
    • If unable to tolerate trendelenberg and on mechanical or non-invasive ventilation consider raising PEEP as this may increase diameter of IJ making for an easier target[4]
  3. Ultrasound survey to identify anatomy before beginning
  4. Don cap, mask, sterile gown and gloves
  5. Chlorhexidine prep the skin. Right sided approach preferred
  6. Place sterile drape over target area
  7. With assistant, place sterile cover over ultrasound probe, with some gel inside, secured with rubber bands from probe cover package
  8. Anesthetize insertion site
  9. Prepare catheter by flushing each lumen with sterile saline
  10. Prepare the guide wire by sliding the plastic sleeve slightly forward to straighten the curved wire tip
  11. Using ultrasound, identify IJ vein and carotid artery - large bore vessels, medial/deep to SCM. Vein is compressible, artery non-compressible.
  12. Align IJ in center of ultrasound screen
  13. Insert needle with syringe under ultrasound guidance, while applying negative pressure on the syringe
  14. When the needle enters the lumen, blood will be aspirated freely
  15. Stabilize the needle hub, carefully remove the syringe from the needle
  16. Confirm blood flow is non-pulsatile. Cap needle hub with thumb to avoid air embolism
  17. Insert the guidewire in through the needle hub, never letting go of the wire. If resistance is met, remove the wire and aspirate with syringe to confirm placement still in the vessel
  18. Remove the needle, keeping the wire in the vessel
  19. Confirm correct placement of wire with ultrasound
  20. Make a small incision to facilitate dilator passage through the skin
  21. Thread the dilator over the wire (making sure the wire moves freely while dilating ensures you are not kinking the wire), and advance several centimeters into the vessel, then remove, while keeping the wire in the vessel
  22. Advance the catheter over the wire, until the wire protrudes from a distal port (For introducer catheters, the dilator and larger single-lumen catheter are inserted as a dilator-sheath unit, assembled prior)
  23. Grasp the wire where it emerged from the port and advance the catheter into the vessel
  24. Remove the wire
  25. Place end cap on port
  26. Withdraw blood then flush each port/lumen with saline
  27. Suture the catheter in place
  28. Place Biopatch
  29. Cover with Tegaderm

Landmark technique

  • Same preparation as above, differences from ultrasound method highlighted below
  • Rotate head 15-30 deg away from target side
  • Anterior approach
    • Insert needle along medial edge of SCM, 2-3 finger breadths above clavicle
    • Entry angle 30-45 deg
    • Aim towards ipsilateral nipple
  • Central approach
    • Insert needle at the apex of the triangle formed by the heads of the SCM and the clavicle
    • Entry angle 30 deg
    • Aim towards ipsilateral nipple
  • Posterior approach
    • Insert needle at the posterior (lateral) edge of the SCM, halfway between the mastoid and the clavicle
    • Entry angle 45 deg
    • Aim for the suprasternal notch

Complications

  • Arterial puncture and hematoma
  • Pneumothorax
  • Hemothorax
  • Vessel injury
  • Air embolism
  • Cardiac dysrhythmia
  • Nerve injury
  • Infection
  • Thrombosis
  • Catheter misplacement

See Also

References

  • Roberts & Hedges 6e, pp 397-431
  1. Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
  2. Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  3. Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
  4. Effect of positive end-expiratory pressure and positioning on jugular vein expansion in emergency department patients Ehrlich C, Hohenstein C, Winning J, et al. [published online August 23, 2019]. Eur J Emerg Med. doi:10.1097/MEJ.0000000000000624