• Place patient in 10-15 degree trendelenburg position to increase size of internal jugular vein and to decrease risk of air embolism
• Turn head slightly from side of planned catheter insertion
• When possible, choose the right internal jugular vein to reduce risk of complications.
  • The right internal jugular vein has a straight course to the superior vena cava and the dome of the right lung is lower than the left.
• Locate internal jugular vein typically between the two heads of the sternocleidomastoid and lateral to carotid artery

• Use high frequency linear array probe to visualize internal jugular vein relative to carotid artery.
• Distinguish between internal jugular vein and artery by applying gentle pressure with ultrasound probe. The internal jugular vein is compressible; the artery is non-compressible and pulsatile
  • To minimize risk of arterial puncture, ensure artery is not posterior to vein at catheter insertion site.

• Dress with sterile gown, mask, cap and gloves
• Apply sterile drape over patient
• Place sterile cover over US probe
• Sterilize catheter insertion area 3 times using antiseptic swabs

• Flush lumens
• Ensure guidewire can be inserted into lumen.

Anaesthetize area

• Using 25 gauge needle, inject “wheel” of lidocaine with into dermis overlying prospective needle insertion site

Needle insertion

• Position introducer needle at 45 degrees to patient’s neck and direct towards patient’s ipsilateral nipple
• Using ultrasound follow needle tip during puncture of skin, subcutaneous tissue and vein.
• Advance needle while applying gentle suction to syringe
  • The needle has entered the vein when flash back of venous blood enters syringe.
• Hold needle in place, remove syringe and advance guide wire through needle ensuring 10-15cm of wire enters the vessel.
  • The guidewire should advance with little resistance.
• Once guidewire is inserted, hold wire at entry point on skin and remove needle

Catheter insertion

• Create small nick in skin and subcutaneous tissue with scalpel where dilator and catheter will be inserted
• Insert dilator 2 cm by applying gentle pressure and twisting movement
• Remove dilator and stabilize wire at skin insertion site.
• Insert catheter device over wire.
• Withdraw wire until tip is visualized at the proximal lumen of catheter.
• Insert catheter over wire using rotating motion until distal tip is at junction between the superior vena cava and right atrium.
• Remove guidewire
• Check for blood return in all ports
• Flush all ports
• Secure catheter with sutures and dressing

• Confirm position with chest xray
• Complete procedure note in chart

Artery puncture:

Confirm by observing for bright red, pulsatile blood from needle hub. If present, do not insert guidewire. Apply pressure to bleeding site.

Pneumothorax:

Suspect pneumothorax if air is aspirated from central venous catheter port and patient is in respiratory distress. Perform urgent chest xray to confirm and treat accordingly

Persistent bleeding:

Apply pressure to site. Replace blood products as required.

Cardiac arrhythmias:

Pull back on the wire or catheter as it may be in heart.