- Hemodynamic monitoring (CVP, PAC insertion)
- Administration of fluids that cannot be administered peripherally:
- Hypertonic fluids
- Vasoactive drugs (vasopressors)
- Total parenteral nutrition (TPN)
- Aspiration of air emboli
- Insertion of transcutaneous pacing leads
- Continuous renal replacement therapy in ICU
- Impossible peripheral IV access
- Renal cell tumor extending into right atrium
- Fungating tricuspid valve endocarditis
- Anticoagulation (relative contraindication), platelets <50,000
- Ipsilateral carotid endartectomy (internal jugular [IJ] cannulation if not US-guided)
- Proper hand hygiene and use maximal barrier precautions including gown, mask, and gloves and a large sterile drape or multiple drapes covering a large area
- Chlorhexidine (alcohol solutions rather than aqueous) associated with lower bloodstream infection rates than povidone–iodine or alcohol-based preparations
- Adequate local anesthetic infiltration (unless under GA)
- Adequate sedation as appropriate
- Protect bed in ICU (“chucks” to avoid soiling sheets with skin prep or blood)
- Trendelenburg position (as tolerated) for IJ/subclavian lines to:
- Increase venous pressure and reduce risk of air embolism
- Increase size of veins
- Know anatomy:
- Relative position of IJ vein to carotid artery (Figure 197-1)
Figure 197-1. Position of IJ Vein Relative to the Carotid Artery (at the Center of the Circle) with the Patient's Head Rotated 30° Toward the Opposite Side
Adapted from Maecken T, Marcon C, Bomas S, Zenz M, Grau T. Relationship of the internal jugular vein to the common carotid artery: implications for ultrasound-guided vascular access. Eur J Anaesthesiol. 2011;28(5):351–355.
- Typical procedure using landmarks:
- Patient supine, arms alongside body
- Ascertain landmarks
- Use finder needle (20G) to obtain venous blood (not used for subclavian access)
- Leave finder needle (and syringe) in place, and use its direction as a guide to insert the introducer needle (16G)
- When venous blood is aspirated in the syringe, remove finder needle
- Ensure free blood flow, and then transduce pressure to ascertain venous placement:
- Some syringes (Raulerson) allow direct transduction (and guidewire insertion) through the plunger, without having to disconnect the syringe
- Otherwise, disconnect needle from syringe. Occlude needle to avoid air embolism
- Insert guidewire and exchange needle for angiocath
- Connect sterile IV tubing and hold tubing down to have blood flow 5-10 cm into the tubing. Then hold tubing up. The blood should oscillate a few centimeters above the skin puncture (venous pressure in cm H2O) but not fill the tubing (arterial puncture). Alternatively, measure pressure using a piezoelectric transducer
- Insert wire to about 20 cm. Avoid inserting too far as this may trigger ventricular arrhythmias
- Never let go of wire end to avoid losing it into the vein
- Insert dilator over guidewire; nick skin with blade and push dilator into the vein. Do not insert dilator more than half its length (risk of vein injury)
- Remove dilator while maintaining wire in place
- Insert catheter over wire. Ensure to have wire exit at the proximal end of the catheter before inserting tip of catheter into skin...
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