This video demonstrates the placement of a central venous catheter (CVC) in the internal jugular vein (IJV) in an infant using real-time ultrasound (US) guidance. Traditionally, the landmark approach has been the technique used to guide CVC placement. Presently, the use of ultrasound (US) for guiding placement has become commonplace due to increased accessibility, improved technology, and evidence of increased first-attempt success rates and decreased complications. Real-time US-guided central venous cannulation is now the recommended technique over the landmark technique by professional organizations. The experienced use of US allows for the detection of abnormal anatomy or findings (e.g. vein thrombosis) and allows for real-time visualization, which is especially helpful during difficult insertions, absence of landmarks, and in challenging patient groups such as in small infants.
Traditionally, the landmark approach has been the technique used to guide CVC placement. Presently, the use of ultrasound (US) for guiding placement has become commonplace due to increased accessibility, improved technology, and evidence of increased first-attempt success rates and decreased complications. The experienced use of US allows for the detection of abnormal anatomy or findings (e.g. vein thrombosis) and allows for real-time visualization, which is especially helpful during difficult insertions, absence of landmarks, and in challenging patient groups such as in small infants.
There are pre-assembled kits for CVC placement. If not, equipment should include at least the following:
- Central venous catheter of chosen size, length, and number of lumens
- Introducer needle
- Tissue dilator
- Suture and needle
- Sterile saline (heparinized) flushes
- Sterile gauze
- Sterile skin cleansing solution such as chlorhexidine
- Sterile drapes
*For the operator: Sterile gown, gloves, cap, and face mask
*For the cleaned ultrasound probe: Sterile ultrasound gel and a sterile ultrasound probe cover
Review indications and the relative contraindications for CVC placement for the patient.
Hold procedure time-out to identify the correct patient, procedure, and site of the procedure.
Position the patient in the Trendelenburg position to minimize the risk of venous air embolism.
Turn the neck slightly to the contralateral side of the IJV cannulation.
Use continuous electrocardiogram(ECG), pulse oximetry, and blood pressure monitoring.
Scan the neck with the US prior to skin preparation and draping to identify relevant anatomy, confirm adequate IJV size and course prior to the procedure, and exclude abnormalities.
Prepare for the aseptic procedure by wearing a surgical mask and head covering, washing hands with antiseptic hand wash, and donning a sterile gown and gloves in a sterile manner as is done for surgical procedures.
Cleanse the skin over the site of puncture with chlorhexidine-alcohol-based solutions or alternatives.
Cover the patient with sterile draping exposing only the cleaned site for cannulation.
Open and prepare the equipment for cannulation.
Place the ultrasound probe and gel in a sterile sheath with the help of a bedside assistant in a sterile fashion.
Secure the US probe so it does not slide off the sterile field.
A high-frequency (5-15 MHz) linear ultrasound transducer is appropriate as the IJV is moderately superficial. Both short and long-axis views help guide and verify desired placement as the structures of interest are imaged in two different views. The short-axis view provides cross-sectional visualization of the vessels so that the diameters and relative positions of the IJV and carotid artery are visible. The long-axis view shows the longitudinal image of the vessels. In small infants, the short-axis view may be preferable and more ergonomic for puncture and tracking of the needle during IJV cannulation, while turning the probe for the long-axis view can be used to confirm and visualize its course. Make sure that the US probe orientation is aligned with the screen. Often, a mark on the side of the probe corresponds to a mark on the scan sector, or touching the side of the probe will match the orientation on the screen.
Scan the neck to identify the IJV and relative location to the carotid artery and external jugular vein. Follow the course of the IJV toward the clavicle and find the take-off of the subclavian vein. Gently apply pressure to the neck with the probe and note that the IJV is easily compressed while the carotid artery is pulsatile and retains its circular shape.
Select the site of puncture where the IJV is most accessible for a straightforward puncture while avoiding other vascular structures.
Puncture the site with the introducer needle under ultrasound guidance while visualizing the tip and ensuring the tip does not enter the carotid artery. Using the short-axis view, visualize the needle tip indenting the IJV, and then drop the angle of the needle until it is almost parallel to the vessel before piercing through the wall of the IJV. Once the tip is visualized inside the IJV lumen, attempt to keep the tip in the center of the lumen, like a “target”. Move the US probe away from the tip until it disappears, and then advance the tip of the needle into view. Repeat until most of the needle has been advanced into the vessel.
