Internal Jugular Central Venous Access.pptx

Internal Jugular Central Venous Access

1. INTERNAL JUGULAR CENTRAL VENOUS ACCESS dr. Erka Wahyu Kinanda – KIN Supervisor : dr. Yuddy Imowanto , Sp. EM, KEC

2. LIST OF CONTENTS History Anatomy Indications Contraindications Complications Advantages vs Disadvantages Equipment Preparation Procedures Summary 2

3. History 3

4. Infraclavicular (IC) Subclavian venipuncture - first described by Aubaniac in 1952 In 1965, the supraclavicular (SC) approach was described IJ approach (later known as the central approach) was described in 1966 Later on came the Femoral and cephalic-basilic approaches 4

5. Anatomy 5

6. Course : Origin from jugular foramen Joins subclavian vein behind sternal extremity of clavicle Medial relations : internal and common carotid arteries , 9th to 12th cranial nerves above common carotid artery and vagus Anterolateral relations : skin , superficial fascia , platysma , cervical fascia , sternomastoid , sternohyoid , omohyoid Posterior relations : transverse process of the cervical vertebrae , levator scapulae , scalenus medius and anterior, cervical plexus , phrenic nerve , thyrocervical trunk , vertebral vein , 1st part of subclavian artery Tributaries : Inferior petrosal sinus, facial , pharyngeal , lingual , superior thyroid , middle thyroid , occipital veins 6

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8. Indications 8

9. Secure or long-term venous access that is not available using other sites Inability to obtain peripheral venous access or intraosseous infusion IV infusion of fluids and drugs for patients in cardiac arrest IV infusion of concentrated or irritating fluids IV infusion of high flows or large fluid volumes beyond what is possible using peripheral venous catheters 9

10. Monitoring of central venous pressure (CVP) Hemodialysis or plasmapheresis Transvenous cardiac pacing or pulmonary arterial monitoring (Swan-Ganz catheter)* Placement of inferior vena cava filter * For transvenous cardiac pacing or pulmonary arterial monitoring, a right internal jugular cannulation or a left subclavian vein cannulation typically is preferred. 10

11. Contrai ndications 11

12. Absolute Contraindications Unsuitable internal jugular vein , thrombosed ( uncompressible ) or inaccessible as seen by ultrasound Untrained or inexperienced ultrasound operator Local infection at the insertion site Antibiotic-impregnated catheter in allergic patient 12

13. Relative Contraindications Coagulopathy, including therapeutic anticoagulation* Local anatomic distortion, traumatic or congenital, or gross obesity Malignant superior vena cava syndrome Severe cardiorespiratory insufficiency or increased intracranial or intraocular pressure (patients will be compromised by Trendelenburg [head down] positioning) 13

14. Relative Contraindications History of prior catheterization of the intended central vein Uncooperative patient (should be sedated if necessary) Left bundle branch block (a guidewire or catheter in the right ventricle can induce complete heart block) * Therapeutic anticoagulation ( eg , for pulmonary embolism) increases the risk of bleeding with internal jugular cannulation, but this must be balanced against the increased risk of thrombosis ( eg , stroke) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient. A femoral line may be preferred. 14

15. Complications 15

16. Arterial puncture Hematoma Pneumothorax Damage to the vein Hemothorax Air embolism Catheter misplacement* 16

17. Arrhythmias or atrial perforation, typically caused by guidewire or catheter Nerve damage Infection Thrombosis * Rare complications due to catheter misplacement include arterial catheterization, hydrothorax, hydromediastinum , and damage to the tricuspid valve. Guidewire or catheter embolism also rarely occurs. To reduce the risk of venous thrombosis and catheter sepsis, CVCs should be removed as soon as they are no longer needed. 17

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19. Advantages vs Disadvantages 19

20. ADVANTAGES Better control of bleeding - Can compress carotid RIJ - straight path to SVC/RA Lower failure rate with inexperienced operators Reliable landmarks ↓ risk of venous thrombosis in ESRD DISADVANTAGES Carotid puncture , hematoma , airway compression Higher incidence of arterial puncture compared with SCV Difficult with tracheostomy Vein collapse with hypovolemia ↑ ­ICP Difficult for long-term LIJ may injure thoracic duct 20

21. COMPARISON Location Advantage Disadvantage Internal Jugular Bleeding can be recognized and controlled Malposition is rare Less risk of pneumothorax Risk of carotid artery puncture Pneumothorax is possible Subclavian Most comfortable for conscious patient Highest risk of bleeding Vein is non-compressible/deep vein Highest risk of Pneumothorax Femoral Easy to find vein No risk of Pneumothorax Preferred site for emergencies Highest risk of infection Risk of DVT Not good for ambulatory patients

