IJ Catheter Insertion 

Background

Central venous access allows rapid high-volume fluid administration, administration of multiple medications, and hemodynamic measurements. It is often used for reliable venous access in ill patients.

There are numerous routes of central venous access including internal jugular (IJ), subclavian and femoral. This module will focus on internal jugular central venous catheter placement.

Procedure Summary

List of key objectives as outlined by the modules:

• Patient positioning

• Patient preparation and sterilization

• Local anesthetic administration

• Needle insertion

• Guide wire insertion

• Dilation

• Insertion of central line catheter

• Securement of central line

• Confirmation of placement

Key anatomy

The internal jugular vein is anterolateral to the common carotid artery at the level of the sternocleidomastoid muscle, and is located superficially (approximately 1.5cm beneath the skin) between the two heads of the sternocleidomastoid muscle at the base of the neck. It then joins the subclavian vein to form the brachiocephalic vein behind the clavicle.

The right IJ vein is preferred to the left IJ vein, due to slightly decreased risks of complications. Anatomically, the right side provides a direct route to the superior vena cava and is often larger than the left one. Additionally, due to the anatomy of the lungs there is a slightly lower risk of pneumothorax.

Indications

• Need for rapid administration of IV fluids or blood

• Inadequate peripheral venous access

• Administration of medications known to cause phlebitis

• Hemodynamic monitoring

Contraindications

There are no absolute contraindications as central venous access could be necessary in severely ill patients when central line placement benefits outweigh the risks.

Relative contraindications include indwelling intravascular hardware at the site (such as pacemaker or hemodialysis access), abnormal neck anatomy, overlying skin infection at the site of access, vascular injury proximal to the insertion site, coagulopathy or thrombocytopenia.

Anesthesia

Local anesthesia is provided at the site of the catheter insertion. General anesthesia or sedation are usually not required.

Post-operative care

No specific care necessary after placement of a central line, although patients usually require close monitoring and treatment of the underlying cause of the condition that led to central line placement.

Possible complications

The most common immediate complications of central line placement include cardiac dysrhythmias, vascular injury, bleeding, catheter malposition and pneumothorax. Less common complications include stroke, airway compromise, air embolism, pericardial tamponade, and the loss or entrapment of the guide wire.

The most common long-term complications include infection and thrombosis.

 References

1. Heffner, Alan C and Androes, Mark P. Overview of central venous access. UpToDate, 13 November 2015. Web. 4 December 2015.

2. Heffner, Alan C and Androes, Mark P. Placement of jugular venous catheters. UpToDate, 10 February 2015. Web. 4 December 2015.

3. Reichman, Eric F. and Miller, Sara K. (2009). Vascular Access In Allan B Wolfson (Ed.), Harwood Nuss’ Clinical Practice of Emergency Medicine (pp 44-53). Philadelphia, PA: Lippincott Williams and Wilkins.

4. Young, Michael P. Complications of central venous catheters and their prevention. UpToDate, 27 August 2014. Web. 4 December 2015.

SURGICAL INSTRUMENTS & O.R. NEEDS

INSTRUMENTS:

·   Excision set/Suturing set

OR NEEDS:

Disposable gowns/ Laparotomy pack

Sterile gloves

Lubricating jelly

Syringes (10cc, 1cc)

Blade 11

Heparin (1000 IU/ml)

Lidocaine

Tegaderm (small and medium)

Operating sponge

Povidone Iodine (7.5%, 10%)

Sleeves/Stockinette

0.9% Sodium Chloride Solution

Alcohol

Hemodialysis catheter (Surgeon’s preference)

SUTURES:

Any atraumatic cutting needle available (Nylon or Silk)

DRESSING:

Operating sponge with Tegaderm

Biopatch (Optional)