Central Venous Access via Posterior

Approach to Internal Jugular Vein

In caring for patients who are critically ill, access to the central venous circulation is important. Central
venous access allows the placement of various types of intravenous (IV) lines to facilitate the infusion of
fluids, blood products, and drugs and to obtain blood for laboratory analysis. It is also an essential
procedure in patients in whom placement of a line in a peripheral vein is impossible. A central line may
be the only means of venous access in such cases.

Subclavian and internal jugular lines can allow the measurement of central venous pressure (CVP), an
important parameter to gauge if a patient has been given an adequate amount of fluids.

Three central veins are typically used for venous access:

Internal jugular vein (IJV)

Subclavian vein
Femoral vein

The capacity to place a line in the IJV is an important skill; this is the preferred vein for placement of a
transvenous pacemaker because it is a straight line down the vein to the right side of the heart. Given that
it can be compressed, the IJV can be used for central venous access in patients who have impaired blood
clotting. However, in such patients, the femoral vein is most often used.

There are three traditional approaches to the IJV:

Anterior
Posterior
Central

The central and posterior approaches are most commonly used and are less likely to result in puncture of
the carotid artery. This article describes the posterior approach to cannulation of the IJV.

Indications

Indications for the posterior approach to the IJV are the same as for any of the indications for a central
line. They include the following:

Fluid resuscitation requiring a large-bore IV line for medical or trauma resuscitation

Need for a multilumen IV line
Lack of peripheral access
Measurement of CVP
Access via the superior vena cava to the right ventricle for passage of a venous pacemaker
Access to the pulmonary artery via the right ventricle for passage of a Swan-Ganz catheter
Access to a large vein for temporary renal dialysis
Access to a large vein for administration of hypertonic solutions (eg, for total parenteral nutrition)
Contraindications

No absolute contraindications exist to placement of a central line in the IJV via the posterior approach.

Relative contraindications revolve around mechanical problems of access to the neck. Skin infection,
abscess, trauma, scarring, or mass along the side of the neck would make cannulation of the IJV difficult
and hazardous. In addition, obesity may obscure landmarks and increase the risk of complications.

A coagulopathy, regardless of etiology, is a relative contraindication even though the IJV, unlike the
subclavian vein, is compressible. The compressibility of the IJV allows it to be used for central line
placement in a patient with a clotting disorder.

The ability to turn the head away from the side where the line is being placed, though not essential, is
helpful with the posterior approach to the IJV. In patients with limited neck mobility (eg, trauma patients
who do not have the cervical spine cleared), the posterior approach can be quite difficult.

Finally, cooperation of the patient is essential because the lung and carotid artery are nearby and the risk
of injury is excessive if the patient moves during the procedure.

Periprocedural Care

Equipment

A preassembled kit for central line cannulation is used, typically containing the following equipment:

Local anesthetic (eg, lidocaine 1%) with needles and syringes

Thin-walled 14- to 18-gauge introducer needle
J-tip guide wire and semirigid dilator
Central line catheter
Antiseptic solution and applicator (eg, povidone-iodine or chlorhexidine)
Sterile drapes, gloves, and gown
Nonsterile mask and cap
Gauze pads
No. 11 blade scalpel
Suture (commonly, 3-0 silk on a straight cutting needle)
Antibiotic ointment for the dressing
Plastic occlusive dressing

Patient preparation

Anesthesia

The most common means of anesthesia for placement of an IV line in the IJV is use of a local anesthetic
(eg, lidocaine). Generous administration of a local anesthetic in the area just posterior to the midportion of
the sternocleidomastoid is typically sufficient for the patient's comfort before tunneling of the catheter.

Care must be taken not to inject the anesthetic into either the internal jugular vein or the carotid artery.
Additional local anesthetic is used on the skin for the sutures that secure the catheter to the skin.
In certain patients, the pain of the procedure is such that additional sedation, pain control, or both might
be prudent. Titrated doses of midazolam, fentanyl, or both are useful because these are agents with
relatively short durations of action and minimal cardiovascular effects.

Positioning

A key aspect of central line placement in the IJV is proper positioning of the patient. Putting the patient in
the Trendelenburg position dilates the vein and makes cannulation easier. In addition, this position makes
the external jugular vein (EJV) more prominent. The point at which the vein crosses the
sternocleidomastoid is a key landmark in the posterior approach.

Some patients cannot tolerate having their head lower than their feet. In such patients, laying them down
as flat as possible is important to the success of the procedure.

