Central Approach to the Internal Jugular Vein
While an internal jugular vein cannula can be inserted using the over-the-needle and through-the-needle techniques, the Seldinger technique is often preferred.37,38 See Chapter 47 and Table 49-5 for a more complete discussion. The Seldinger technique uses a flexible guidewire, inserted through a special thin-walled hollow needle, to guide a catheter of any desired length through the skin and into the central circulation. This technique is described below and summarized in Table 49-6.
Table 49-5 Comparison of Central Venous Catheterization Methods ||Download (.pdf)
Table 49-5 Comparison of Central Venous Catheterization Methods
|Number of steps||4+||1||2|
|Risk of catheter shear||None||Low||Highest|
|Catheters and lumens available||Single- or multiple-lumen, sheath/introducer||Single-lumen only||Single-lumen only|
|Rate of infusion||Highest (with sheath)||Moderate||Low to moderate|
Table 49-6 Summary of the Seldinger Method of Central Venous Cannulation* ||Download (.pdf)
Table 49-6 Summary of the Seldinger Method of Central Venous Cannulation*
|Step||Action||Tips and caveats|
|1||Prep and drape the skin puncture site.||For internal jugular vein, prepping down to the clavicle and up to the jaw will enable an attempt at the ipsilateral subclavian vein (or vice versa).|
|2||Anesthetize the puncture site if not already done.||Anesthetize the suture sites also.|
|3||Uncap the distal lumen.||Additional lumens may be flushed at this point or after insertion, as desired.|
|4||Locate the vein using the finder needle and aspirating syringe.||Internal jugular vein should be reached within 3 cm. Stop advancing after 4–5 cm if the vein is not located.|
|5||Remove the finder needle, noting the direction and depth of the internal jugular vein. Or withdraw the needle slightly so it is outside the internal jugular vein and leave it in place as a guide||A few drops or a line of blood may be left on the skin as the finder is withdrawn to show the proper direction.|
|6||Insert introducer needle on a syringe along the “finder's” path until venous blood is aspirated. Alternatively, an introducer catheter and needle assembly can be used to cannulate the internal jugular vein; the needle is then withdrawn.||Syringe must have a nonlocking hub. A little saline in the syringe allows any occluding skin plug to be ejected. The vein is often located on withdrawal of the needle, since the friction of the large needle in the tissues can compress the internal jugular vein.|
|7||Disconnect the syringe from the needle, immediately occluding the open needle hub to prevent air embolism.||Do not move the needle at all! Keep the hand holding the needle in contact with the patient's skin to prevent movement.|
|8||Insert the guidewire through the introducer needle and into the vein.||Do not move the needle! Do not force the guidewire—it should pass easily!|
|9||Advance the guidewire into the vein to the desired depth or until ventricular ectopy is seen on the ECG monitor.||The guidewire must be securely in the vein, not just in the subcutaneous tissue.|
|10||Withdraw the introducer needle a few millimeters and use the scalpel to enlarge the puncture site slightly.||Keeping the needle in place eliminates any possibility of cutting the guidewire.|
|11||Remove the introducer needle.||Never let go of the guidewire!|
|12||Thread the dilator over the guidewire until it can be grasped outside the hub, then insert and withdraw the dilator.||Always keep a firm grip on the guidewire!|
|13||Thread the catheter tip over the guidewire and withdraw the guidewire from the skin until it can be grasped at the infusion hub.||Never let go of the guidewire.|
|14||Insert the catheter to the desired depth; most catheters are marked in centimeters, with larger markings every 5 and 10 cm. Introducer sheaths should be inserted completely.||The tip of the catheter should be in the superior vena cava, at the level of the manubriosternal angle.|
|15||Holding the catheter in place, remove the guidewire. Occlude the open hub with a gloved finger to prevent air embolism.||Do not apply excessive force to the guidewire. If it is trapped, withdraw the catheter a few centimeters and try again. Do not break the wire!|
|16||Attach a syringe to the catheter hub and aspirate blood, taking samples as desired; then flush the lumen with saline and begin the desired venous infusion.||Other lumens may be aspirated, flushed, and clamped.|
|17||Verify intravenous placement before suturing the catheter in place||If the patient's blood travels up the intravenous tubing, the catheter is in the carotid artery!|
|18||Remove the patient from the Trendelenburg position.|
|19||Suture the catheter to the skin with sutures and tape.||Take care not to puncture the catheter or to occlude it with a tight suture|
|20||Apply a dressing to the catheter site.|
|21||Verify catheter tip position by chest X-ray.||Catheter tip must be in the superior vena cava, not in the right atrium. Tip should be above the azygos vein and the carina, with the tip parallel to the vessel wall.|
Clean, prep, and drape the area as described previously. Place the patient in the Trendelenburg position with their head down 15° to 30°. Slightly rotate the patient's head away from the side that will be cannulated. Excessive rotation will distort the anatomic landmarks and may bring the internal jugular vein closer to the carotid artery.
