anatomical review of internal jugular vein cannulation.pptx

relevant venous cannnaulation anatomy

1. Anatomical review of Internal Jugular Vein Cannulation Presenter : Dr.Abhishek G upta Moderator:Dr.Madan Mohan G upta

2. Objective Overview of the anatomical variations, morphometrics based on various imaging modalities, and the clinical anatomy of IJV cannulation . Additionally, the anatomical basis of complications, techniques to avoid complications, and cannulation in special instances .

3. The internal jugular vein (IJV) is a paired vessel found within the  carotid sheath  on either side of the  neck . The internal jugular vein receives eight tributaries (Inferior petrosal sinus, vein of cochlear duct, meningeal veins, pharyngeal venous plexus, lingual vein, common facial vein, sternocleidomastoid vein, superior and middle thyroid vein) along its course. Drains into brachiocephalic vein Its function is to drain the venous blood from the majority of the skull,  brain ,and   superficial  structures of the  head and neck .

4. ANATOMY

5. Relevant Anatomy for Internal Jugular Vein Cannulation The anterior cervical triangle is bordered by the clavicle inferiorly and by the sternal and clavicular heads of the sternocleidomastoid muscle medially and laterally. The carotid artery is usually palpated near the lateral side of the sternal head of the sternocleidomastoid , and the internal jugular vein usually lies superficial and lateral (often minimally lateral) to the carotid artery. The right internal jugular vein is usually preferred over the left for cannulation because it has a larger diameter and affords a straighter path to the superior vena cava

6. ANATOMICAL VARIATIONS Embryologically , the IJV develops from the right and left cardinal veins at eight weeks of gestation Developmental abnormalities may result in a variety of anatomical variations, which range from Complete agenesis Bifurcation Duplication Fenestration Trifurcation

7. LANDMARK

8. Three approaches are used for IJV cannulation : central, anterior, and posterior . The location of the carotid artery is felt by palpation in the space between the trachea and SCM, and then the IJV is found lateral to the carotid pulse Most commonly, the central approach to the internal jugular vein is used, which may decrease the chance of pleural or carotid arterial puncture. The central/ middle approach utilizes Sedillot’s triangle, which is a triangle formed by the sternal and clavicular heads of the SCM, and the needle is inserted at the apex of the triangle

9. In the anterior approach, the needle is inserted along the medial border of SCM, 2-3 finger breadths superior to the clavicle. This approach accesses the IJV at a slightly higher level than the low approach in central approach; In the posterior approach, the needle is inserted along the lateral border of the SCM, halfway between the mastoid process and the clavicle

10. INTERNAL JUGULAR APPROACH APPROACHES ANTERIOR CENTRAL-Common POSTERIOR

11. COMMON APPROACHES AND LANDMARKS INTERNAL JUGULAR POSITION NEEDLE INSERTION ANGLE OF NEEDLE ANTERIOR - Trendelenburg -Head turned to opposite side Anterior border of SCM midway between angle of mandible & clavicle Advance needle towards medial aspect of ipsilateral nipple at 30-45˚ MIDDLE - Trendelenburg -Head turned to opposite side Apex of the triangle formed by the two heads of SCM Advance needle towards ipsilateral nipple at 30-45˚ POSTERIOR - Trendelenburg -Head turned to opposite side 1cm above the point where external jugular vein crosses lateral edge of SCM Advance needle towards sternal notch at 30˚

12. Ultrasound-guided cannulation of the internal jugular vein is the real-time procedure to guide venipuncture and a guidewire ( Seldinger technique) to thread a central venous catheter through the internal jugular vein and into the superior vena cava. An internal jugular central venous catheter (CVC) or a  peripherally inserted central catheter (PICC)  is usually preferred to a subclavian CVC (which has a higher risk of bleeding and pneumothorax ) or a femoral CVC (which has a higher risk of infection).

