1. ULTRASOUND GUIDED CENTRAL VENOUS CANNULATION By Dr Sunil Chhajwani (MD. Anaesthesia)

2. A video presentation

6. Indications : Haemodynamic monitoring Infusion of inotropes, vasodilators, vasopressors pacing Aspiration of air embolised into right side of heart Infusion of fluids

7. Placement of ultrasound guided central venous catheter Ultrasound (with high resolution probe)to be kept at the head end of patient Probe to kept transversely caudad to needle placement Probe marker should face patient's left side Trace the IJV from angle of mandible to supraclavicular fossa using linear probe in transverse orientatiion

8. Assessment of IJV IJV diameter should be 7 mm. Avoid access point to IJV where there is overlap with carotid artery Rule out thrombus in IJV Avoid head tilt more than 30 degrees to avoid transversing carotid artery

9. Use local anaesthetics without adrenaline (to prevent inadvertent injection into carotid artery) CVC insertion site should be prepared with usual sterile technique Ultrasound gel should be applied to linear probe and sterile cover to be placed over the probe Make sure no air bubbles between face of probe and sterile sleeve.

12. IJV should be imagined and placed in centre of ultrasound field Needle should be angled at 40-60 degrees at the angle of neck and 1 cm back from the middle of ultrasound probe If the needle is aligned correctly the soft tissue depression should lie exactly over the IJV Advance the needle in small increments of 0.5 cm

13. If the needle is seen to grow medially or laterally, it is withdrawn till below skin tissue and then directed towards IJV. Correct placement of needle is indicated by indent on IJV wall. Make sure needle is seen inside the IJV lumen Aspirate free flow of blood from IJV Pass guide wire through the puncturing needle

14. Look for guide wire inside the lumen of IJV by USG probe which is seen as hyper echoic dot like shadow when probe is kept transversely or hyperechoic straight shadow when probe is kept longitudinally to IJV Dilate the tract with help of dilator Pass central venous catheter over guide wire Confirm the position of cvc by USG and free aspiration of blood from all the lumens.