1. Right Internal Jugular Central Vein Catheterization A Course for Emergency Department Rotators Updated 11/3/11 M Zwank, MD

2. INDICATIONS Definitive access in difficult access patients Critically ill patients needing multiple infusions Central vein infusions – ie. pressors CONTRAINDICATIONS Uncooperative patient Known IJ DVT Adequate peripheral access Bleeding diathesis

3. Equipment Face Shield Hair Covering (bouffant cap anyone?) Sterile Gown Sterile Gloves Sterile Gloves for attending when you miss it Central Line Kit Ultrasound Machine, Probe Covering Saline Flush(es)

4. Anatomy Multiple traditional approaches – Anterior, central (most common), posterior IJ generally courses lateral to carotid but don’t count on it Use ultrasound Seriously, use ultrasound SCM I JC lateral   medial

5. Why Bother With Ultrasound Agency for Healthcare Research & Quality promotes it Multiple multiple studies support it Takes all trepidation out of procedure – Priceless

6. Agency for Healthcare Research & Quality 2001 Ultrasound guidance for central line placement Other recommendations – Venous thromboembolism (VTE) prophylaxis – Perioperative beta-blockers – Sterile barriers AHRQ. Making health care safer: a critical analysis 2001;43:i–x, 1–668.

7. Challenges – Internal Jugular Anatomic Variations (Troianos) – 1009 patients admitted for surgery – 54% had internal jugular vein overlying carotid Double wall puncture (Docktor) – 150 patients – Double wall puncture in 30 Troianos CA, et al. Anesthesiology 1996; 85:43–8; Docktor B, et al. Can Assoc Radiol J 1996;47: 195–201.

8. Real Life Examples

9. Universal Protocol ! ! ! Guidelines intended to prevent procedure errors – Wrong Site – Wrong Procedure – Wrong Person Required by JCAHO Currently applicable to several ED procedures – Central Line, LP, Thora/Paracentesis, Chest Tube Includes three major steps

10. Universal Protocol Three Steps The verification processes to confirm – Correct Patient – Correct Procedure – Correct Site The marking of the procedure site A “time-out” immediately before starting the procedure

11. Procedure Consent if possible Prep Perform Confirm

12. Prep Gather everything, Relax, Clear your head Ultrasound machine on Patient in trendelenburg Wash hands Head covering, face covering, gown, gloves Open kit Sterile Prep and Drape

13. Perform Prepare items to be used Flush and clamp ports Locate vein with ultrasound Anesthetize skin and tissue Needle to vein, be careful of tenting vein Get flash of blood, hold needle still

14. Perform Wire – Rotate wire and/or needle 90° if trouble wiring Skin nick (be generous) Dilate tissue to vein Catheter over wire Draw and flush ports Secure with suture Secure line Apply sterile dressing

15. Confirm Generally CXR Consider Ultrasound – Agitated saline injected will be seen in R atrium / ventricle on ultrasound

16. Cautions Stop if you break sterile technique Don’t sweep needle when in tissue Never let go of guidewire Don’t force guidewire Watch for cardiac ectopy if wire is too deep Stop procedure if arterial stick Clean up your sharps after!

17. Video http://www.nejm.org/doi/full/10.1056/NEJMvcm 055053 Start video at Chapter 4; 6:10