13. Seldinger technique: Needle puncture with subsequent guidewire introduction into vessel through needle; Needle exchanged for sheath/catheter over wire – Jugular vein access: Most frequent access site for procedures and catheter placements □ Internal jugular (IJ) typically preferable to external jugular □ External jugular often enlarged in cases of IJV occlusion □ Right is preferable to left □ Shortest distance to central veins for catheter placement □ Most direct path to superior vena cava (SVC), right heart, and pulmonary vasculature □ Direct path to inferior vena cava (IVC) □ Anatomically most suitable route for hepatic vein

14. Indications for Central venous access ○ Catheter insertion for infusion or exchange therapy Central venous pressure monitoring Pulmonary artery catheterization and monitoring Transvenous cardiac pacing Temporary hemodialysis ○ Procedural access – Transjugular liver biopsy – Transjugular intrahepatic portosystemic shunt/balloon-occluded retrograde transvenous obliteration (TIPS/BRTO) – IVC filter insertion/retrieval – Treatment of occluded/ stenotic central veins – Gonadal /pelvic vein embolization – Transvenous cardiac pacemaker/defibrillator placement – Extracorporeal oxygenation ○ Diagnostic venography

15. Contraindications • General ○ Coagulopathy – Low bleeding risk: INR > 2.0; platelets < 50,000/ μL – Moderate and high bleeding risk: INR > 1.5; platelets < 50,000/μ L ○ Occlusion of targeted veins ○ Focal skin infection Tricuspid vegetations/clots

16. Positioning for Internal Jugular Vein Cannulation Raise the bed to a comfortable height for you ( i.e , so you may stand straight while doing the procedure). Place the patient supine and in Trendelenburg position (bed tilted head down 15 to 20°) to distend the internal jugular vein and prevent air embolism. Turn the patient's head only slightly (or not at all) to the contralateral side to expose the internal jugular vein but not cause overlap with the carotid artery. Stand at the head of the bed.

17. PT IS PLACED IN A TRENDELENBURG POSITION

18. CLEAN THE AREA UNDER STRICT STERILE PRECAUTION

19. Equipment list ○– 5- to 8-MHz US probe, cover, gel ○ Elements for maximum sterile barrier technique – Sterile gown and gloves, cap, mask, eyewear ○ Preparatory solution for cutaneous antisepsis ○ Sterile barrier drape ○ Microaccess set – 21-g access needle (long for transhepatic and translumbar technique) – 0.018" microwire – Microaccess dilator/sheath combination 0.035" guidewires and short angled catheter may be required if there is stenosis or tortuous target vein anatomy ○ Scalpel: #11 blade ○ Dilators ○ Sheath

20. ○ US guidance – Allows real-time visualization of vein, artery, and needle □ Highest rate of successful access □ Decreased risk of access site complications □ Decreased risk of artery puncture – Scan to identify target vein and adjacent arterial Structures(Diameter ,cross sectional area ,any anatomical variations) □ Pressure with transducer should easily compresses vein □ Artery is less compressible, pulsatile

21. Axial US with needle lateral to target vein (image perpendicular to target vein) □ Vein seen in cross section, possibly off to one side □ Needle inserted parallel to transducer and remains in plane of scan □ Needle enters from side of screen and seen in entire length □ Needle indents side of vein during access □ Can be challenging to determine needle depth

22. Axial US with needle over target vein (image perpendicular to target vein) □ Vein seen in cross section in middle of screen □ Needle inserted directly over target vein, in parallel with target vein, accessing skin at midpoint of transducer □ Needle angled to plane of scan and only segmentally visualized □ Needle indents top of vein during access □ Can be challenging to advance wire down vessel lumen

23. Longitudinal US with needle over target vein (image parallel to target vein) □ Transducer parallel over target vein □ Needle inserted parallel to transducer and remains in plane of scan □ Needle enters from side of screen and seen in entire length □ Needle inserted directly over target vein □ Needle indents top of vein during access □ Can be challenging to track needle and vessel simultaneously

24. IJV access ○ Identify IJV ○ Determine "low" or "high" access – Low access □ Preferred for tunneled catheters, port catheters □ Access from side (laterally) allows gentle curvature of tunneled catheters and ports □ Place transducer just above clavicle transverse and slightly lateral relative to vein

25. High access □ Preferable for nontunneled catheters and most interventions □ Access from top ( anteriorly ) generally easiest □ Place transducer superior to clavicle, axial over to target

26. Venous Puncture Technique Administer local anesthetic to skin over target vein– Adequate cutaneous wheal allows elevation of skin from vein in thin patients for safe skin incision – Caution □ Choose needle trajectory away from artery; prevents inadvertent arterial puncture □ Do not aim needle steep inferiorly; reduces risk of pneumothorax – After tenting wall, advance needle meaningfully and rapidly with "pop" until wall releases, needle enters vein lumen – Visualize needle tip within lumen ○ Confirm blood return at needle hub – If no spontaneous return, may try aspiration – If no aspiration, inject saline to clear needle and then aspirate again – Venous blood dark red; arterial blood bright red

