Published on 07/02/2015 by admin
Filed under Anesthesiology
Last modified 07/02/2015
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Michael J. Murray, MD, PhD
Central venous cannulas are frequently placed to measure central venous pressure; to administer fluid, blood products, parenteral nutrition, and vasoactive drugs; and to provide access for insertion of pulmonary artery catheters and transvenous cardiac pacing electrodes. Anesthesia providers most often cannulate the internal jugular vein (IJV), subclavian vein, or femoral vein, although the latter is not commonly used because cannulating the femoral vein increases the risk of infection. This chapter discusses placement of a cannula in the IJV.
Because the IJV is readily accessible, cannulating the IJV is easier than cannulating other sites (and is therefore associated with a lower rate of complications), resulting in the IJV being most anesthesia providers’ preferred site for obtaining central venous access. Although either side may be used, the favored approach is from the right because the angle of entry into the right IJV is close to 180 degrees (resulting in a slightly higher success rate and, therefore, a slightly lower complication rate), whereas, on the left, the angle is closer to 90 degrees. In addition, the performance of this technique on the right is easier for right-handed operators.
An important landmark in cannulating the IJV is the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle. With the patient’s head turned 20 to 30 degrees to the side opposite the site of insertion, the apex of the triangle is identified by palpating the juncture of the two heads of the muscle. (Turning the head further than 30 degrees tends to compress the IJV and pulls it posteriorly and medially so that it lies behind the internal carotid artery.) The IJV lies just medial to the lateral head of the sternocleidomastoid muscle at a depth of 1 to 3 cm.
The traditional approach to cannulating the IJV was to place the patient in the Trendelenburg position, sterilize the skin with a povidone-iodine topical antiseptic, and drape the patient after drawing a line along the medial aspect of the lateral sternocleidomastoid and a line along the lateral aspect of the medial sternocleidomastoid. Where the two lines intersected was the point typically chosen to infiltrate a small amount of local anesthetic and the site for insertion of a “finder” needle that was attached to a 3-mL to 5-mL syringe. While applying negative pressure, the syringe with needle attached was advanced at a 45-degree angle to the skin toward the ipsilateral breast. If deoxygenated blood was not aspirated after penetrating to a depth of 3 to 5 cm, the needle was withdrawn and moved 1 to 2 mm medially or laterally and another attempt was made. More cephalad or caudal insertion sites were typically avoided because the carotid artery lies anterior to the IJV high in the neck and the cupola of the lung lies low in the neck. With this technique, many clinicians palpated the carotid artery before performing a venipuncture to verify the position of the artery in relationship to the IJV.
Fausts Anesthesiology Review Expert Consult 4e
