Procedure: Central Venous Catheter (IJV)

Procedure, instructions and discussion

Internal Jugular Central Venous Catheter

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Instructions

Indications

INFUSIONS

• Vasoactive agent (noradrenaline)
• Irritant (potassium chloride)

EXTRACORPOREAL THEARAPY

• Haemodialysis
• Apheresis

INADEQUATE PERIPHERAL VENOUS ACCESS

TRANSVENOUS PACING

Contraindications (ABSOLUTE/relative)

• UNABLE TO LIE FLAT (FEMORAL PREFERRED)
• CERVICAL TRAUMA OR COLLAR
• Obstructed vein (thrombosis)
• Coagulopathy (APTT>50 secs, INR>1.5, plat<50,000/mm³)
• Antiplatelet medications or NOACs
• Overlying infection
• Distorted or damaged local anatomy
• Uncooperative patient

Alternatives

• Femoral central venous access
• Peripheral IV access (reduced infusion concentration)
• Intraosseous access

Informed consent

VERBAL – IF HAS CAPACITY

• Simple procedure with a low risk of complications

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to serious injury or death
• Brief verbal explanation of the procedure is still recommended.

Potential complications

• Pain and discomfort
• Failure
• Bleeding
• Arterial puncture
• Venous damage (erosion and stenosis)
• Nerve damage
• Air embolus
• Shearing or loss of guidewire
• Thrombosis
• Infection (local and systemic)

Infection control

• Standard precautions
• PPE: sterile gloves and gown, surgical mask, eye protection, sterile ultrasound probe cover

Area

• Resuscitation bay

Staff

• Procedural clinician
• Assistant

Equipment

• Ultrasound
• Catheter: multi-lumen, rated for pressure contrast injection
• Catheter set: syringe, needle, guidewire, dilator, fixation, saline and syringe)
• Suture and suture set
• Swappable capless valves for each lumen
• Drawing up needle
• 25g needle with 5ml syringe for lignocaine
• Sterile transparent semipermeable dressing

Positioning

• Supine on an incline
• Head down 15 degrees
• Head slightly rotated away from puncture site
• INSERTION SITE
• Between medial and lateral heads of SCM muscle
• Lateral to the carotid
• Aiming to ipsilateral nipple

Medication

• 10ml lignocaine 1%
• Consider analgesia and sedation

Sequence (Insertion)

• Set up equipment and flushes all lumens with 0.9% Saline
• Ultrasound identification of internal jugular vein and depth (confirm vein is compressible and locate artery)
• Anaesthetise skin and soft tissue with lignocaine
• Insert needle for guidewire under ultrasound guidance, aspirating until you withdraw blood
• Remove syringe and thread guidewire through needle (or pass-through syringe with some kits)
• Insert guidewire to a depth of 15cm (checking for arrythmia on ECG monitoring)
• Removing needle after wire placement and confirm that the guidewire is in a vein (using ultrasound)
• Use scalpel to lance a tract (through skin only) next to the guidewire
• Thread dilator over wire into the vein (6-8cm usually enough)
• Thread the catheter over the wire, making sure you always visualise and hold the guidewire
• Insertion depth: right 15cm, left = 19cm (at extremes of size: right = height/10cm, left = height/10 + 4cm)
• Remove wire and lock catheter to prevent flow of blood
• Confirm that the guidewire is complete, and the tip has not been damaged
• Aspirate and flush all lumens
• Suture at the skin and at the anchor point (if present)
• Apply sterile transparent semipermeable dressing

Post-procedure care

CHEST X-RAY

• Assess for pneumothorax
• Confirm tip in SVC outside right atrium (approximating the carina)

DOCUMENTATION

• Completion, technique, attempts, guidewire removal, complications

Tips

• Maintain light pressure only with ultrasound probe to avoid vessel compression
• Catheters placed in an artery, should be discussed with vascular before removal (correct clotting, direct pressure)

Discussion

The internal jugular route has the least acute complications (after PICC) and more often results in a satisfactory catheter location. The Internal jugular vein on the right is our preferred site of central venous access.

The femoral route is commonly useful when the patient cannot lie in the Trendelenburg position. The subclavian route has the lowest rates of infection, but the greatest risks of pneumothorax and serious haemorrhage. Although sometimes useful for emergency vascular access in an arrest, we do not recommend the routine use of this route for initial central lines.

This contrasts to the Australian and New Zealand Intensive Care Society which generally preferences the subclavian route due to the low infection rates.

References

• Australian and New Zealand Intensive Care Society [Internet]. Melbourne; 2012. ANZICS Safety and Quality Committee. 18pp. Available from: www.clabsi.com.au and www.anzics.com.au
• American Society of Anesthesiologists Task Force on Central Venous Access; Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, Fleisher LA, Grant S, Mark JB, Morray JP, Nickinovich DG, Tung A. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012 Mar;116(3):539-73.
• Murgo M, Spencer T, Breeding J, Alexandrou E, Baliotis B, Hallett T, Guihermino M, Martinich I, Frogley M, Denham J, Whyte R, Ray-Barruel B and Richard C. Central venous access device – post insertion management. Sydney: ACI; 2014. 978-1-74187-953-7
• Smith RN, Nolan JP. Central venous catheters. BMJ. 2013 Nov 11;347:f6570.
• Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017 Aug 28;21(1):225
• Czepizak CA, O’Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest. 1995 Jun;107(6):1662-4
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019. Chopra V. Central venous access devices and approach to device and site selection in adults. In: UpToDate. Waltham (MA): UpToDate. 2019. Available from: https://www.uptodate.com/contents/central-venous-access-devices-and-approach-to-device-and-site-selection-in-adults

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