Ultrasound guidance central line insertion

The internal jugular vein (No. 1) and the common carotid artery (No. 2) are adjacent structures in the neck. US image guidance is invaluable when inserting jugular venous central lines.

A high frequency linear or curvilinear probe should be selected. If no previous lines have been inserted, the right side is generally chosen as this is the larger vein with a more direct course to the SVC. Scanning the neck will identify the course of the jugular, confirm patency, the relationship to the carotid and assess whether there are any intervening structures such as lymph nodes. The jugular is thin walled, its calibre varies with respiration and it can be occluded with mild compression. The carotid is smaller, thick walled, and can be seen pulsating. The carotid cannot be occluded with mild pressure. Once the internal jugular is identified using these criteria, then a puncture site can be chosen and a mark made on the skin superficial to this.

The skin is then cleansed with antiseptic solution and local anaesthetic infiltrated. The jugular is then punctured using a introducer needle (18 gauge) and blood is aspirated into a connected syringe to confirm a venous puncture. The puncture is performed under direct US visualisation. It should be possible to follow the needle tip from the subcutaneous layers into the vein. Introducer kits vary but most comprise a guide wire which is inserted via the initial needle. The introducer needle is then withdrawn leaving the guide wire. The central line is then inserted over the guide wire. Air embolus is a theoretical complication when the system is open to the atmosphere, e.g. withdrawing the wire. This should be done in arrested respiration where possible.

Complications of line insertion include carotid puncture and haematoma formation in the soft tissues of the neck (see Fig. 7.16). Ultrasound should reduce the incidence of these complications.

Fig. 7.16 Failed jugular line insertion. There is a large haematoma (arrow) compressing the internal jugular vein.

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