Background
Central venous access is essential in providing quality medical care to many patients for whom intensive therapy is required. In many situations, a semipermanent tunneled central line is preferred (see Indications). An anterior approach to the internal jugular vein (IJV) is the best option in this situation because it offers the easiest route with a low risk of complications.
In this procedure, a tunneled catheter is surgically inserted into a vein in the neck or chest and passed under the skin. Only the end of the catheter is brought through the skin. Medicines and intravenous (IV) fluid can be administered through this catheter; other tasks, such as blood sampling, can also be performed. Passing the catheter under the skin helps secure the catheter, reduces the rate of infection, and permits free movement of the catheter port. Placement of a tunneled catheter should be carried out by practitioners with specific experience in the procedure.
Compared with femoral site access, IJV or subclavian vein access was associated with a lower risk of catheter-related bloodstream infections (CRBSIs) in some studies; however, subsequent studies found no significant differences in CRBSI rates between these three sites. [1] Overall, the IJV is a more suitable site, especially in children, though other factors (eg, interindividual variations in vein size) must be kept in mind. [2]
Indications
Indications for a tunneled approach to the IJV include the following:
-
Complex or critically ill patients who need continuous hemodynamic monitoring [3]
-
Patients who require secure venous access for the infusion of agents that are very irritating or that have a very narrow therapeutic index and therefore require a very precise rate of delivery into the circulation (eg, cytotoxic drugs or inotropic agents)
-
Patients who require long-term venous access for parenteral nutrition, chemotherapy, or long-term antibiotic prophylaxis
-
Patients in whom very frequent blood sampling or access to the circulation for other reasons is needed
-
Patients in whom venous access cannot be secured by any other route
Contraindications
This procedure has no absolute contraindications. Relative contraindications include the following:
-
Severe coagulopathy
-
Physical status that renders the patient unfit for anesthesia
-
Unavailability of a suitable access site
-
Thrombosed veins
-
Overlying skin infection
-
Insertion of central line into internal jugular vein (IJV). Procedure performed by James Lee, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).
-
Correct positioning of patient, with head down and turned to opposite side with roll under neck.
-
Correct exposure and draping of patient.
-
Seldinger technique for internal jugular vein (IJV) puncture.
-
Guide wire passage.
-
Dilator peeloff sheath threaded over guide wire.
-
Line tunneled in.
-
Line length being adjusted. Handle the line with vascular forceps only (no-touch technique).
-
Line insertion into peeloff sheath.
-
Radiograph showing final position of line in right atrium.
-
Line fixation with suture.
-
Mepore dressing.
-
Ultrasonogram of neck showing venous anatomy: (a) internal jugular vein; (b) common carotid artery. Image reproduced with permission from BMJ Publishing Group.
-
Ultrasound-guided internal jugular vein (IJV) puncture (arrow shows needle entering IJV). Image reproduced with permission from BMJ Publishing Group.
-
Double-lumen tunneled line.
-
Neck anatomy showing course of internal jugular vein (IJV). Image reproduced with permission from BMJ Publishing Group.
-
Hemocatheter.