22. Equipment 22

23. Sterile Procedure, Barrier Protection Antiseptic solution ( eg , chlorhexidine-alcohol , chlorhexidine , povidone iodine , alcohol ) Large sterile drapes , towels Sterile head caps , masks , gowns , gloves Face shields 23

24. Ultrasound Guidance Ultrasound machine with a high-frequency ( eg , 5 to 10 MHz), linear array probe (transducer) Ultrasound gel, nonsterile and sterile Sterile probe cover to ensheathe probe and probe cord, sterile rubber bands (alternatively, the probe may be placed within a sterile glove and the cord wrapped within a sterile drape) 24

25. Seldinger (Catheter-over-guidewire) Technique Cardiac monitor Local anesthetic ( eg , 1% lidocaine without epinephrine, about 5 mL) Small anesthetic needle ( eg , 25 to 27 gauge, about 1 inch [3 cm] long) Large anesthetic/finder* needle (22 gauge, about 1.5 inches [4 cm] long) Introducer needle ( eg , thin-walled, 18 or 16 gauge, with internally beveled hub, about 2.5 inches [6 cm] long) 3- and 5-mL syringes (use slip-tip syringes for the finder and introducer needles) Guidewire, J-tipped Scalpel (#11 blade) Dilator 25

26. Seldinger (Catheter-over-guidewire) Technique Central venous catheter (adult: 8 French or larger, minimum length for internal jugular catheter is 15 cm for right side, 20 cm for left side) Sterile gauze ( eg , 4 × 4 inch [10 × 10 cm] squares) Sterile saline for flushing catheter port or ports Nonabsorbable nylon or silk suture ( eg , 3-0 or 4-0) Chlorhexidine patch, transparent occlusive dressing A finder needle is a thinner needle used for locating the vein before inserting the introducer needle. It is usually not needed for ultrasound-guided cannulations. The external diameter of the CVC should be less than or equal to one third of the internal diameter of the vein (as measured by ultrasound) to reduce the risk of thrombosis. Having an assistant or two is helpful. 26

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28. Preparation 28

29. Explain risks and benefits, if possible. Risks include infection, pain, local bleeding or hematoma, or pneumothorax/hemothorax. Ideally, the patient should be placed on a cardiac monitor to detect any dysrhythmias triggered while advancing with wire. Sterilize the neck and clavicle area with chlorhexidine. Provide adequate local anesthesia. For the uncooperative patient, consider sedation. 29

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32. Procedures 32

33. Central Approach Landmark: Triangle by clavicle & 2 heads of SCM muscle, carotid pulse Start high in the triangle, 1cm below apex Angle 30-45° from skin Toward ipsilateral nipple Vein usually 2-3 cm from skin surface 33

34. Anterior Approach Landmark: Between midpoint of medial border of sternal SCM & carotid laterally Angle 30-45° from skin Toward ipsilateral nipple Vein usually 3-5 cm from skin surface Don’t press on carotid (reduces cross-sectional area of IJ) 34

35. Posterior Approach Landmark: Posterolateral edge of clavicular SCM high in the neck (3-5 cm above clavicle) Shallow angle 15-30° from skin Inferomedially toward contralateral nipple/ sternal notch Vein usually 3-5 cm from skin surface Higher risk of carotid puncture Lower risk of pneumothorax 35

36. US-Guided Approach Increases first attempt success rates, decreases the number of attempts needed for success Complication rates are similar in both techniques 36

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38. Summary 38

39. 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). Ultrasonographic guidance for placement of internal jugular lines increases the likelihood of successful cannulation and reduces the risk of complications. When ultrasonographic guidance and trained personnel are available, this method of placement is preferred. 39

40. LIST OF REFERENCES le Fevre , P. (n.d.). written and illustrated by Central Venous Catheter Insertion Guide Central Venous Catheter Insertion Guide About This Guide . www.philippelefevre.com Mendenhall BR, Wilson C, Singh K, et al. Internal Jugular Vein Central Venous Access. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436020/ Central venous catheter insertion (Internal jugular vein ) - YouTube . ( n.d .). Retrieved June 3, 2024, from https://www.youtube.com/watch?v=O75D99DxWmM How To Do Internal Jugular Vein Cannulation, Ultrasound-Guided - Critical Care Medicine - MSD Manual Professional Edition . (n.d.). Retrieved June 3, 2024, from https://www.msdmanuals.com/professional/critical-care-medicine/how-to-do-central-vascular-procedures/how-to-do-internal-jugular-vein-cannulation,-ultrasound-guided Central Venous Catheters • LITFL Medical Blog • CCC . (n.d.). Retrieved June 3, 2024, from https://litfl.com/central-venous-catheters/ 40

41. THANK YOU 41