IJ catheter placement technique
Once we have confirmed the need for central venous catheterization, obtained the patient’s consent, and collected all equipment, we work as follows:
(i) Optimally position the patient: Trendelenburg’s position2 (head-down, to increase the size of the vein and prevent air embolism), with the head turned about 45 degrees to the opposite side.
(ii) Prepare: gown, sterile gloves, cap, mask, with catheter tray open and in easy reach.
(iii) Prepare the site: we prefer chlorhexidine, but an iodine solution that has dried can be substituted depending on the patient’s allergies.
(iv) Identify the insertion point: while there are many possible sites along the vessel, we advocate a mid to high approach, minimizing the possibility of pneumothorax. One technique: place the third finger of the left hand in the sternal notch, the thumb on the mastoid process, and then bisect the line with the index finger, adjusting to palpate the carotid at this level. Do not try to push the carotid out of the way, as both vessels lie in the same sheath. If the external jugular vein crosses at this location, move above or below it.
(v)Using a finder needle (22–23 g) attached to a syringe, begin about 1 cm lat-eral to the carotid pulse, aiming toward the ipsilateral nipple. Advance the needle through the skin, then gently aspirate on the plunger as you slowlyadvance the needle. In the average patient, the IJ should be no more than about 1.5 cm deep. If blood is not aspirated, slowly withdraw the needle and adjust the angle slightly. First check that the vein does not lie more lateral, then cautiously check more medially and caudally.
(vi) When blood is aspirated, carefully transfer the finder needle/syringe to the left hand. With the right hand, carefully advance the introducer needle along the finder needle and into the vessel until blood is easily aspirated.
(vii) Remove the finder needle and the syringe from the introducer needle, and confirm intravenous location (see below). Keep your thumb (in a sterile glove!) over the hub of the needle when there is nothing attached to minimize blood loss and avoid a potentially catastrophic air embolism if the central venous pressure is low, or should the patient suddenly decrease it by taking a gasping breath.
(viii) Advance the wire through the needle. Here, we must monitor ECG to detect the common extra systoles. Should there be a sustained run of ventricular tachycardia, withdraw the wire a few centimeters.
(ix) Remove the needle and advance the catheter over the wire to the desired depth (sometimes there will be a dilator step in-between). Make sure to hold the wire while advancing or removing equipment over it, so as not to remove it, or (worse yet) fully insert it into the patient.
(x) Remove the wire, cap off the ports, aspirate and flush each, suture the catheter in place, and dress with a clear occlusive dressing.
(xi) Obtain a chest radiograph to confirm the catheter tip position. The optimal location for a catheter placed via the IJ or SC route is just above the right atrium, where it will not perforate atrial tissue. An X-ray can also rule out pneumothorax and can suggest an extravascular location of the catheter.
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