Overview
Definition:
Central venous catheter (CVC) insertion is a medical procedure to place a catheter into a large vein, typically the superior vena cava or right atrium, to facilitate access for fluid resuscitation, medication administration, hemodynamic monitoring, and parenteral nutrition
The internal jugular (IJ) vein approach is one of the most common and preferred routes due to its relatively large size, straight trajectory to the superior vena cava, and lower risk of pneumothorax compared to subclavian access.
Epidemiology:
Central venous catheters are used in a significant proportion of critically ill patients in intensive care units and perioperative settings
Millions of CVC insertions are performed annually worldwide
The IJ vein is the most frequently chosen site for CVC insertion in many clinical scenarios.
Clinical Significance:
Reliable vascular access is paramount in managing critically ill patients
CVCs provide a route for administering vasoactive drugs, chemotherapy, and total parenteral nutrition, as well as for monitoring central venous pressure
Proper technique and site selection, such as the IJ approach, are crucial for minimizing complications and ensuring patient safety, making this a core skill for surgeons and intensivists preparing for DNB and NEET SS exams.
Indications
Indications For Cvc:
Administration of vesicants or irritant medications
Need for long-term intravenous therapy
Hemodynamic monitoring (e.g., CVP measurement)
Administration of blood products
Total parenteral nutrition
Access for emergent fluid resuscitation in shock
Hemodialysis or apheresis
Placement of temporary pacing wires
Difficult peripheral venous access.
Indications For Ij Approach:
Preferred site for mechanically ventilated patients to reduce pneumothorax risk
Patients with coagulopathy where ultrasound guidance is crucial
Anticipated difficult cannulation of other sites
When direct visualization and palpation are feasible
As a primary site in many ICU protocols.
Contraindications:
Absolute contraindications are rare
Relative contraindications include ipsilateral carotid artery surgery or trauma, severe coagulopathy (relative, use ultrasound), infection over the insertion site, ipsilateral thoracic surgery, severe anatomical distortion, and patient refusal
Bilateral IJ cannulation should generally be avoided if possible.
Preoperative Preparation
Patient Assessment:
Assess patient's coagulation status (INR, PTT, platelet count)
Review relevant anatomy and identify potential difficulties
Ensure informed consent is obtained
Assess for infection at the insertion site
Confirm indication for CVC placement.
Equipment Checklist:
Sterile tray with central venous catheters (appropriate size, e.g., 7-9 Fr)
Introducer needle (18-20 gauge)
Guidewire with a J-tip
Dilator
Suture material (e.g., 2-0 or 3-0 silk)
Scalpel blade (e.g., #11)
Gauze pads
Antiseptic solution (e.g., chlorhexidine)
Sterile drapes
Local anesthetic (e.g., lidocaine 1%)
Syringes and needles
Pressure bag for transducer (if monitoring CVP)
Sterile gloves, gown, mask, and cap
Occlusive dressing or sterile transparent dressing
Ultrasound machine and sterile probe cover (highly recommended).
Patient Positioning:
Place the patient in a supine or Trendelenburg position (10-20 degrees) to distend the IJ vein and reduce the risk of air embolism
The head should be turned 30-45 degrees away from the side of insertion to optimize anatomical landmark visualization and palpation.
Procedure Steps Ultrasound Guided
Site Identification And Marking:
Using ultrasound, identify the IJ vein in a transverse view
Locate the most superficial and compressible part of the vein, typically between the heads of the sternocleidomastoid muscle, anterior to the carotid artery
Mark the intended needle entry point.
Anesthesia:
Administer local anesthetic (e.g., 1% lidocaine) to the skin and subcutaneous tissue overlying the insertion site, ensuring adequate local anesthesia without intravascular injection.
Needle Insertion And Venipuncture:
Using a sterile technique, insert the introducer needle at the marked site with a cephalad trajectory, aiming towards the apex of the triangle formed by the clavicle and sternal and clavicular heads of the sternocleidomastoid muscle
Connect a 10 mL syringe filled with saline and aspirate gently
Observe for pulsatile venous blood return, which indicates successful IJ cannulation.