Several cardinal rules for the insertion of the catheter should be observed. Always occlude the open hub of a needle or catheter in a central vein to prevent an air embolism. Never let go of the guidewire, so as to prevent its embolization into the central venous circulation. Never apply excessive force to the guidewire on insertion or removal. Doing so may injure the vessel, break the guidewire, and/or embolize the guidewire.
Attach the thin-walled introducer needle to a 5 mL syringe containing 1 mL of sterile saline or local anesthetic solution. The specially designed introducer needle included with the catheter should be used, as it has a relatively thin wall and a larger internal diameter relative to its external diameter. It has a shorter bevel than a conventional hypodermic needle. It also has a tapered hub to guide the guidewire into the needle proper.
If there is doubt about the exact location of the vein, it may first be located with a small “finder” needle. Insert a 25 or 27 gauge needle attached to a 5 mL syringe through the skin puncture site previously chosen. Advance the needle at a 30° to 60° angle to the skin while applying negative pressure to the syringe. A flash of blood signifies that the tip of the needle is within the vein. Note the depth and location of the vein. Remove the finder needle. Alternatively, the finder needle may be left in place for reference.
Insert the introducer needle at a 30° to 60° angle at the apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle (Figure 49-4). This point is just lateral to the carotid artery pulse. Direct the introducer needle toward the ipsilateral nipple. Shallower angles make it necessary to traverse a greater amount of subcutaneous tissues and structures before entering the vessel. Steeper angles make insertion of the catheter over the guidewire difficult, as the guidewire tends to kink. Shallower angles are generally necessary in children whose vessels are smaller. Inject a small amount of the fluid in the syringe to remove any skin plug that may block blood return once the vein has been penetrated.
Apply negative pressure to the syringe by withdrawing the plunger. Advance the introducer needle into the vein (Figure 49-10A). If the vein is not located within 3 to 5 cm of the skin—this distance will vary depending on the patient's size and the target vessel's location—stop advancing the introducer needle. Withdraw the needle slowly while continuing to aspirate. Often, the vessel will have been completely traversed and no blood will return due to collapse of the vein by the pressure of the skin being forced inward as the introducer needle passes through it. Under normal physiologic conditions, veins have very low pressures within them and are easily collapsed by external pressure. If no blood is aspirated while withdrawing the needle, withdraw the introducer needle to the subcutaneous plane and redirect it slightly medially. Avoid putting continuous pressure on the carotid artery pulse, as even gentle pressure may collapse the internal jugular vein (Figure 49-3B).
The Seldinger technique. A. The vein is punctured by the introducer needle and blood is aspirated. B. The syringe has been removed. The guidewire is inserted through the introducer needle and into the vein. C. The introducer needle and guidewire sleeve are withdrawn over the guidewire. D. The skin puncture site is enlarged. E. The dilator is advanced over the guidewire until the hub is against the skin; then it is removed. F. The catheter is advanced over the guidewire and into the vein. G. The guidewire is withdrawn through the catheter.
Stabilize and hold the introducer needle perfectly still with the nondominant hand once blood returns in the syringe. The carotid artery has been entered if the blood is bright red and/or forces the plunger of the syringe back. Remove the syringe. Blood should flow slowly and freely from the hub of the needle. The introducer needle is in the carotid or subclavian artery if blood squirts out the introducer needle hub. If blood dribbles out or does not flow from the hub and the patient has spontaneous circulation, reattach the syringe and reposition the introducer needle until free flow is obtained. Occlude the open hub of the introducer needle with the thumb of the nondominant hand while keeping the small finger of the hand in contact with the patient's skin. The Emergency Physicians proprioceptive reflexes will prevent movement of the introducer needle by maintaining contact with the patient's skin. Even a millimeter of movement may result in failure of the needle tip to stay within the lumen of the vein.
Prepare the guidewire (Figure 49-11). Grasp the guidewire and its sleeve with the dominant hand. The tip of the guidewire has a “J” shape when the sleeve is retracted (Figure 49-11A). Slide the sleeve forward to straighten out the “J” of the guidewire (Figure 49-11B). Insert the wire sleeve into the hub of the introducer needle (Figures 49-10B & 49-11C). Advance the guidewire through the sleeve and into the introducer needle. Never let go of the guidewire! One end of the wire must always be held to prevent loss of the wire and embolization into the central circulation.
