Equipment
A preassembled kit for central line cannulation is used, typically containing the following equipment:
-
Local anesthetic (eg, lidocaine 1%) with needles and syringes
-
Thin-walled 14- to 18-gauge introducer needle
-
J-tip guide wire and semirigid dilator
-
Central line catheter
-
Antiseptic solution and applicator (eg, povidone-iodine or chlorhexidine)
-
Sterile drapes, gloves, and gown
-
Nonsterile mask and cap
-
Gauze pads
-
No. 11 blade scalpel
-
Suture (commonly, 3-0 silk on a straight cutting needle)
-
Antibiotic ointment for the dressing
-
Plastic occlusive dressing
Patient Preparation
Anesthesia
The most common means of anesthesia for placement of an intravenous (IV) line in the internal jugular vein (IJV) is the use of a local anesthetic (eg, lidocaine). Generous administration of a local anesthetic in the area just posterior to the midportion of the sternocleidomastoid is typically sufficient for the patient's comfort before tunneling of the catheter.
Care must be taken not to inject the anesthetic into either the IJV or the carotid artery. Additional local anesthetic is used on the skin for the sutures that secure the catheter to the skin. (See Local Anesthetic Agents, Infiltrative Administration.)
In certain patients, the pain of the procedure is such that additional sedation, pain control, or both might be prudent. Titrated doses of midazolam, fentanyl, or both are useful because these are agents with relatively short durations of action and minimal cardiovascular effects. (See Procedural Sedation.)
Positioning
A key aspect of central line placement in the IJV is proper positioning of the patient. Putting the patient in the Trendelenburg position dilates the vein and makes cannulation easier. In addition, this position makes the external jugular vein (EJV) more prominent. The point at which the vein crosses the sternocleidomastoid is a key landmark in the posterior approach.
Some patients cannot tolerate having the head lower than the feet. For such patients, being positioned as flat as possible is important to the success of the procedure.
The patient’s head should be turned away from the side on which the IJV is being accessed so as to provide optimal access to that side of the neck. Having an assistant hold the patient’s head in that position is often necessary. Turning the patient’s head to the side also makes the sternocleidomastoid more prominent and makes the landmarks easier to identify.
-
Diagram of external jugular vein going up over edge of sternocleidomastoid (main landmark for posterior approach).
-
Point of insertion for introducer needle is along posterior edge of sternocleidomastoid at level just superior to where external jugular vein crosses muscle. This is typically one third of distance between mastoid and clavicle.
