Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Hemodynamic monitoring (CVP, PAC insertion)Administration of fluids that cannot be administered peripherally: Hypertonic fluidsVasoactive drugs (vasopressors)Total parenteral nutrition (TPN)Aspiration of air emboliInsertion of transcutaneous pacing leadsContinuous renal replacement therapy in ICUImpossible peripheral IV access ++ Renal cell tumor extending into right atriumFungating tricuspid valve endocarditisAnticoagulation (relative contraindication), platelets <50,000Ipsilateral 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 areaSkin: Chlorhexidine (alcohol solutions rather than aqueous) associated with lower bloodstream infection rates than povidone–iodine or alcohol-based preparationsAdequate local anesthetic infiltration (unless under GA)Adequate sedation as appropriateProtect 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 embolismIncrease size of veinsKnow 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 SideGraphic Jump LocationView Full Size||Download Slide (.ppt)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 bodyAscertain landmarksUse 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 needleEnsure 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 syringeOtherwise, disconnect needle from syringe. Occlude needle to avoid air embolismInsert guidewire and exchange needle for angiocathConnect 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 transducerInsert wire to about 20 cm. Avoid inserting too far as this may trigger ventricular arrhythmiasNever let go of wire end to avoid losing it into the veinInsert 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 placeInsert catheter over wire. Ensure to have wire exit at the proximal end of the catheter before inserting tip of catheter into skinPush catheter ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth