Equipments required • Patient on a tilting bed, trolley or operating table • Sterile pack and antiseptic solution • Local anaesthetic • Appropriate CV catheter for age/route/purpose • Syringes and needles • Saline or heparinised saline to prime and flush the line after insertion • Suture material - e.g. 2/0 silk • Sterile dressing • Shaving equipment for the area if very hairy (especially the femoral) • Facility for chest X-ray if available
Equipments required • Additional equipment required for CVP measurement includes: manometer tubing, a 3-way stopcock, sterile saline, a fluid administration set, a spirit level and a scale graduated in centimeters.
ROUTEs OF ACCESS • Right internal jugular vein cannulation • ANATOMY Base of the skull through jugular foramen Carotid sheath with ICA Runs beneath the SCM Slightly ant & lateral to the carotid artery → joins the subclavian vein to become the innominate vein.
central approach • Supine position , head low & turned to the left side. • Anatomic landmarks- sternal notch, clavicle & SCM. • Skin preparation with antiseptic solution. • Palpate the carotid pulsations. • At the apex of the head of SCM, lateral to the carotid pulse, advance 22G finder needle, bevel up at 30-450 angle to the patient,directed at the ipsilateral nipple while aspirating. • Dark venous blood enters the syringe.
Gently withdraw the needle. • Puncture vein with 18 G, thin along the same track with the finder needle. • Hold needle, remove syringe & insert guide wire while monitoring the ECG. • If resistance is met, remove guidewire, withdraw blood with the syringe & advance the guidewire again. • Hold the guidewire & remove the introducer needle. • Pass the dilator over guidewire, dilate the tract & remove it.
RIGHT IJV cannulationcontd….. • Pass the catheter over guidewire to an appropriate depth (rt IJV- 15-17 cm) ( lt IJV- 17-19 cms) • Feed the guidewire out until it emerges from the distal port of the catheter & grasp it. ↓ • Hold the catheter in place & withdraw the guidewire. • Flush all the ports. • Secure the catheter with sutures ↓ • Cleanse the site with antiseptic solution & place a sterile dressing • Obtain a stat CXR for correct placement.
Complications OF JVP CANULATION • Carotid artery puncture and stroke – 2%. • Vertebral artery damage. • Airway obstruction from carotid hematoma. • Sympathetic nerve damage ( Horner’s syndrome). • Tracheal and esophageal puncture.
ADVANTAGES DISADVANTAGES • High success rate- 90-98%. • Low complication rate. • Suitable for long term catheterization. • Easily accessible. • Best for pulmonary artery catheterization • Requires experience. • Difficult to fix and securely dress. • Major complications possible.
Left ijvcannulation • Anatomical difference. • The cupola of the pleura is higher on left side→ ↑ risk of pneumothorax. • Thoracic duct may be injured. • Left IJV demonstrates a greater degree of overlap of the adjacent carotid artery during head rotation. • Catheters inserted from the left side must traverse the innominate vein & enter the SVC perpendicularly, & their distal tips may impinge on the right lateral wall of the SVC →increase potential for vascular injury.
Subclavian vein cannulation • ANATOMY • Subclavian vein is continuation of axillary vein , beginning at the lateral border of the first rib. ↓ • Passes through under surface of the clavicle , joins the IJV → becomes brachiocephalic vein behind the sterno-clavicular articulation.
Technique- • Infraclavicular. • Supraclavicular. INFRACLAVICULAR APPROACH • Patient placed in 15-300trendelenburg position with a small roll b/w the shoulder blades. ↓ • Head turned to contralateral side • Arm – adducted • Landmarks- clavicle, two heads of SCM, suprasternal notch.
Puncture skin 2-3 cm caudad to the midpoint of clavicle with 18G mounted on 10 ml syringe. ↓ • Direct the needle towards supra-sternal notch while aspirating. ↓ • Keep the needle parallel to the floor during advancement • Depress the needle with the thumb until it passes under the clavicle ↓ • On cannulation of vein, dark blood is seen in the syringe. • If no return of blood after advancing the needle 5 cm →withdraw it while aspirating. • Redirect the needle more cephalad.
Securely hold the needle , remove the syringe & insert the guidewire using standard Seldinger technique. • Rest is similar to the steps followed in IJV cannulation.
Land marks- clavicular insertion of the SCM muscle & the sterno-clavicular joint. • Operator - positioned at the head end of the patient. • Site of skin puncture- clavicluo sternal-cleidomastoid angle ( just above the clavicle & lateral to the insertion of the clavicular head of the SCM ). ↓ • Advance needle (22 G with a syringe) towards the contralateral nipple just under the clavicle about 2-3cm behind the S-C joint at an angle of 450 to the saggital plane . ↓ • Aspirate gently while advancing the needle. • Needle should enter the jugulo- subclavian venous bulb after 1-4 cms.
18 G needle inserted in the direction of locator needle & advanced into vein. ↓ • Guidewire inserted through the needle. • Pass the catheter over the guidewire. ↓ • Rt side- 10-15 cms. • Lt side- 15-20 cms. ↓ • Remove guidewire & securely fix the catheter.
complications • Pneumothorax - 0-3% infraclavicular approach 0-4.7% supraclavicular approach. • Arterial puncture- 0.5-1% • Hematomas- 1.5-3% • Hydrothorax & hemothorax- 0.1-2% • Thoracic duct puncture- rare • Catheter embolism.
Advantages disadvantages • High success rate-90-95% infraclavicular 85-90%- supraclavicular. • Lower risk of infection • Ease of insertion in trauma patients. • Increased patient comfort. • Long term I/V thearpy such as hyperalimentation & chemotherapy. • Emergency volume resuscitation. • Requires experience. • Relatively high complication rate.