27. ○ Introduce 0.018" guidewire through needle – Should not encounter resistance to wire passage □ Consider removing wire and aspirating blood to confirm location within vessel □ Consider changing microwire (e.g., gold-tipped Nitrex , Covidien ) □ Caution: If resistance met pulling wire back, stop and remove needle and wire as unit; prevents shearing portion of wire with sharp needle bevel

28. Fluoroscopically monitor guidewire insertion – Advance into SVC near cavoatrial junction – Wire must stay to right of midline; wire left of midline may indicate arterial placement, persistent left SVC, extraluminal location – If wire will not advance centrally, consider possible central venous tortuosity or occlusion □ Venography may be performed via access needle/ microaccess sheath to assess IJ/central venous patency □ If IJV occluded inferiorly, consider external jugular access □ If central veins occluded, consider alternate access sites

29. Remove needle, introduce transitional dilator ( microaccess sheath) over 0.018" guidewire Remove inner dilator and microwire from sheath – Caution: Do not leave needles/sheaths/catheters open to air; occlude with thumb/digit, clamp, stopcock, or wire to prevent air embolism ○ Introduce 0.035" guidewire , advance into SVC, further Advance into IVC for stability – Monitor guidewire passage fluoroscopically – Guidewire in atrium may cause cardiac arrhythmia; retract/reposition guidewire if cardiac arrhythmia induced – Caution: Do not advance dilator past end of guidewire ; may result in life-threatening vascular injury, mediastinal hemorrhage, pericardial tamponade ○ Introduce appropriate sheath/catheter over wire under fluoroscopy – Gentle traction to wire will improve trackability of catheter/sheath – Align sheath or catheter with venous axis to avoid wire kinking

30. COMPLICATION Early Arterial puncture- 10% Pneumothorax - 1-3% Bleeding Cardiac arrhythmias Injury to the thoracic duct Injury to surrounding nerves Air embolism - 0.1% Catheter embolus Late Venous thrombosis Cardiac perforation and tamponade Infection Hydrothorax

31. Management of Complications • Arterial puncture ○ Remain calm ○ Do not withdraw access needle/sheath/catheter until considering options ○ Treatment dependent on diameter of access device and location of access ○ Potential treatment – Needle: Consider removal with digital pressure untilhemostasis – Dilator/sheath: Consider emergent conversation with vascular surgery prior to withdraw of access device □ Surgical repair may be necessary/preferable □ Arteriography with occlusion of inadvertent accesswith balloon or covered stent may be necessary/preferable – Carotid: Consider CTA neck

32. Pneumothorax ○ Evaluate size of pneumothorax – Fluoroscopically during procedure – AP upright chest expiratory/ inspiratory radiographs immediately post procedure if needed – CT thorax as needed ○ Stable small pneumothorax can be managed conservatively ○ Moderate or increasing pneumothorax of any size; consider small bore chest tube placement – Attach to water seal, Heimlich valve, wall suction (-20 mm Hg)

33. Air embolism ○ Turn patient left decubitus (left side down) or partial left decubitus (Durant maneuver) position and allow bed rest for 2 hours or until stable Institute high-flow oxygen In decompensating patients, air embolus can be aspirated via catheter ○ Cardiopulmonary resuscitation may be required with massive venous air embolism

34. Take home message A detailed understanding of the neck anatomy surrounding the IJV, complications associated with IJV cannulation , and the best approach and imaging modality aid in successful cannulation . While cannulation can be done by the landmark technique or the USG-guided technique, it is important to be comfortable utilizing the landmark technique in cases when USG is not available

35. References Alderson P, Burrows F, Stemp L, Holtby H. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Br J Anaesth . 1993;70(2):145-8. Wible interventional Radiology Anatomical review of internal jugular vein cannulation PMID: 36794685 DOI:  10.5603/FM.a2023.0008 , Natalie Kosnik   1 ,  Taylor Kowalski   1 ,  Lorraine Lorenz   1 ,  Mer cedes Valacer   1 ,  Sumathilatha Sakthi-Velavan   2023 Feb 16.

36. THANX

37. EQUIPMENTS Tilting table Sterile pack and antiseptic solution Local anaesthetic Appropriate CV catheter for age/route/purpose Syringes and needles Saline Suture material Sterile dressing Facility for chest X-ray if available

38. INTERNAL JUGULAR VEIN CANNULATION Most commonly chosen; Consistent and predictable anatomic location, Palpable surface landmarks, Short, straight and valveless course to SVC and right atrium.

