This week, we have a post from regular contributor Nick Mancuso on how to excel when performing a procedure common in the ED as well as upstairs: ultrasound guided central line placement.
The three most common veins used in central line placement are the internal jugular (IJ), subclavian (SV), and femoral (FV). I will focus on IJ placement and the use of dynamic ultrasound.
- Sterile technique is paramount (if time permits).
- Linear array probe is used with a sterile probe cover, and sterile gel. A CVC kit is obviously required, along with sterile personal protective equipment. This procedure can be done with one person, but two can be helpful especially during training.
- Operator on the isiplateral side of the pt, pt in Trendelenburg, probe indicator to the left of operator, in transverse position.
- Place probe superior to clavicle, IJV usually larger, lateral to carotid artery.
- The IJV will compress with pressure, vs. the artery. If hypotensive or dehydrated, may disappear with inspiration.
- Center vein on screen, lidocaine can be used to anesthetize pt. Use center of probe as guide, while not looking at monitor, stick pt skin with entry needle.
- Look at monitor after puncture. Visualize needle or tissue compression. Puncture vein looking at monitor.
- If needle can’t be visualized, a long-axis (longitudinal) view can help
- It is extremely important to visualize the needle tip and not proceed with advancement of the needle without visualization of the tip. The tip can be followed with slow fanning or sliding of the probe distally as you advance. The most common mistake is not following the tip of the needle and letting the needle get “ahead of” the probe. This leads to visualization of the proximal portion of the needle while the tip is in a different location in the neck, possibly causing complication.