The landmark and ultrasound-guided techniques may be used to cannulate usually the right IJV.
The patient is supine in a Trendelenburg position (head down) to distend the right IJV.
With the head turned to the left, the IJV may be identified superiorly in the carotid triangle anterior to the anterior border of sternocleidomastoid muscle, or inferiorly between the two heads of the sternocleidomastoid.
Local anaesthesia is infiltrated in the skin (3-5ml). It may be applied after draping using ultrasound so as to get an idea of the depth and passage of the infiltration needle in relation to the IJV.
The ultrasound machine settings are set to using the linear probe with a depth of not more than 5cm (depending on the patient size).
Scrub up (wash hands, wear mask/hat/sterile gloves/gown).
Prep the area using chlorhexidine sponges and allow it to dry.
Place a sterile drape with the fenestration bordering the superior edge of the clavicle and exposing the entire width of the sternocleidomastoid.
Place a sterile cover over the ultrasound machine and check the position of the IJV. Adjust the fenestration if necessary.
The IJV is identified on ultrasound by its compressibility to near-occlusion, lack of pulsatile flow on Doppler, large caliber and position next to an incompressible pulsatile vessel (the carotid artery). Valves may be present in this segment.
Flush each lumen (3-5) of the catheter with heparinised saline. Clamp each port in turn, except the central lumen which is left open for the passage of the guide-wire.
Ensure the guide-wire is made wet with heparinised saline.
Attach the needle to a 5ml syringe and flush it with heparinised saline. Ensure the needle is completely empty.
Place a swab in the neck for catching blood from the catheter.
Using the non-dominant hand, hold the probe across the width of the IJV with the vein in the middle of the screen. The vein appears as a dark circle (hypoechoic). Check it is the vein as mentioned above.
Using the dominant hand, the needle is advanced at an angle of 45 degrees while continuously aspirating on the syringe. This action is achieved by holding the syringe flap and piston handle, rather than the needle itself. Entry of the needle is made at exactly the mid-point of the probe as that signifies the midpoint of the screen below which the vein is identified. The needle may be seen as a hyperechoic (white) area advancing through the superficial structures. Care is taken not to deviate towards the carotid artery.
For a vein located at a depth of 1cm and needle entry at 45 degrees, the needle has to be advanced at least 1.4cm to reach the vein. 2cm at 30 degrees, 1.cm at 60 degrees.
When flashback is seen, the needle is advanced by 2mm and confirmed to be in the vein by checking the non-pulsatile character of flow, dark red colour of blood and location of the needle tip on the ultrasound screen.
The probe is then put down and the needle held at exactly the same position by the non-dominant hand.
The principle of the guide-wire is that it is always grasped by the operator by one hand.
Using the dominant hand, the guide-wire is threaded through the needle into the IJV, leaving a small portion (10-15cm) outside the body.
The needle is removed over the wire which is regrasped by the non-dominant hand at the skin once the needle is outside the skin.
A 1cm wide & deep stab incision using size 11 blade (straight blade with a pointed tip) is made right up against wire to ensure only a single lumen is created through the subcutaneous tissue.
The plastic dilators are advanced over the wire (keeping the wire always in either hand) in increasing order of diameter. Once advanced through the subcutaneous tissues, it is inserted into the vein with a single, fluid motion. That is, a swift push to the dilator hilt with a half-twist by slight pronation, followed by a swift withdrawal.
The wire is then withdrawn, and in doing so, simultaneously threaded by the non-dominant hand through the central lumen of the catheter held in the dominant hand, until the wire appears on the opposite end of the catheter through the port site. It is grabbed again and held steady while the catheter is then pushed over the wire into the vein, to the hilt. The guide-wire is completely removed and its integrity checked.
Each port is aspirated to see blood appearing in the port tubes, flushed with heparinised saline and clamped. When flushing ensure the syringes are pointing down to avoid any air being injected.
The catheter is sutured to the skin, and secured with adhesive dressings.
Confirmation of placement is by checking the CVP trace, blood gas measurement, dark colour of the blood and location on ultrasound.
The patient requires a chest radiograph to check correct placement of the tip at the junction of the SVC and right atrium, and for excluding a pneumothorax.