Procedure

Ultrasound-Guided Internal Jugular Vein Catheterization

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Ultrasound-Guided Internal Jugular Vein Catheterization, Catheterization of Internal Jugular Vein, IJ Line, Internal Jugular Central Line, Jugular Vein Catheterization

  • See Also
  1. Central IV Access
  2. Intravenous Access
  3. Peripheral IV Access
  4. Intraosseous Access
  • Indications
  1. Sepsis catheter
    1. PreSep Central Venous Oximetry Catheter for ScvO2
  2. Venous access
    1. Indicated when unable to obtain peripheral venous access
    2. Consider Ultrasound-Guided Antecubital Line
  3. Emergency Resuscitation
    1. Indicated when unable to get rapid peripheral access
    2. Consider Intraosseous Access instead
  4. Central Venous Pressure Monitoring (CVP Line)
    1. Consider Ultrasound assessment of volume status instead
  5. Temporary venous pacing
  • Contraindications
  1. Coagulopathy (relative contraindication)
    1. Compressible sites may be considered (e.g. in this case the internal jugular)
  2. Contralateral Pneumothorax or Hemothorax
    1. Do not place a Central Line on the "good side" opposite a compromised lung
    2. Applies most to subclavian line placement
    3. Pneumothorax can however still complicate internal jugular catheterization
  3. Internal jugular thrombosis
    1. Pre-scan the internal Jugular Veins prior to catheterization (identify thrombosis)
  4. Morbid Obesity (relative contraindication)
    1. Internal jugular landmarks are more difficult in the morbidly obese
  • Adverse Effects
  1. Infectious complications
    1. Cellulitis at insertion site
    2. Line Sepsis
  2. Lung complications
    1. Pneumothorax
    2. Hemothorax
    3. Chylothorax (left-sided IJ)
  3. Cardiovascular complications
    1. Carotid Artery puncture
    2. Air Embolism
    3. Hematoma
    4. Vessel Laceration or dissection
    5. Catheter embolism
    6. Deep Venous thrombosis (DVT)
    7. Arrhythmia (guidewire or catheter irritation of Myocardium)
  4. Technical complications
    1. Failed placement
    2. Guidewire lost, broken or coiled
  5. Neurologic complications
    1. Phrenic Nerve injury
    2. Recurrent Laryngeal Nerve injury
  • Technique
  • Ultrasound Guidance of right Internal Jugular Line
  1. Preparation of Ultrasound Machine
    1. Linear array transducer (frequency 7.5 to 10 MHz)
    2. Transducer Orientation
      1. Typical: Short access (transverse) with indicator toward left (patient's 3:00 position)
      2. Alternative: Oblique
    3. Ultrasound transducer/probe sterile cover (accordian folded)
    4. Sterile gel
    5. Sterile Rubber bands (2) to fix cover around the transducer
  2. Images
    1. ultrasoundProbePositionGuidedCentralIJ.jpg
    2. cvCentralLineSheathedProbe.png
  3. Pre-scan neck with Ultrasound
    1. Apply non-sterile gel to Ultrasound probe
    2. Probe in transverse (short access) orientation with indicator towards patient's 3:00 position or left side
    3. Probe should remain perpendicular to skin surface (until following needle entry)
    4. Start over trachea and slide laterally over Thyroid onto carotid and then internal jugular
      1. Positions probe with most medial view of vessels which separates the vessels optimally
      2. Lateral approach often overlaps the vessels
    5. Apply gentle pressure with the probe to avoid compressing the internal Jugular Vein
    6. Slowly move the transducer down the neck, over the course of the internal jugular, toward the right clavicle
    7. Internal Jugular Vein localization
      1. Internal jugular is lateral and anterior to the Carotid Artery in most cases (right side of screen)
      2. Internal Jugular Vein is typically much larger diameter than Carotid Artery
      3. IJ vein increases in diameter with valsalva, trandelenberg position or abdominal applied pressure
      4. Internal Jugular Vein will compress with skin pressure or neck extension
      5. Doppler flow can be used if necessary to distinguish internal Jugular Vein from the Carotid Artery
    8. Position the internal Jugular Vein in the center of the monitor
    9. Length of central venous catheter
      1. Should be at least 1.4 times the measured depth of the internal Jugular Vein
      2. Based on insertion angle of 45 degrees
  4. Prepare Ultrasound transducer for sterile technique
    1. Images
      1. ultrasoundProbeCoverApplication@0,25x.jpg
    2. Prior to gowning and gloving
      1. Reapply non-sterile gel to Ultrasound transducer (while it sits in holder)
      2. Position the Ultrasound machine in front of you and to your right side
    3. After gowning and gloving and after preparing Central Line (see below)
      1. Open sterile probe cover package on sterile field
      2. Position the sterile cover with the "well" (inside of bag) facing down
      3. Insert non-dominant hand onto the "well" and push hand through
      4. Transfer the cover to the dominant hand, grasping the inside of "well"
      5. Grasp the pre-gelled transducer probe (from above as it sits in its holder) through the cover
      6. Lift the transducer probe out of its holder so the transducer and cord are held in mid-air
      7. Slide the cover over the transducer and cord, stripping the cover of air
      8. Tap/compress the sterile cover against the pre-gelled transducer to eliminate air bubbles
        1. A smooth layer of gel should remain between the probe cover and the transducer
      9. Use sterile Rubber bands to fix the sterile cover to the underlying transducer probe
        1. Apply each of 2 sterile Rubber bands to the cover overlying the body of the transducer
    4. Precautions
      1. Sterile transducer and cord cover is essential to reduce the risk of infection with Central Line Placement
      2. Any bubbles between transducer and skin will markedly decrease the quality of the Ultrasound image
      3. Sterile cover makes the transducer and cord very slippery
        1. When not being held, place the $10,000 transducer in a secure location
        2. Should not be in a position where it will slide, fall, and break
        3. When done with placement, hand off the transducer to an assistant
  5. Technique of Ultrasound-guided needle placement
    1. Consider using 18 gauge long angiocatheter in Central Line kit (see description below)
    2. Hold the Ultrasound transducer in non-dominant hand
      1. Needle insertion is performed with dominant hand
    3. Transducer is in short axis (transverse) with indicator facing left (patient's 3:00 position)
      1. Long axis is rarely possible in the neck due to inadequate space (except for guidewire confirmation)
      2. Oblique technique allows for some features of both short and long axis
        1. Transduce oriented with indicator pointing toward 4-5:00 (between short and long axis)
        2. Phelan (2009) J Emerg Med. 2009 37(4):403-8 [PubMed]
    4. Position Jugular Vein in midline of Ultrasound image
    5. Insert needle at midline of transducer (typically near apex of sternocleidomastoid)
      1. Direct needle such that it is not in-line to strike Carotid Artery (toward ipsilateral nipple)
    6. Advance needle with jack hammer technique
      1. Small ocillations of forward movement enhance the visualization of the needle
      2. Small foward movements decrease possibility of entering posterior vessel wall
    7. Observe needle enter vessel
      1. Needle tip typically enhances with hyperechoic line
      2. Gentle insertion decreases risk of striking posterior internal jugular wall
    8. Confirm guidewire placement prior to dilation and catheter insertion
      1. Use long axis (with indicator away from you toward patient's feet or 6:00 position)
      2. Visualize the guidewire within the internal Jugular Vein
  • Technique
  • Right internal jugular central venous catheter insertion
  1. Position patient in trendelenburg position (head angled down toward floor)
    1. Lower risk of Air Embolism
    2. Engorges vessels and allows for easier visualization
  2. Preparation of the catheter
    1. Flush all three central venous catheter lumens with Normal Saline
    2. Flushing lines is preferred to aspirating as low volume may result in line collapse on aspiration
  3. Preparation of skin
    1. Perform Ultrasound machine preparation and pre-scanning as above
    2. Position head extended and turned away from the insertion site
    3. Apply Hibiclens to a wide area over the anterior-lateral neck
    4. Drape the neck to shield all but the prepped skin
  4. Local Anesthetic
    1. Clear any air bubbles in a syringe of Lidocaine 1% without Epinephrine
      1. Air bubbles will markedly decrease quality of Ultrasound image
    2. Inject Lidocaine 1% without Epinephrine at the entry site
      1. Raise a skin wheal at insertion site
      2. Infiltrate along expected needle insertion tract
        1. Aspirate prior to injecting to prevent intravascular injection
  5. Needle insertion site
    1. Use Ultrasound localization technique described above
    2. Insertion site
      1. Insertion site will be lateral to palpated carotid pulsation
      2. Approximately at top of triangle formed by sternocleidomastoid Muscles bodies and clavicle
      3. Caution
        1. Internal Jugular Vein positioning is variable
        2. Ultrasound guidance is far preferred as landmarks are unreliable
        3. Avoid inserting needle through the sternocleidomastoid Muscle (Hematoma risk)
      4. Landmark triangle (insertion is at the apex of triangle, where two bodies of SCM meet)
        1. Anterior sternocleidomastoid Muscle (SCM) body
        2. Posterior sternocleidomastoid Muscle (SCM) body
        3. Clavicle (base of triangle)
      5. Landmarks by finger breadths
        1. Three fingers lateral to midline trachea
        2. Three fingers superior to clavicle (approximate level of cricoid ring)
    3. Needle insertion
      1. Needle types (either is attached to a 10 cc syringe)
        1. Steel Needle 18g (standard, more rigid)
        2. Angiocatheter 18g - long (alternative to steel needle)
          1. Angiocatheter (18 gauge) is typically included in the Central Line kit
          2. Once in lumen, remove needle and thread wire through catheter
          3. May be easier to maintain catheter within vessel lumen while threading guide wire