Thread the catheter and remove the needle; blood should be flowing out.
Attach tubing for manometry if this is the technique chosen to rule out carotid placement. Blood should flow into the tube. Let enough blood fill the tube such that when the tube is held vertically with the open end pointing up, a falling blood column will indicate that it is in the vein. The height of the blood column will need to be higher than the central venous pressure of the patient, for the blood column to decrease in height.
Remove the manometry tubing.
Thread the guidewire through the catheter and insert slightly beyond the anticipated catheter length, avoiding advancement into the ventricle.
Carefully monitor the electrocardiogram to identify any arrhythmias induced by the guidewire. If an arrhythmia does occur, pull back the guidewire until it resolves.
If manometry was not performed to rule out intra-arterial cannulation, an alternative is to track the guidewire along the IJV toward the heart and verify that it does not cross over to the carotid artery, in two different views. Usually, the probe can image as far as the junction of the IJV and the subclavian artery. Additional methods for confirmation that the wire is headed towards the right atrium include following the wire caudally with the ultrasound probe held perpendicular to the wire to the level of the clavicle. Tilt the probe posteroinferiorly, if necessary, to visualize the junction of the IJV and SVC. Now turn the probe longitudinally, adjusting the depth of view if needed, to visualize the wire in the superior vena cava.
Gently nick the skin against the guidewire with the scalpel. Insert the dilator without bending the guidewire. A twisting motion may help. Remove the dilator. Advance the CVC over the guidewire.
In pediatric patients, proper CVC insertion length should be determined so that the CVC ends at the cavoatrial junction. Several formulas are available to estimate the proper insertion depth using patient height or available anthropometric data. Alternatively, concurrent transesophageal echocardiogram (TEE) can help determine depth.
Once the CVC is at the desired insertion length, remove the guidewire.
Aspirate all ports for blood return and flush through with saline or heparinized saline.
Secure the CVC and place an antimicrobial disc and sterile dressing over the site.
Practitioners who want to incorporate US technology into their line placement practice --and are familiar only with the landmark technique for central venous catheterization, require ultrasound training and repeated exposure to gain proficiency so that this added technology can improve their first-attempt success rates and decrease complications. In addition to developing technical proficiency, the practitioner must also understand aspects of ultrasound technology such as imaging capacity (e.g. imaging depth associated with probe frequency) and its limitations (e.g. artifacts, 2-dimensional view). Failure to understand the technology may lead to improper interpretation of the images; for example, the needle shaft may be mistaken for the needle tip, resulting in complications including arterial puncture and cannulation. In practice, ultrasound operation requires good hand-eye coordination, and in small infants, the physical size of the probe may limit its utility. Indications for CVL placement in this procedure include monitoring for central venous pressure, administration of medication infusions that are irritants or sclerosing to peripheral vessels, and administration of large fluid volume. Additional indications include venous access when peripheral intravenous access is difficult, transvenous pacing wire placement, or aspiration of air in case of venous air embolism. Contraindications to this procedure are always relative. It depends on the urgency, the risk, and other alternatives for venous access. Contraindications to the cannulation site include abnormal anatomy, skin infection over the site, and thrombus inside the vein. Severe coagulopathy is a relative contraindication. In this situation, ultrasound-guided CVC placement is the method of choice for these patients at high risk of bleeding. Although the use of real-time ultrasound guidance can significantly decrease the complication rates of this procedure, it is important to remain aware of the ultrasound limitations in addition to those intrinsic to the catheterization process. Possible complications include arterial puncture, catheter malposition, pneumothorax, subcutaneous hematoma, hemothorax, and arrhythmia leading to cardiac arrest. To minimize the risk of these occurring, do not force the guidewire on insertion to avoid vessel damage or tearing of structures, and intermittently check that the wire is free to move when placing the dilator. Pushing the dilator in a different angle than the trajectory of the guidewire may cause it to bend, making removal difficult and causing damage to the vessel wall. Additionally, prevent air emboli by keeping the patient in the Trendelenburg position and carefully monitoring to ensure that blood flows out and not towards the heart through open ports that could entrain air. In summary, the proficient use of US for central venous catheterization facilitates real-time visualization, which is especially helpful during difficult insertions, absence of landmarks, and in challenging patient groups such as in small infants.