Ultrasound Guided Central Venous Catheter Insertion

Ultrasound Guided Central Venous Catheter Insertion

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This high quality video demonstrates ultrasound guided central venous catheter insertion. One of the most important hospital and emergency procedures, ultrasound guided internal jugular line insertion is shown step by step.  Clinical pearls and common pitfalls associated with ultrasound guided central lines are discussed in detail. The video is not downloadable but may be accessed indefinitely by internet from any computer, smart phone, or tablet.  Click below to preview the ultrasound guided IJ line video.

 

This is a non-sterile gel being applied to a linear array probe, which is a probe used for vascular ultrasound. This is a sterile sheath that is used to grasp the probe and then the sterile sheath is draped over the probe, as far down on the probe line as possible. The sheath is pulled tight to eliminate all air bubbles, and then is kept in place with sterile rubber bands.

We're now drawing up 1% lidocaine into a syringe. The site of a probe has a marker that is aligned to the patient's left which corresponds to the teal blue marker on the ultrasound screen. The higher more ovoid thin walled structures internal jugular vein which compresses when the probe is pushed down as is shown there, below it is the carotid artery, which is rounder, thick walled and does not compress when the probe is pushed down.

This is a sagittal view of the internal jugular vein, when the probe is parallel to the vein. This is the color mode which shows that there is a red in the internal jugular vein because the blood is flowing towards the probe which is direct at cephalad, the carotid artery has blue flow because the flow is in the direction of the probe.

This is a venous wave form. This is the arterial waveform.

This is local anesthesia that is being used to anesthetize the skin and underlying soft tissue. As the needle is advanced, negative aspiration is applied so as not to have an intra-arterial lidocaine injection. A dilator can be used to push down in the center of the probe. As you can see it is a way to locate the appropriate insertion point for the introducer needle which is not being advanced with beveled tip up. It's under real time ultrasound. You can see the indentation of the vein and the ring down artifact which occurs right there with a bright spot which shows that you're going in the correct direction. And the needle can be advanced safely until you get a flash of blood in the barrel of the syringe as is shown there, confirm that you have a very brisk flow of blood to confirm that the needle tip is in the center of the lumen.

The needle hub is then grasped and then the syringe is withdrawn to reveal purple non-pulsatile blood. The wire is then advanced through the needle with the curve of the wire directed towards the heart, which would towards the left side in this patient. It is advanced to the 20 centimeter mark which is designated by two gray lines on the wire. And the two gray lines are shown there.
At this point the sheath can be withdrawn, leaving the wire in place. Now the needle can be pulled back over the wire always having control of the wire. A scalpel can then be used to knick the skin and underlying soft tissue over the wire.

Now the wire is curled to have better control of the wire as the dilator is applied and introduced over the wire.

Now the dilator is grasped close to the skin and is advanced with a twisting motion back and forth, dilating up the skin, soft tissue and the vein.

The dilator is now withdrawn over the wire, and now the catheter is introduced over the wire, the wire is withdrawn into the catheter until the distal tip of the wire can be grasped beyond the brown distal port of the catheter. At this point, the operator is withdrawing the wire such that it can be grasped beyond the brown port.

At this point, you can see the tip of the wire, which is being grasped just beyond the brown port and with full control of the wire the catheter is advanced to a designated depth of insertion which is 13 centimeters in this patient as the patient is quite small and petite.

Now the wire can be withdrawn fully and once the wire is out, the clamp must be clipped over the line immediately to minimize the chance of an air embolus. Now each of these three ports will be serially flushed with sterile saline withdrawing to assure that there is no air in the line and as the saline is flushed in, the line is clipped prior to removal of the syringe. After the syringe is removed, each port can then be capped. 

Now a proximal clip is applied, it should be applied at a half to one centimeter from the skin insertion site. Local anesthesia can be used to anesthetize the skin on each side of the clip.

Now the needle is pulled through and then an air knot is tied with the suture so as not to strangulate the skin.

And the clip is secured on both sides. The catheter is then curved laterally and the distal portion of the catheter is also secured in two locations with suture in the same fashion as the more proximal clip.

A sterile occlusive dressing is now being applied with the transparent portion allowing visualization of the insertion site.