Guidewire preparation. A. The plastic sleeve is retracted, showing the “J” tip. B. The plastic sleeve is advanced to cover the guidewire tip, allowing the wire to be threaded into the introducer needle. C. The sleeve is inserted into the hub of the introducer needle.
Do not simply reverse the guidewire if the sleeve used to straighten the curved end of the guidewire is lost. The straight end of the guidewire can puncture the wall of the vein. Grasp the guidewire between the fourth and fifth fingers and the palm of the dominant hand (Figure 49-12A). Apply gentle traction on the curved guidewire tip with the thumb and the second and third fingers in order to straighten the guidewire (Figure 49-12B). The guidewire can then be inserted into the introducer needle hub without the use of the sleeve.
Straightening the “J” tip. A. Grasp the guidewire between the ring and small fingers and the palm. B. Apply traction using the thumb and index fingers, stretching the outer coil of the wire over the solid core to straighten the “J” tip.
Advance the guidewire through the introducer needle and into the vein (Figure 49-10B). The guidewire should advance easily into the vein. Never force the guidewire. Guidewire resistance may indicate that the introducer needle is not within the vein, is against the wall of a vessel, or is caught as the vessel bends. Slightly withdraw the guidewire, rotate it slightly, and readvance it. The use of force will kink the guidewire and may cause it to damage the vein and adjoining tissues. Advance the guidewire 5 to 10 cm into the vessel or until ectopic beats are seen on the cardiac monitor. Withdraw the introducer needle and guidewire sheath while securely holding the guidewire (Figure 49-10C). Grasp the guidewire with the nondominant hand as soon as the guidewire is visible between the tip of the introducer needle and the skin. Finish removing the needle over the guidewire.
Make a small incision in the skin adjacent to the guidewire using a #11 scalpel blade (Figure 49-10D). Place the dilator over the straight end of the guidewire (Figure 49-10E). Advance the dilator over the guidewire, through the skin, and into the vein. A slight twisting motion of the dilator as it is advanced may aid in its insertion. Continue to advance the dilator until its hub is against the skin. Do not release hold of the guidewire at any time. Remove the dilator over the guidewire.
Place the catheter tip over the guidewire. Advance the catheter over the guidewire and into the vein to the desired depth (Figure 49-10F). Do not release hold of the guidewire. Gently rolling or twisting the catheter between the thumb and the forefinger may aid in its advancement. Hold the catheter securely in place and remove the guidewire (Figure 49-10G). Occlude the open catheter lumen with a sterile-gloved finger to prevent an air embolization and excessive blood loss.
Attach a syringe to the catheter hub and aspirate blood to confirm that the catheter is within the vein. Withdraw any necessary blood samples from the catheter. Attach infusion tubing or a heparin lock to the port and flush the catheter to prevent a blood clot from obstructing the lumen. If a multilumen catheter is inserted, flush any other lumens after first withdrawing any air (Figure 49-13). Securely attach the catheter to the skin with nylon or silk sutures. Cover the skin puncture site with a sterile dressing.
Aspiration and flushing of catheters. A. Any air in the lumen of the tubing is aspirated into the syringe of flush solution. The syringe must be held upright, as shown. B. Stop aspirating once all the air is removed from the catheter and blood begins to enter the syringe. C. Flush solution is injected until the lumen is filled and contains no blood. This usually requires 2 to 4 mL of flush solution.
Anterior Approach to the Internal Jugular Vein
The skin puncture site is at the anterior border of the sternal head of the sternocleidomastoid muscle, just lateral to the carotid artery and at the level of the cricoid cartilage (Figure 49-5). Enter the skin at a 45° to 60° angle. Direct the introducer needle toward the ipsilateral nipple. The internal jugular vein in an adult should be encountered within 3 to 5 cm. If the vein is not encountered by 5 cm, withdraw the tip of the introducer needle to the subcutaneous space and redirect it slightly medially. The remainder of the procedure is as described for the central approach above and in Table 49-6.
Posterior Approach to the Internal Jugular Vein
Enter the skin at the posterior edge of the sternocleidomastoid muscle, one-third of the way from the clavicle to the mastoid process (Figure 49-6). Alternatively, the point where the external jugular vein crosses the lateral border of the sternocleidomastoid muscle can be used. Direct the introducer needle under the sternocleidomastoid muscle at a 30° to 45° angle to the skin and toward the sternal notch. Place the index finger of the nondominant hand in the sternal notch to provide a landmark with the patient draped. In an adult, the internal jugular vein should be encountered within 5 cm. This approach is not recommended in children. The remainder of the procedure is as described for the central approach above and in Table 49-6.