To today's young burgeoning emergency physicians, ultrasound guided internal jugular central catheters have more or less become standard of care. And for good reason! They are safe, and after a good amount of experience, quite easy to perform.
But technology has a tendency to break down. You might be working someplace that has only one ultrasound machine at its disposal, and just when you have a septic patient who could benefit from some central access and pressors, your probe stops working. You start to sweat, because while femoral access is easy, it has a limited lifespan infection-wise, its SvO2 readings will be inaccurate, and everyone will question your CVPs (though theoretically the water column of your central venous system should be the same pressure everywhere in a supine patient, and CVPs are useless anyway.
Well fear not, dear reader, because you too can be like those grizzled colleagues of ours who point out that in their day, every IJ central line was done blind.
First off, some basics are probably worth going over. The IJs lie parallel and lateral to the carotid arteries until the level of the clavicle, at which point they migrate medially to overlie the carotid. Obviously, differences will exist between patients, but this is a good rule of thumb to start with.
It will be worth your time to maneuver to give yourself the biggest possible target, especially if you’re doing this blind. In most people, the right IJ is slightly larger than the left owing to its more direct connection to the RA. For this reason, and also because your catheter will have a more direct path to the SVC-RA junction, the right IJ is preferred.
You will also want to give yourself a little Trendelenberg (assuming, of course, your patient isn’t at too high a risk for aspiration). This will use gravity to force some blood back into the IJ and make your target even bigger.
You can access the IJ anteriorly, centrally, or posteriorly. These refer to your entry point in front of, at the bifurcation of, or behind the sternocleidomastoid muscle, who will be your best friend for this procedure.
The anterior approach is probably most user-friendly, since at this spot the carotid artery is most easily palpated, and can be retracted by your non-needle-bearing hand. Place one hand on the carotid, and insert your needle at an angle of 30-45° to the skin on the anterior edge of the SCM about 2-3 fingerbreaths above the clavicle. Aim the point of your needle toward the ipsilateral nipple. Be advised that statistically, this approach has the highest likelihood of hitting the carotid.
The central approach is the most commonly used. Find the bifurcation of the SCM muscle and insert your needle just caudal to its apex at a 30° angle, aiming toward the ipsilateral nipple. The IJ will often be a little more lateral than you expect with this approach, and can move around depending on how much your patient’s head is turned. This approach does have the highest likelihood of causing a pneumothorax, so if you don’t get blood within 3 cm or so, don’t keep advancing your needle.
Finally, the posterior approach is probably the hardest landmark-wise, but it carries the lowest likelihood of complications. Find the posterior border of the SCM muscle, and insert your needle about halfway up the muscle at an angle of 45°, with the point aimed toward the sternal notch. Make sure to lift the body of the SCM out of the way as you advance, and wave at the EJ as you pass by. Blood should come out around 5cm in most people.
The official New England Journal of Medicine video on IJ placement is largely ultrasound driven, but they do have some pretty impressive graphics regarding positioning in an ultrasonographically poor world.
Scott Weingart has a demonstration on the EMCrit blog:
Just as always, these posts are meant for EDUCATIONAL PURPOSES ONLY. Are you still only comfortable with doing these with a probe? Maybe you should go practice on a model first.
Stay tuned, folks--Procedures Club Videos are coming to a website near you!
jps & ak
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- Roberts and Hedges' Clinical Procedures in Emergency Medicine. Chapter 22
- New England Journal of Medicine Videos in Clinical Medicine
- Life in the Fast Lane Website, Central Venous Catheters