The patients head should be turned away from the side of the internal jugular vein being accessed to
provide access to the side of the neck. Having an assistant hold the patients head in that position is often
necessary. Turning the patients head to the side also makes the sternocleidomastoid more prominent and
makes the landmarks easier to identify.

Technique

Approach considerations

The method most commonly employed to place a cannula in the internal jugular vein (IJV) is the
Seldinger wire technique. Various catheters can be placed in the IJV, including single lumen, multiple
lumen, large-bore sheaths, and dialysis catheters such as the Quinton catheter.

The posterior approach does not lend itself as easily to ultrasonographic guidance as the anterior approach
does. However, the use of ultrasonography can allow visualization of the IJV and carotid artery and is
often helpful regardless of the particular approach taken to the IJV.

In placing a central line in the IJV or the subclavian vein, the Trendelenburg position distends the veins in
the patient's neck and thereby makes them easier to cannulate. Either side of the neck can be used, but the
right IJV is most often used.

Cannulation of internal jugular vein via posterior approach

To begin the procedure, inspect the neck to identify landmarks, including the posterior edge of the
sternocleidomastoid (see the image below) and the external jugular vein (EJV), and palpate the carotid
artery to ascertain its position. Also, look for any skin infections or neck masses
Place the patient in the Trendelenburg position, 10-15o, and turn the patients face to the contralateral
side.

Drape with sterile sheets or towels as with any sterile procedure. The use of large sterile sheets to cover
the patient and the use of a cover over the hair, a mask, and a sterile gown and gloves for the practitioner
have been shown to decrease the rate of line infection.

Clean the skin of the patients neck down to the clavicle and upper chest with the antiseptic solution, and
apply the drape to allow visualization of the middle of the neck.

Identify the point of insertion for the introducer needle along the posterior edge of the
sternocleidomastoid at the level just superior to where the EJV crosses the muscle. This is typically one
third of the distance between the mastoid and the clavicle.

Anesthetize the skin and subcutaneous tissue at this point, aspirating so that lidocaine is not injected
directly into a vessel. Typically, a 25-gauge needle is used to administer the local anesthetic. This same
needle can be used to localize the IJV to determine how deep and at what angle to the skin the vein might
be. Even a long 25-gauge needle may not have sufficient length to reach the IJV. However, hunting for
the vein with a smaller-gauge needle tends to be less traumatic than using the introducer needle would be.

Place the introducer needle at the area of anesthetized skin, aiming down toward the sternal notch.
Advance the needle while aspirating; the easy flow of venous blood assures that the needle is in the
internal jugular vein. Typically, the vein is entered within 1-3 cm; if the vein is missed, draw the needle
all the way back to the skin before redirecting it.

If the bevel of the introducer needle is swung back and forth in the deeper tissues, a vessel or nerve may
be inadvertently lacerated. Redirecting the needle more laterally, toward the sternoclavicular joint as
opposed to the notch, often allows the vein to be entered.

Once venous blood is free-flowing in the syringe, carefully remove the syringe so that the needle remains
in the IJV.

Introduce the guide wire down the needle, with the J-wire bend going in first. The wire should advance
with little resistance. If any significant resistance is noted, remove the guide wire and ascertain if the
needle is in the vein by checking for free-flowing blood with syringe aspiration.

Once the guide wire is in place, carefully remove the needle, leaving the guide wire in the vein. Hold on
to the wire at all times so that it is not lost down the vein.

Make a skin incision is made around the entry point. This incision should be relatively generous because
if it is too small, the skin will tent around the catheter and will eventually necrose, which can quickly lead
to a catheter site infection.

Carefully advance the semirigid dilator along the guide wire, and create a passage for the catheter in the
soft tissue. Rotating the dilator back and forth allows more gentle insertion and lowers the risk of tearing
the vein.
Thread the catheter over the guide wire to the level of the skin. Back the wire out so that it just sticks out
of the intravenous (IV) hub at the end of the catheter. Then hold the guide wire firmly while advancing
the catheter over the wire into the IJV. Once the catheter is advanced to an appropriate depth, remove the
guide wire.

Reattach a syringe to the catheter, and verify that blood can be easily aspirated; this confirms that the
catheter is indeed in the vein. Flush all lumina of the line with saline.

Place sutures to hold the catheter in place. Most often, a wing device is placed over the catheter to allow it
to be secured to the skin. Place antiseptic ointment over the entry point, and cover the site with an
occlusive dressing.

Finally, obtain a chest radiograph to confirm correct placement and to verify that no injury to the lung has
occurred. Hold off on infusion of fluids until radiographic confirmation of appropriate placement is
completed. The tip of the line should be above the right atrium and below the level of the clavicle. If the
tip is in the heart, it can whip back and forth as the heart contracts, and penetration of the heart wall can
occur.