Guidewire Insertion:
Once venous blood return is confirmed, advance the J-tipped guidewire through the needle into the vein
Advance the guidewire until it is well within the vessel, usually 15-20 cm
Ensure the guidewire does not kink or coil
If resistance is met, do not force it.
Catheter Advancement:
Remove the needle while holding the guidewire in place
Make a small skin incision with the #11 scalpel blade at the guidewire entry point to facilitate catheter passage
Advance the central venous catheter over the guidewire until the hub is at the skin
Ensure the guidewire can be smoothly removed from the catheter lumen.
Guidewire Removal And Flushing:
Remove the guidewire completely, applying digital pressure to the catheter hub to prevent air embolism
Aspirate blood from each lumen to confirm venous placement and check for patency
Flush each lumen with sterile saline or heparinized saline according to institutional protocol to prevent clotting
Secure the catheter with sutures and apply an occlusive dressing.
Postoperative Care
Confirmation Of Placement:
Ideally, confirm catheter tip position with a post-procedure chest X-ray, particularly for non-tunneled catheters
The tip should be located at the cavoatrial junction
For ultrasound-guided IJ insertion, immediate chest X-ray may not always be necessary if proper technique is followed and the catheter is advanced appropriately.
Dressing And Site Care:
Maintain sterile dressing changes as per protocol, usually every 48-72 hours or if the dressing becomes loose or soiled
Inspect the insertion site daily for signs of infection (redness, swelling, purulent discharge, pain).
Flushing And Locking:
Flush each lumen with saline after each use and before capping to prevent thrombus formation
Lock each lumen with heparinized saline or an appropriate locking solution as per institutional guidelines to maintain patency between uses.
Monitoring And Antibiotics:
Monitor for signs and symptoms of catheter-related bloodstream infection (CRBSI), thrombosis, pneumothorax, or bleeding
Prophylactic antibiotics are not routinely recommended but may be used in specific high-risk situations or based on institutional policy.
Complications
Early Complications:
Pneumothorax/hemothorax (especially with subclavian approach, less common with IJ but possible)
Arterial puncture with bleeding or hematoma formation
Air embolism
Arrhythmias (if guidewire or catheter irritates the atrium)
Nerve injury (phrenic nerve, recurrent laryngeal nerve)
Incorrect placement (e.g., subclavian vein, jugular vein, carotid artery, thoracic duct)..
Late Complications:
Catheter-related bloodstream infection (CRBSI)
Venous thrombosis
Catheter occlusion
Erosion of the catheter through the skin
Catheter fracture or kinking..
Prevention Strategies:
Use of ultrasound guidance for site selection and venipuncture
Strict aseptic technique during insertion and dressing changes
Proper patient positioning
Correct catheter length and securement
Appropriate flushing and locking protocols
Diligent monitoring of the insertion site
Prompt removal of the catheter when no longer necessary
Use of chlorhexidine-based skin antisepsis.
Key Points
Exam Focus:
Understanding indications, contraindications, and relative contraindications
Mastery of anatomical landmarks for IJ approach
Step-by-step procedure including complications
Importance of ultrasound guidance
Recognition and management of complications like pneumothorax and CRBSI.
Clinical Pearls:
Always use ultrasound if available for IJ cannulation to increase success rates and decrease complications
Remember the Trendelenburg position to distend the vein
Turn the head away from the insertion side
Aim cephalad towards the clavicle
If arterial blood is aspirated, withdraw needle and apply firm pressure
Do not force guidewire if resistance is met
reposition
Confirm catheter tip position with CXR, especially if any doubt about placement.
Common Mistakes:
Failure to obtain informed consent
Inadequate aseptic technique
Incorrect patient positioning
Poor anatomical landmark identification or reliance on palpation alone
Forcing guidewire or catheter
Failure to confirm catheter tip position
Inadequate flushing leading to occlusion
Neglecting to monitor for signs of infection or thrombosis.