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  • 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)

  • Hygiene:
    • 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
  • Skin:
    • 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
    • Push catheter ...

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