Surgical pearls

Adequate local anesthesia in the area of cannulation is important to the success of this procedure. This is
important for the patient's comfort and helps the patient hold still during the procedure.

A long 25-gauge needle can be used for the administration of the local anesthetic and to ascertain the
position of the IJV. This can give the practitioner an idea of the depth and direction of the IJV without the
trauma associated with searching for the vein with the larger introducer needle.

Take care to avoid injecting the local anesthetic into a vessel when hunting for the vein.

Placing the patient in the Trendelenburg position helps dilate the IJV. The bigger the vein, the easier it is
to cannulate. Once the guide wire is in place, the patient can be taken out of the Trendelenburg position,
which is often uncomfortable.

Thorough cleansing of skin and complete draping of the patient and practitioner have been shown to
decrease infections of a central line. These lines often must remain in place for a long time; therefore, it is
important to perform the procedure in as sterile a manner as possible.

As in any procedure performed to gain access to a central vein, the angle of the introducer needle may
have be altered if the vein is not cannulated the first time. The large-bore introducer needle must be
withdrawn out to the skin before the angle of insertion is adjusted.

Moving a beveled needle back and forth in an area with several large vessels can lacerate those vessels.

The introducer needle should be advanced slowly to make sure that it does not go entirely through the
vein. Ultrasonographic guidance can aid in the establishment of central venous access. However, a 2009
study reported that 64% of the residents participating penetrated the posterior wall of the IJV, even under
ultrasonographic guidance.
Complications

One of the more common, and feared, complications of central line placement in the IJV is injury to the
lung resulting in pneumothorax or tension pneumothorax. This is particularly true if the cupula of the lung
is above the clavicle, as it can be inadvertently punctured, causing a pneumothorax.

Any shortness of breath following or during the procedure warrants immediate investigation with chest
radiography. Air embolism can occur if the catheter is allowed to be open to the air; to prevent air
aspiration, the practitioner should keep his or her finger over the hub when the guide wire is removed or a
syringe is attached or removed.

A hematoma at the site of insertion can occur, particularly if the carotid artery is punctured.

Loss or breakage of the guide wire has been described, and control of the wire must be maintained at all
times. If any resistance is encountered during withdrawal of the wire through the needle, remove the
needle and the wire as a single unit to avoid breakage of the wire against the bevel of the needle.

Laceration of a vessel or nerve has been described with IJV central line placement.

Procedure- Arterial Line Insertion

Indications
1. Continuous, beat-to-beat blood pressure measurement.
- Hemodynamically unstable pts /ICU pts requiring inotropic support.
- Patients undergoing major surgery
2. Frequent arterial blood gas analysis
-pts with respiratory failure on ventilator
-severe acid/base disturbance.
Advantages of IBP measurement
Continuous blood pressure recording
Accurate blood pressure recording even when patients are profoundly hypotensive vs NIBP
which is difficult or inaccurate
Real time Visual Display
Disadvantages of IBP measurement
Potential complications
Skilled technique reqd
Expensive
Selection of arterial site
The radial artery has low complication rates compared with other sites.
It is a superficial artery which aids insertion, and also makes it compressible for haemostasis.
The ulnar, brachial, axillary, dorsalis, pedis, posterial tibial, femoral arteries are alternatives.
 The Palmar Arch

Preparation- Allens Test

Allens test is recommended before the insertion

of a radial arterial line.

This is used to determine collateral circulation

between the ulnar and radial arteries to the hand

If ulnar perfusion is poor and a cannula occludes

the radial artery, blood flow to the hand may be
reduced.

The test is performed by asking the patient to

clench their hand. The ulnar and radial arteries are
occluded with digital pressure.

The hand is unclenched and pressure over the

ulnar artery is released. If there is good collateral
perfusion, the palm should flush in less than 6
seconds.
The idea here is to figure out if the ulnar
Equipment artery will supply the hand with enough blood,
if the radial artery is blocked with an a-line.
Arterial cannula

Made from polytetrafluoroethylene (Teflon) to minimize the risk of clot formation

20G (pink) cannula - adult patients
22G (blue)- paediatrics
24G (yellow) - neonates and small babies
Larger gauge cannulae increase the risk of thrombosis, smaller cannulae cause damping of the
signal.
 The cannula is connected to an arterial giving set.

