1. CVP measurement- II

2.  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

3.  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.

5.  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.

7.  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 30-45 0 angle to the patient,directed at the ipsilateral nipple while aspirating.  Dark venous blood enters the syringe.

8.  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.

9.  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.

11. 1. Carotid artery puncture and stroke – 2%. 2. Vertebral artery damage. 3. Airway obstruction from carotid hematoma. 4. Sympathetic nerve damage ( Horner’s syndrome). 5. Tracheal and esophageal puncture.

12. 1. High success rate- 90-98%. 2. Low complication rate. 3. Suitable for long term catheterization. 4. Easily accessible. 5. Best for pulmonary artery catheterization 1. Requires experience. 2. Difficult to fix and securely dress. 3. Major complications possible.

13.  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.

14.  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.

16.  Technique- a) Infraclavicular. b) Supraclavicular. INFRACLAVICULAR APPROACH  Patient placed in 15-30 0 trendelenburg 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.

17.  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.

18.  Securely hold the needle, remove the syringe & insert the guidewire using standard Seldinger technique.  Rest is similar to the steps followed in IJV cannulation.

20.  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 45 0 to the saggital plane. ↓  Aspirate gently while advancing the needle.  Needle should enter the jugulo- subclavian venous bulb after 1-4 cms.

21.  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.

22. 1. Pneumothorax - 0-3% infraclavicular approach 0-4.7% supraclavicular approach. 2. Arterial puncture- 0.5-1% 3. Hematomas- 1.5-3% 4. Hydrothorax & hemothorax- 0.1-2% 5. Thoracic duct puncture- rare 6. Catheter embolism.

23. 1. High success rate-90- 95% infraclavicular 85-90%- supraclavicular. 2. Lower risk of infection 3. Ease of insertion in trauma patients. 4. Increased patient comfort. 5. Long term I/V thearpy such as hyperalimentation & chemotherapy. 6. Emergency volume resuscitation. 1. Requires experience. 2. Relatively high complication rate.