Interventional nephrology dr? ahmed donia

Introduction to insertion of temporary IJ line

Ahmed Donia, MD, MRCP (UK)Consultant of nephrology

Urology and nephrology centerMansoura University, Egypt

Innominate (brachiocephalic) artery

Left innominate (brachiocephalic) vein

Innominate (brachiocephalic) artery

Left innominate (brachiocephalic) vein

At the level of the thyroid cartilage, the IJ vein can be found just deep of the sternocleidomastoid muscle

Innominate (brachiocephalic) artery

Left innominate (brachiocephalic) vein

The IJ vein emerges from under the apex of the triangle of the two heads of the sternocleidomastoid muscle and joins the subclavian vein behind the clavicle.

Artery and vein slightly separateVein overlaps artery

Innominate (brachiocephalic) artery

Left innominate (brachiocephalic) vein

Unlike the subclavian vein, the IJ vein is quite distensible. The vessel diameter is increased with performance of a Valsalva maneuver and the assumption of the head-down (Trendelenburg) tilt position.

Innominate (brachiocephalic) artery

Left innominate (brachiocephalic) vein

Prolonged palpation of the carotid pulse will decrease the diameter of the IJ vein.

Rotating the head 90 degrees toward the opposite side or extending the neck will not change the size of the IJ vessel significantly

Severe rotation of the head will bring the sterno-cleidomastoid muscle anterior or medial to the IJ vein and may make cannulation impossible without first traversing the carotid artery

ANTERIOR APPROACH

ANTERIOR APPROACH

POSTERIOR APPROACH

POSTERIOR APPROACH

POSTERIOR APPROACH

The posterior approach is probably the hardest landmark-wise, but it carries the lowest likelihood of complications.

CENTRAL APPROACH

CENTRAL APPROACH

CENTRAL APPROACH

The central approach is the most commonly used. The IJ will often be a little more lateral than you expect with this approach, and can move around depending on how much your patient’s head is turned

This approach does have the highest likelihood of causing a pneumothorax, so if you don’t get blood within 3 cm or so, don’t keep advancing your needle

The needle is inserted at the apex of the triangle between the two heads of the sternocleidomastoid muscle, at a 45° angle to the skin in the direction of the ipselateral nipple.

The needle should enter the vein at a depth approximately 2-3 cm from the skin

Apex of triangle formed by 2 heads of sternocleidomastoid muscle ('high' approach)

The needle is inserted at the centre point of this triangle at a 30° angle to the skin in a caudal direction.

Care should be taken not to insert the needle too deeply as this will increase the risk of causing a pneumothorax - the IJV should be located within a few centimeters depth from the skin

Central low approach

The first, and perhaps the most important, part of UGCVC is the initial ultrasonographic examination of the neck to determine the best site for needle puncture and central line placement.

If tolerated, place the patient in 15 degrees of Trendelenburg to optimize vessel diameter

the needle is more likely to traverse the common carotid artery if the head is turned more than 30 degrees from midline

Track the internal jugular vein from the angle of the mandible down into the supraclavicular fossa using the linear ultrasound probe in the transverse orientation.

Track the internal jugular vein from the angle of the mandible down into the supraclavicular fossa using the linear ultrasound probe in the transverse orientation.

The ideal location for needle puncture and central line placement depends on various factors

During the initial scan of the internal jugular vein, make note of vessel patency, diameter, degree of collapse with respiration, overlap with the internal carotid artery, and depth from the skin.

During the initial penetration of the needle through the skin, the operator should note a depression of the skin on the ultrasound monitor. If the needle is aligned correctly, this soft tissue depression should be located directly over the target vessel.

The operator should be looking at the patient's neck and the needle during any adjustments in needle position.

The operator should be looking at the patient's neck and the needle during any adjustments in needle position.

advancing the needle in small (approximately 1cm) increments. This will allow the operator to be immediately aware of the first sign of blood "flashback" in the syringe and avoid the common mistake of through-and-through vessel puncture

If the needle tip is angled lateral or medial to the vessel, withdraw the needle to just below the skin surface, and then adjust the needle's orientation.

Once the needle is passed in the correct plane, the needle tip will be seen on the ultrasound screen to "indent" the wall of the internal jugular vein.

Negative pressure should be applied to the syringe

Once blood flashback is obtained, the guide wire can be passed through the needle into the vein. A transverse image of the internal jugular vein should now be obtained from the puncture site down to the supraclavicular fossa while noting the guide wire location

Price = 2500 USD