ARTERIAL CANNULA

Arterial set.
- Specialized plastic tubing, short and stiff to reduce resonance, connected to a 500 ml bag of
saline.
Saline bag
o 500 ml 0.9% saline pressurized to 300 mmHg using a pressure bag, i.e. a pressure higher
than arterial systolic pressure to prevent backflow from the cannula into the giving set.
o The arterial set and pressurized saline bag with 2500units Heparin incorporate a
continuous slow flushing system of 34 ml per hour to keep the line free from clots.
o The arterial set and arterial line should be free from air bubbles.
o The line is attached to a transducer.
o Do not allow the saline bag to empty
To maintain patency of arterial cannula.
To prevent air embolism
To maintain accuracy of blood pressure reading
To maintain accuracy of fluid balance chart
To prevent backflow of blood
Transducer, amplifier and electrical recording equipment.
-The transducer is zeroed and placed level with the heart.
Tape and/or steri-strips
An arm board or towel roll
Opsite or Tegaderm cover dressing
Local anesthetic (1% or 2% lidocaine ,lidocaine cream)
Suture material for femoral arterial line placement (2.0 silk)
Scissors
Monitor cable for transducing arterial waveform.
Benzoin solution
Procedure
Ensure that all preprocedure steps are taken
Assure that pressure tubing with transducer is connected to bedside monitor.
Perform the Allens test to assure adequate collateral blood flow if using the radial artery.
Wash hands and don gloves
For the radial artery, the arm is restrained, palm up, with an armboard to hold the wrist
dorsiflexed.

For the radial artery, the most common insertion, the arm is
restrained, palm up, with an arm board to hold the wrist
dorsiflexed

Apply anesthetic agent (local lidocaine 1-2% or lidocaine cream).

Locate pulsating artery via palpation.
Cleanse area selected for arterial line placement.
Prepare patient for puncture.
Stabilize artery by pulling skin taut.
Puncture skin at 45-60 degree angle for radial artery; 90 degrees for femoral artery.
Advance catheter when flash of blood is observed in catheter.
Connect to pressure I.V. tubing and check for arterial waveform on bedside monitor.
Cleanse area of any blood and allow site to dry.
Apply Benzoin to cleansed area and allow to dry and become tacky.
Secure arterial line with tape and cover with a Tegaderm dressing.
Secure I.V. tubing to prevent it from being caught and pulling on arterial catheter. If a femoral
arterial line is placed, it should be secured with a suture.
Properly dispose of the I.V. sharps and other used materials.
Insertion techniques (Seldinger)

Step 1
Step 3 Step 4

Step 5 Step 6

Complications

Haemorrhage may occur if there are leaks in the system. Connections must be tightly secured
and the giving set and line closely observed..
Emboli. Air or thrombo emboli may occur. Care should be taken to aspirate air bubbles
Accidental drug injection may cause severe, irreversible damage to the hand.
-No drugs should be injected via an arterial line
- The line should be labelled (in red) to reduce the likelihood of this occurring
Arterial vasospasm
Partial occlusion due to large cannula width, multiple attempts at insertion and long duration of
use
Permanent total occlusion
Sepsis or bacteraemia secondary to infected radial arterial lines is very rare (0.13%);
-local infection is more common.
if the area looks inflamed the line site should be changed.
Procedure- Insertion of PA Catheter
Equipments: In addition to insertion supplies, you should have prompt access to Amiodarone or
Lidocaine and crash cart during insertion.

1. Supplies for Insertion of Introducer (required unless there is an existing introducer that was
inserted under full barrier precautions and the access port maintained with a sterile cap).
Arrow introducer kit (contains yellow sleeve for insertion of PA catheter)
Central line insertion kit
Ultrasound machine
Central line cart
Single use local anaesthetic
2. Pulmonary Artery Catheter: Choose one of the two models

VIP is the usual model (check expiration date). The extra lumen (Venous Infusion Port)
terminates at 31 cm in the right atrium.
Paceport model can be used in same way as VIP but the extra lumen terminates at 19 cm in
the right ventricle. A special pacemaker wire called a Chandler Probe can be inserted through
the Paceport lumen to provide transvenous pacing, however, it is not the most reliable
method of pacing. If pacing is the reason for the catheter, a Swan Ganz Pacing catheter is
recommended (kept with the pacemaker pulse generators). The Swan Ganz Pacing catheter is
a 5 French catheter that is inserted through a 6 French introducer. It has a balloon at the tip to
facilitate flow directed insertion, plus a positive and negative pacing electrode. The catheter
has no intravenous lumens. A continuous infusion is required through the introducer lumen.
All Swan Ganz catheters contain latex. The VIP is heparin free. Both the Paceport and Swan
Ganz Pacing catheters are heparin bonded.
3. Supplies for Measurement of Pulmonary Artery Pressure

