Procedure: Central Venous Catheter (IJV)

The Procedure

Hello again from the Emergency Procedures team,

Internal Jugular Central Venous Catheter

Today we cover a core procedure, and we take a deep dive into the evidence. The emergency procedures team have taken a deep dive into artificial evidence tools and had a hard think about many of the details on this procedure.

Detailed written instructions and explanation are available in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions

So, without further ado…here is the video

The rationale…

Which types of central lines should I be able to place as an Emergency Medicine doctor?

We consider the placement of ultrasound-guided internal jugular or femoral central lines a core emergency medicine skill, with the right internal jugular route the preferred site for central venous catheter insertion.

The femoral route is commonly useful when the patient cannot lie supine on an incline with the head down, tolerate a drape over their head, or when the neck cannot be accessed (e.g., C-spine collar).

Subclavian central lines can be useful for experienced doctors in specific situations. However, they present the greatest challenge in ultrasound guidance and carry the highest risks of pneumothorax and non-compressible haemorrhage, making them our least preferred option for standard central access in emergency situations

Do I always need to use real-time ultrasound guidance?

Yes, absolutely.

Central venous catheters should be placed under real-time ultrasound guidance. This has been shown to greatly increase success and reduce complications through the ability to assess anatomy, confirm vessel patency, and confirm guidewire position.

Ultrasound techniques also reduce infection rates, provided a sterile probe cover and sterile gel are used over a clean probe. Always assume the probe is dirty unless proven otherwise and be rigorous with cleaning and aseptic non-touch technique.

Should I use a short or a long-axis ultrasound technique when inserting my line?

Central lines can be inserted with a short or long-axis approach, depending on clinician preference and skill level.

We recommend clinicians begin learning with the short-axis technique and consider progressing to the long-axis technique as their ultrasound line skills grow. The short-axis view is easier to learn, shows surrounding anatomy, and is easier in obesity and short necks. The long axis, although more challenging, allows full visualization of the needle shaft and tip throughout the procedure, reducing the risk of penetrating the posterior wall of the vein, which can more easily occur in the short axis if the needle tip is lost from view.

Always insert your needle at a shallow angle to maximize ultrasound visibility. Use the needle with the bevel facing downward (toward the posterior wall of the vessel); this reduces the risk of posterior wall puncture and enhances ultrasound visibility of the needle.

Should I pierce the skin with a needle or a cannula?

Some central line kits have two options for accessing the vein: either a thin-walled introducer needle on a syringe (traditional) or a cannula-over-needle option.

We recommend the traditional thin-walled needle, which has higher first-pass success and lower complication rates in available trials comparing both methods. Success rates are high with both methods, and experienced clinicians may prefer the cannula in selected cases.

What do I need to know about using a guidewire?

The main thing is always to keep hold of one end of your wire as you insert your line; it is very important not to lose the wire inside your patient’s vessel.

As you insert your wire, point the curve of the wire downwards towards the bed to avoid malpositioning in an incorrect vessel (subclavian, internal mammary, brachial veins). Next, you must visualise the guidewire in two planes after insertion to confirm its position in the vein before dilating and placing your line. If you have doubts as to wire position, pushing the neck skin can enhance guidewire visibility on ultrasound.

Never dilate and place a line if you are not confident in the position of your wire; instead, withdraw the wire and restart the procedure. An arterial puncture will self-seal, whereas a dilated tract into an artery may require surgical closure.

Should I perform additional checks after placing my line to confirm it is in the right place?

Once you have placed a right IJ CVC, it usually needs to be inserted to 15 cm to lie correctly positioned in the distal superior vena cava next to the trachea. This depends on an insertion point approximating the cricoid membrane in an average-sized person. For larger patients, use insertion depth (cm) = Height (cm) / 10. If you are inserting on the left side, add 2 cm.

Confirm catheter tip placement opposite the carina with a chest X-ray prior to use. If a central venous catheter is found to be mispositioned in the wrong vessel, it should be removed and replaced as soon as practicable.

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