Ultrasound Guided Internal Jugular Lines

ER Lines

Subclavien VeinFemoral VeinInternal Jugular Vein

IJ is the BEST!!!

Lower risk of pneumothorax compared to subclavian.

Compressibility of the vessel in the event of bleeding or arterial puncture (less likely with use of ultrasound).

Straight path from the right IJ to the SVC, better for pacemaker insertion.

Less line sepsis compared to femoral lines.

IJ with Ultrasound

Takes half as much time and half the number of attempts compared with landmark technique

About 90% reduction in incidence of PneumothoraxHemothoraxCarotid artery canulationNerve injury

“Full Barrier Precautions”

All central line insertions Mask for everyone in the room Wash your hands first Gown, gloves, hat Broad draping—the entire bed should be covered

Use of this technique has led to a exceedingly low rate of catheter related infections

Chlorhexidine (aqueous) is the preferred antiseptic

Terminal Positioning of the Catheters

Catheters should terminate in the distal innominate vein or proximal SVC

3 to 5 cm proximal to the junction of the SVC and right atrium to eliminate the risk of cardiac perforation.

The caval junction: Right side 14 to 16 cm from right-sided IJ or SC skin

punctures Left side 16 to 18 cm CVCs in IJ and SC veins should not be inserted to a depth of

>20 cm Confirm catheter tip position with a CXR.

Ultrasound Tips

Know your probe orientation.

Optimize screen position

Prior to getting sterile, check vein for compressibility.

Optimize the Image

Probe Prep – the hardest part

You hold open sterile probe cover. Assistant dumps non-sterile gel inside

probe cover.Assistant puts non-sterile gel on probe.Using gravity, assistant puts probe into

cover.You put on the sterile rubber bands.Put sterile gel on outside of probe cover.

Cover and Rubber Band Probe

Visualizing and Cannulating

Transverse is easier, longitudinal is better.

Line up the vein so it is in the middle of the screen, insert the needle in the middle of the probe.

Gently bounce the needle and manipulate the probe to see the tip.

Check the wire.

Transverse, Longitudinal

Post Line Placement CXR

Tip should be in the Superior Vena Cava, not the right atrium.

Ideally 2 cm below the sterno-manubrium junction.

Pneumothorax

Subclavian line placement results in a pneumothorax

Positive Lung Sliding Sign-No Pneumothorax

Complications

Carotid artery injury

Nerve injury PhrenicBrachial plexus

Seldinger

Maintain control of the wire.

Make a big enough nick, avoid skin bridge.

Cather Insertion Length

Formulas for Catheter Insertion Length Based on Patient Height and Approach

Site Formula In SVC (%) In RA (%)RSC (Hgt/10) – 2 cm 96 4LSC (Hgt/10) + 2 cm 97 2RIJ Hgt/10 90 10LIJ (Hgt/10) + 4 cm 94 5

Thread the catheter to approximately 2 cm below the manubriosternal junction

http://dhmcsedation.com/CVC/index.asp