Pressure transducer kit

500 ml bag of normal saline
Tycos
Bridge (Do not open; this will be added to the sterile field)
P4 Module
4. Supplies for Measurement of Cardiac Output
Cardiac output cable with both thermistor and injectate temperature probes
Room temperature cardiac output CO Set
D5W (any size)

1. Prepare Bedside Monitor for Insertion:

Perform hand hygiene

Go to Admit/Discharge function of Datex monitor and do the following:
1.Ensure patient name and PIN is entered
2.Go to Demographics and enter height and weight (BSA will auto-populate)
3.Change monitor mode to Swan Ganz.
2. Prepare Pressure Monitoring System:

Prime pressure tubing with normal saline.

Connect pressure cable to P4 pressure module.

3. Assist with insertion:

Review procedural steps with physician before starting including strategies for managing
complications such as ventricular arrhythmias
Review steps below before starting.
Apply bouffant and face mask; be careful not to lean into sterile field
Perform hand hygiene
Assist with preparation of sterile field and opening of central line insertion kit.
Open introducer kit (if required) and aseptically transfer to physician
Once introducer has been inserted, peel back outer packaging of pulmonary artery catheter and
aseptically transfer to physician
Peel back package and aseptically transfer bridge to physician
Open and aseptically transfer 4 sterile saline syringes.
Connect (physician) a syringe to VIP or Paceport lumen, and both the blue and yellow female
ports of the bridge. The yellow male port of the bridge is connected to the PA port of the catheter,
and the blue male port of the bridge is connected to the blue port of the PA catheter.
Flush (physician) the VIP or Paceport, blue (proximal injectate) and yellow (PA) lumens, and
the cross bar of the bridge.
 Transfer (physician) bridge to nurse aseptically. Physician holds PA port of catheter and nurse
completes transfer by grabbing saline syringe.

Connect pressure tubing to PA port.

 Flush PA port of catheter thoroughly using the flush device of the pressure tubing. This will
remove any residual air bubbles that can impair waveform quality.

Flush across bridge, then through blue (injectate) port of catheter with flush device of pressure
tubing.
 Secure catheter ports (VIP, bridge, and thermistor) to the edge of the sterile field using towel
clamp that is included in central line insertion kit.

Non Sterile Area. Provides Nurse with

access to balloon port to assist with
balloon inflation.

Advance (physician) PA catheter through yellow sleeve.

 Fill (physician) sterile tray will saline from 4th syringe. Inflate balloon under saline to check for
leaks, and to evaluate symmetry and retention of air.

Level and zero transducer.

Wiggle (physician) Swan Ganz to ensure artifact tracing appears on Datex monitor (ensuring
you can view waveform during insertion).
 Observe monitor for arrhythmias during insertion. Ventricular arrhythmias frequently occur
during advancement through the RV but usually resolve as soon as the catheter is advanced (or
withdrawn) from RV
Inflate (nurse) balloon once catheter has been inserted ~15 cm.
Keep balloon inflated during catheter advancement.
Ensure balloon is deflated before catheter is withdrawn. Deflate by disconnecting from port (do
not manually aspirate air as this may rupture balloon).
Watch for transition from RA to RV to PA to PWP. Select snapshot as each waveform change
appears. Waveforms can also be retrieved from central station using full disclosure feature.
Print, label and post waveforms in the clinical record after completion of the pulmonary artery
insertion to serve as a reference for waveform identification.
Replace vented cap on transducer stop-cock with dead-end luer lock cap.
Connect a Microclave to sampling stopcock on PA (yellow) side and maintenance infusion port
of CVP (blue) side. Do not place Microclave on ports used for pressure monitoring;
connect pressure tubing directly.
Complete post insertion chest X-ray.
Vasoactive drugs can be administered through the introducer and VIP lumen prior to completion
of chest X-ray (waveform verifies catheter location).
Introducer is the preferred location for infusion of vasoactive drugs; this prevents disruption of
infusion during catheter repositioning or removal.

Document the length of catheter inserted, measured from the point where the catheter first becomes
visible at the sleeve. Thin lines represent 10 cm lengths; thick line is 50 cm marker.
 Balloon port should be left in the UNLOCKED position with syringe empty and attached to port.
The unlocked position shown below ensures that the balloon will always default into the deflated
position. The syringe is specially designed to prevent filling with more than 1.5 ml of air and is
left attached so that it does not get misplaced.