          4. In large patients, angiocatheter may be too short to access the vessel lumen
      2. Needle is directed toward nipple on side of insertion
      3. Insert needle at 45 degrees to the skin plane (when using Ultrasound guidance)
        1. Landmark insertion (without Ultrasound) is typically at a 30 degree angle to the skin plane
      4. Advance needle as described above under technique of Ultrasound-guided needle insertion
        1. Internal jugular is typically superficial (2-3 cm depth from skin surface)
        2. Aspirate while inserting needle
        3. Advance the needle another 0.5 cm past the time blood is first aspirated (to ensure in lumen)
  6. Guide-wire insertion
    1. Remove syringe from needle
    2. Occlude the open needle base to prevent bleeding and Air Embolism
    3. Insert guidewire
      1. Some recommend observing guidewire enter vessel on Ultrasound
    4. Typically insert guidewire until free end is approximately at the level of the patient's head
      1. Withdraw guidewire a short distance if ectopy seen on telemetry monitor
  7. Withdraw needle
    1. Firmly grasp guide wire
    2. Back out over the wire
    3. Adjust grasp on wire to be at skin entry site once needle is withdrawn
  8. Make skin nick
    1. Nick skin with #11 blade along the edge of the wire insertion site
    2. Confirm that the nick is contiguous with the space the wire lies within
  9. Dilator insertion
    1. Insert dilator over the wire and into the skin
      1. Do not fully insert dilator
      2. Only insert dilator far enough to dilate skin and soft tissue, but not vessel
    2. Twist the dilator to assist in advancing past resistance
    3. Withdraw the dilator
  10. Central catheter insertion
    1. Always have hold of guidewire throughout this process
    2. Insert catheter over the guide wire via the longest, most distal port (remove brown cap)
      1. As catheter approaches skin, if guidewire does not emerge through port
        1. Withdraw the guidewire from skin until it emerges via port
      2. Grasp the guidewire at the distal port prior to letting go of guidewire at skin
    3. Advance catheter through skin to estimated depth
      1. Err on the side of caution by inserting further than estimate (e.g. 15 cm right, 20 cm left)
        1. Line may be withdrawn if inserted too far
        2. Line may not be inserted deeper after initial placement
          1. Deeper insertion requires replacement of line over another guidewire
      2. Typical final insertion depths (as above, insert further than these depths initially)
        1. Right side: Men 12-13 cm, Women: 11-12 cm
        2. Left side: Add 5 cm to right side length
    4. Remove guidewire
    5. Flush all 3 lines (all three lines should have been filled with saline in preparation)
  11. Confirm catheter placement
    1. Secure Central Line
    2. Portable Chest XRay
      1. Central Line tip should be at superior vena cava junction with right atrium
      2. Approximate tip position is 2 cm below the superior right heart sillhouette
      3. Tip will be 4-5 cm below the carina, just below the hilum
    3. Bedside Ultrasound
      1. Alternative to Chest XRay for line confirmation
      2. Confirm line is not tracking superiorly (intracranially)
        1. Follow catheter into internal Jugular Vein and inferiorly with linear probe
      3. Confirm no Pneumothorax
        1. See Lung Ultrasound for Pneumothorax
      4. Confirm venous catheter placement
        1. Agitate Normal Saline in a syringe (mix the syringe back and forth to create microbubbles)
        2. Connect the agitated saline to the distal port on Central Line
        3. View right ventricle on Ultrasound (cardiac probe at subxiphoid or apical view)
        4. Flush the saline and observe the bubbles in the right ventricle
      5. References
        1. Montrief and Long in Swadron (2021) EM:Rap 21(12): 15-6
    4. Adjust Central Line based on Chest XRay (may withdraw, but may not insert further due to infection risk)
      1. Lines in the brachiocephalic or subclavian veins are tolerated well and do not need repositioning
      2. https://emcrit.org/pulmcrit/does-central-line-position-matter-can-we-use-ultrasonography-to-confirm-line-position/
    5. Suture the Central Line in place
  • Resources
  1. Internal jugular central venous catheter placement video (part 1)
    1. http://www.youtube.com/watch?v=4-uyTUzPSJ8
  2. Internal jugular central venous catheter placement video (part 2)
    1. http://www.youtube.com/watch?v=UrHwKQY8qEQ
  3. Internal jugular central venous catheter placement video (ACEP Critical Decisions Video)
    1. http://www.acep.org/cdem_2014_lesson_10-1/
  • References
  1. Abbott Northwestern Residency
    1. http://www.anwresidency.com/simulation/guide/ij.html
  2. Dewitz (2012) Ultrasound-Guided Vascular Access Video, GulfCoast Ultrasound, VL-90-UGVAHD
    1. https://www.gcus.com/products/about.asp?product=306/Ultrasound-Guided-Vascular-Access
  3. Hoffman - Ultrasound Guide for Emergency Physicians
    1. http://www.sonoguide.com/line_placement.html
  4. Weingart - EM-Crit: Central Lines
    1. http://emcrit.org/central-lines/