Mark A. Malangoni

Introduction

Understanding the anatomic relationships of the large veins used for placement of central catheters is key to successful cannulation and avoidance of complications. The internal jugular, subclavian, and femoral veins can be accessed for fluid infusion, blood sampling, hemodialysis, cardiac pacemaker placement, and measurement of central venous pressures. Ultrasonography is a safe and noninvasive imaging method that can help identify the target vessels and their relationship to surrounding structures. Ultrasound allows for assessment of the patency of the target vessel and reduces complications when using the internal jugular approach. Infection or injury in the local area, distortion at the entry site, occlusion of the target vein, and an uncooperative patient are relative contraindications to line placement in these vessels.

Common Details for Venous Catheterization

When internal jugular or subclavian vein catheterization is selected, the patient is placed in the Trendelenburg position with a roll put lengthwise between the shoulders. This position helps distend the veins, improve the line of access, and reduce the incidence of air embolism. The head is rotated slightly away from the proposed insertion site.

After the skin is prepared with a chlorhexidine-based solution, the area for insertion is draped; a cap, mask, eye protection, and sterile gowns and gloves are donned; and aseptic technique is maintained. Local anesthetic, usually 1% lidocaine, is injected into the patient’s skin and surrounding tissues. The ultrasound probe should be covered with a sterile transparent sheath and sterile acoustic gel applied.

Although a variety of methods are used for central venous cannulation, this chapter describes the most common approaches.

Internal Jugular Vein Catheterization

The internal jugular vein is located in the triangle formed by the two heads of the sternocleidomastoid muscle and clavicle in the anterior neck (Fig. 40-1). Cannulation of the right internal jugular vein is preferred to the left vein because the right provides more direct access to the right atrium, avoids the thoracic duct, and is associated with fewer complications. The ultrasound probe is placed to position the vein in the center of the image. The surgeon differentiates the internal jugular vein from the carotid artery by noting that the vein compresses with gentle pressure.