Practical guide for safe central venous catheterization and management 2017

Abstract

Central venous catheterization is a basic skill applicable in various medical fields. However, because it may occasionally cause lethal complications, we developed this practical guide that will help a novice operator successfully perform central venous catheterization using ultrasound guidance. The focus of this practical guide is patient safety. It details the fundamental knowledge and techniques that are indispensable for performing ultrasound-guided internal jugular vein catheterization (other choices of indwelling catheters, subclavian, axillary, and femoral venous catheter, or peripherally inserted central venous catheter are also described in alternatives).

Keywords: Catheter-related infection; Mechanical complication; Medical education; Pediatric; Ultrasound-guided central venous catheterization.

Fig. 1

Sedillot’s triangle. Sedillot’s triangle comprises the sternocleidomastoid muscle and the clavicle. The triangle can be visually approximated or palpated. In most cases, the internal jugular vein is located within the triangle. Furthermore, insertion and catheterization within the triangle have the benefit of easy handling of the needle and dilator because of the thin tissue layer between the skin surface and the vein

Fig. 2

Anatomical consideration for preventing mechanical complications. a Vessels and nerves surrounding the internal jugular vein. b Magnified figure of the dashed square in part a showing the transparent view of the internal jugular vein and surrounding vessels and nerves. IJV internal jugular vein, CA carotid artery, SA subclavian artery

Fig. 3

Small arteries posterior to the IJV. a Ultrasound image of the IJV and CA around the middle of the Sedillot’s triangle. b Color Doppler reveals several arteries (asterisk) dorsal to the IJV, which shows the high risk of mistakenly puncturing an artery if the posterior wall of the IJV is penetrated. IJV internal jugular vein, CA common carotid artery

Fig. 4

Static approach. The triangle shows the Sedillot’s triangle. The line lateral to the Sedillot’s triangle indicates the IJV location confirmed in an ultrasound image. In some cases, the IJV is located outside of the Sedillot’s triangle. If the operator inserts the needle immediately above the line, which was the IJV location confirmed in an ultrasound image, the sternocleidomastoid muscle (clavicular head) would likely be penetrated, which may cause difficulty in the insertion of the dilator. When enlarging the route of the guidewire through the thick muscle using the dilator, a patient who is awake may feel discomfort and fear. Furthermore, difficulty in the insertion of the dilator may sometimes cause kinks and aberrant movement of the guidewire from the vein. Even the procedure has been performed safely, the patient will complain of discomfort when they move their neck. If the operator chooses the real-time ultrasound-guided approach in this case, the operator can insert the needle on the line at a relatively cephalad portion, which can prevent the penetration of the sternocleidomastoid muscle, rendering it safer

Fig. 5

Pitfall of the short-axis out-of-plane technique. The yellow dotted line shows the dimple-like deformed anterior vein wall. It indicates the needle reaching and pushing the anterior vein wall. The white dot represents the shaft of the needle. a The needle tip (dotted red circle) is on the ultrasound beam. b The ultrasound image depicts part of the needle shaft (dotted red circle)

Fig. 6

Sweep scan technique (reproduced from [12]). W, the scan is not following the path of the vessel; thus, the target vein, which was at the center of the image, moves toward the edge of the image; R, when the scan follows the path of the vessel, the vein stays at the center of the image. Conversely, if the vein remains at the center of the image during the sweep scan, the scan is following the path of the vessel

Fig. 7

Swing scan technique (reproduced from [12]). W, if the probe is not perpendicular to the long axis of the vein, the vein will move to the edge of the image when the probe is swung; R, if the probe is perpendicular to the long axis of the vein, the vein will stay at the center of the image when the probe is swung. Conversely, if the vein stays at the center of the image during a swing scan, the probe is perpendicular to the path of the vessel

Fig. 8

Probe placed perpendicular to the path of a vessel (reproduced from [12])

Fig. 9

Manipulation of the needle and confirmation of the tip (reproduced from [12]). a When the needle is guided into the scan plane, b the first point of brightness to appear is the needle tip. c Next, the scan plane is moved slightly forward, which causes the point of brightness to disappear. d The needle is again advanced slowly into the scan plane, which causes a point of brightness to reappear. e Repeating this manipulation, the needle gradually reaches the target vein. f When the needle tip touches the anterior wall of the target vein, it creates a small dimple, turning the vein into a heart shape. Pushing the needle into the vein with a snapping motion allows it to move a short distance so that it only penetrates the anterior wall. (Venous pressure is normally low; thus, if the needle is pressed slowly into the anterior wall and the tip reaches the posterior wall, it could penetrate the posterior wall as well.) g Finally, the anterior wall returns to its original shape, the shaft comes into view, and the tip can no longer be seen. h To see the tip, move the scan line forward

Fig. 10

Long-axis in-plane technique. To perform the procedure safely, the operator should identify the center of the vein using the scan called the “side-scape scan technique” [48], which includes the following steps: First, turn the distal part of the probe to the right until the right lateral wall is identified (the yellow arrow shows the turning direction). The lateral wall appears to have a bullet shape because of the merging of the anterior and posterior walls. Second, turn the distal part of the probe to the left, and the left lateral wall can then be identified. The operator can estimate the distal center of the vein and then repeat the same motion at the proximal side of the vein to estimate the proximal center of the vein. Third, the operator can obtain the longitudinal ultrasound view of the center of the vein. Finally, with the needle guide and/or personal skills, advance the needle within the ultrasound beam, which can prevent “anterior to lateral wall penetration.”

Fig. 11

Confirmation of the guidewire. The white arrow indicates entering point of the guidewire into the vein. V long axis of the internal jugular vein, AW anterior wall of the internal jugular vein, PW posterior wall of the internal jugular vein. The white arrow indicates entering point of the guidewire into the vein

Fig. 12

Optimal catheter placement (modified from [49]). Zone A, inferior portion of the superior vena cava up to the superior portion of the right atrium; zone B, portion of the right innominate vein confluent with the left innominate vein and the superior portion of the superior vena cava; zone C, innominate vein peripheral to the superior vena cava

Fig. 13

Central venous catheterization methods with a static approach. *Venous blood cannot be confirmed using only the color or flow of backflow blood. **Insert the guidewire about 10 cm and insert the cannula up to its base, then confirm by attaching an extension tube to measure pressure, display a pressure waveform, or perform blood gas analysis. TEE, transesophageal echocardiography

Fig. 14

Confirmation of central venous catheterization with real-time approach. **Insert the guidewire about 10 cm and insert the cannula up to its base, then confirm by attaching an extension tube to measure pressure, display a pressure waveform, or perform blood gas analysis. TEE, transesophageal echocardiography

Fig. 15

Confirmation of guidewire location using ultrasound images. The patient was a 6-month-old infant. The guidewire can be seen inside the internal jugular vein in the short-axis image (a). However, this alone cannot determine if the guidewire tip is inside the vein. The long-axis image shows that the guidewire path gradually becomes parallel to the vessel wall (b)