Central venous catheterization is a vital technique to enable care of critically ill patients. Whether it is for fluid resuscitation, vasopressor administration, multiple drug infusions, hemodialysis or other indication, it is vital that front-line health care providers are able to perform this skill safely and competently.
In the following video clips and images, we will highlight selected fundamental points to enhance your understanding and performance of this procedure. This is not intended to be a guide for central venous cannulation from start to finish, but simply to enhance your understanding of key steps in the approach.
In the following video clips and images, we will highlight selected fundamental points to enhance your understanding and performance of this procedure. This is not intended to be a guide for central venous cannulation from start to finish, but simply to enhance your understanding of key steps in the approach.
STEps in central (IJ) venous cannulation
Pre-scanPrior to setting up and prepping the skin, ensure the internal jugular vein is clearly visible and the anatomy is clear for venous access (ex. the IJ does not directly overlap the carotid artery). Many beginners will turn the head to the contra-lateral side, which may lead to significant anatomical distortion.
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Orientation and compressionDouble check orientation of the probe to ensure proper anatomic alignment. The screen marker on the left in this clip aligns with the patient's left. Compression also ensure the vein is free of thrombus.
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anesthetize the skin Ultrasound can be used to plan the site of cannulation and help guide infiltration of local anaesthesia in the superficial tissues.
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SHort vs long axis approachIn this clip, we can see the short vs long axis approach for venous cannulation. While either can be used, the long axis plane can be more technically challenging to the novice or even intermediate practitioner. The more common approach, particularly for those learning, is the short axis approach.
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Creep technique Be aware that your short-axis plane must be constantly shuffling between advance of the needle tip and at the needle tip to prevent confusion in imaging the needle shaft. Make sure to visualize the needle tip in short axis at a shallow depth and track slowly as you enter ("Creep technique"). The video clip demonstrates that two probes (both are probes are end-on) may come to the same conclusion, despite the fact they are capturing two different areas. Always be at the distal tip of the needle. Carefully insert the needle until a venous flash.
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COnfirm wire placementAfter successful venous cannulation and insertion of the wire, it should be visualized in two planes along its anatomical course. While this practice does not have a robust evidence base, it is evident that unequivocal intra-vascular visualization is reassuring prior to dilatation and final catheter insertion.
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Procedural videos
NEJM procedural video
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Please check out this excellent video tutorial by New England Journal of Medicine. While this video discusses internal jugular cannulation exclusively, the Seldinger technique (over-the-wire technique) and execution of the procedure is similar regardless of site.
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procedural videoThis video tutorial delves further into the practical use of ultrasound to guide venous cannulation. While ultrasound offers much benefit, technical mastery can optimize safety and increase the chance of successful placement.
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References
ReferencesHoffman T, Du Plessis M, Prekupec MP, et al. Ultrasound-guided central venous catheterization: A review of the relevant anatomy, technique, complications, and anatomical variations. Clin Anat. 2017;30(2):237-250.
Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105-1117. doi:10.1007/s00134-012-2597-x.
Ortega R.Song M.Hansen C.J.Barash P. Ultrasound-Guided Internal Jugular Cannulation. N Engl J Med 2010; 362:e57.
Saugel B, Scheeren TWL, Teboul J-L. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225. doi:10.1186/s13054-017-1814-y.
Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105-1117. doi:10.1007/s00134-012-2597-x.
Ortega R.Song M.Hansen C.J.Barash P. Ultrasound-Guided Internal Jugular Cannulation. N Engl J Med 2010; 362:e57.
Saugel B, Scheeren TWL, Teboul J-L. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225. doi:10.1186/s13054-017-1814-y.