Preprocedural Planning
In patients who need long-term venous access (eg, patients with a small-bowel transplant), imaging of the neck veins may be necessary before the procedure.
Doppler ultrasonography (US), magnetic resonance (MR) venography, or both can be used to establish venous patency and anatomy, thus improving planning and anticipation of potential problems with access. [3]
Particularly in patients with multiple medical problems, a complete blood count, clotting profile, and relevant renal and liver function tests should be included in the preprocedural workup. Depending on the platelet count, platelet transfusion may be needed.
Equipment
Materials required for the procedure include the following:
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Central venous catheter tray (line kit; see the images below)
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Sterile gloves
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Antiseptic solution with skin swab
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Sterile drapes or towels
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Sterile gown
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Sterile saline flush, approximately 30 mL
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Lidocaine 1%
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Gauze
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Dressing
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Scalpel, No. 11
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Vascular forceps (DeBakey)
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Needle driver
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Polypropylene suture 4-0
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Steri-Strips
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Mepore adhesive tape
Patient Preparation
Anesthesia
A local anesthetic agent is used before the catheter is tunneled. For more information, see Local Anesthetic Agents, Infiltrative Administration.
Positioning
Trendelenburg positioning with the head turned to the side opposite the central venous line insertion is optimal (see the image below); the internal jugular vein (IJV) distends in this position, providing a maximal cross-sectional area for access. [4] The ipsilateral arm should be extended minimally at the axilla. In adults, neutral position of the neck has been shown to be equally safe. [5]
Correct positioning of patient, with head down and turned to opposite side with roll under neck.
A 10º-15º head-down (Trendelenburg) position distends the IJV and also elimimates the risk of air embolism. This dual advantage also facilitates successful venipuncture on the first attempt. [6]
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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).
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Correct positioning of patient, with head down and turned to opposite side with roll under neck.
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Correct exposure and draping of patient.
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Seldinger technique for internal jugular vein (IJV) puncture.
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Guide wire passage.
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Dilator peeloff sheath threaded over guide wire.
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Line tunneled in.
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Line length being adjusted. Handle the line with vascular forceps only (no-touch technique).
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Line insertion into peeloff sheath.
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Radiograph showing final position of line in right atrium.
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Line fixation with suture.
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Mepore dressing.
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Ultrasonogram of neck showing venous anatomy: (a) internal jugular vein; (b) common carotid artery. Image reproduced with permission from BMJ Publishing Group.
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Ultrasound-guided internal jugular vein (IJV) puncture (arrow shows needle entering IJV). Image reproduced with permission from BMJ Publishing Group.
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Double-lumen tunneled line.
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Neck anatomy showing course of internal jugular vein (IJV). Image reproduced with permission from BMJ Publishing Group.
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Hemocatheter.