39. TURN THE HEAD SLIGHTLY TO LEFT ( 20-30 degrees) GENTLY PALPATE THE CAROTID ARTERY

40. Infiltrate the skin at the level of cricoid with local anaesthetic 25 g locator needle at 30 degree angle to skin in sagittal plane At the medial border of lateral head of sternomastoid pointing towards the ipsilateral nipple

41. Negative pressure to be maintained in syringe IJV is encountered at a depth of 2-4 cm Blood splash may not occur until the needle is withdrawn

42. Once IJV is located, 18G needle is placed immediately adjacent to locator needle Continuous aspiration technique employed

43. Once position confirmed a guide- wire is placed through it ; not more than 18 cms Monitor pulse & ECG tracing Remove the needle over guide-wire

44. A dilator is introduced and removed Catheter is threaded over the guide-wire to a depth of 12-15 cms Monitor pulse & ECG tracing Guide-wire is withdrawn

45. Aspirate blood from catheter Attach a three-way connector & tubing Suture in place and apply sterile dressing Get x-ray chest to rule out pneumothorax and to localize tip of catheter.

46. SUBCLAVIAN VEIN CANNULATION Infra- clavicular and supra- clavicular approach, Position – head down with head turned towards contralateral side ; rolled up sheet between shoulder blades longitudinally ; arms by side assistant giving traction to arm of same side,

47. COMMON APPROACHES AND LANDMARKS SUBCLAVIAN POSITION NEEDLE INSERTION ANGLE OF NEEDLE INFRACLAVICULAR - Trendelenburg -Head turned to opposite side - Ipsilateral arm adducted 2 cm inferior to midportion of the clavicle, ”walk” down clavicle and advance just deep to the clavicle Advance the needle under the clavicle towards the sternal notch SUPRACLAVICULAR - Trendelenburg -Head turned to opposite side - Ipsilateral arm adducted Just above the clavicle , lateral to the clavicular head of the SCM Advance the needle at a 45˚ angle, just under the clavicle towards the contralateral nipple

48. INFRA CLAVICULAR APPROACH

49. STEPS Local infiltration 1-2 cms below inferior border of clavicle in midclavicular line, 18 G needle inserted at infiltrated site 2 cm inferior to midportion of the clavicle, ”walk” down clavicle and advance just deep to the clavicle

50. Advance the needle under the clavicle towards the sternal notch Needle is kept horizontal at all times (10 degree upward bend on needle adjacent to hub maybe applied) Continuous aspiration technique applied

51. STEPS

52. ULTRASOUND-GUIDED CENTRAL VENOUS CANNULATION The veins appear as Non- pulsatile Easily compressible Undergo Marked enlargement with valsalva maneuver

53. APPEARANCE

54. INSERTION OF THE NEEDLE- visual confirmation

55. GUIDEWIRE INSERTED UNER DIRECT VISION

56. Advantages of USG guided CVP cannultion Easy identification of any variation in anatomy Direct visualization of important structures Decreases the rate of complications. Ensures faster placement of central catheters

57. CVP MEASURMENT Indirect calculation of CVP through physical examination of the neck veins is a fundamental aspect of cardiovascular assessment, but the bedside diagnosis of low, normal, or high CVP is often inaccurate, particularly in critically ill patients.

58. PROCEDURE FOR CVP MEASUREMENT IS ZERO MANOMETER AT THE LEVEL OF RT. ATRIUM [level of the 4th intercostal space in the mid- axillary line while the patient is lying supine] FILL MANOMETER WITH SALINE USING A THREE WAY TAP

59. CLOSE OFF TAP FROM SOLUTION BAG OPEN TAP TO PATIENT OBSERVE FALLING FLUID IN MANOMETER RECORD MEAN LEVEL

60. PERIPHERALLY INSERTED CENTRAL CATHETER Originally used by cardiologists, adapted for intensivist usage. Inserted via basilic or cephalic veins in the ante- cubital fossa The catheter is advanced upto the central veins Conflicting studies regarding superiority as compared to centrally inserted catheters

61. ADVANTAGES AND DISADVANTAGES OF PERIPHERALLY INSERTED CENTRL CATHETERS ADVANTAGES Easy placement Faster Long lasting Low infection Ambulatory Low cost Low complications DISADVANTAGES CVP monitoring inadequate Inadequate for rapid bolus injections Inadequate for resuscitation