Hey, first day intern. Everyone's busy and we need a central line upstairs. Can you go handle that?
Don't let this happen to you. Join us for our episode all about central lines. Today Dr. Frankel will be the model for the right internal jugular central line. It's probably the one you're most likely to do, but stick around because we do discuss the other common sites.
A smooth central line is all about preparation, and Dr. Parsons is helping me out by attending to patient positioning. So first, he unlocks the bed and moves it so that there's ample room at the head to stand. Next, he elevates the bed to a comfortable working height for me.
Thanks Mike, that's good. And then he places the patient in a little bit of Trendelenburg, which helps to engorge the veins of the neck. He takes the headboard off the head of the bed, and then we slide the patient as far up as he'll go in the bed. Finally, gently tilt the patient's neck off to the side.
Let's have a look at some landmarks. We'll do the line with ultrasound that is absolutely the standard of care. you should be doing, but in the old days people used the two heads of the sternocleidomastoid, the sternal head and the clavicular head, which form a triangle whose apex marks the vein.
By the way, that prominent visible vein on Dr. Franco's neck is the external jugular. Sometimes medical students will mistake that for the real target. Always look at the site under ultrasound before you drape to make sure it's suitable. This has saved me before from going after a vein that is thrombosed or has unfavorable anatomy. I start by tracing the jugular from as far inferior as I can and then up to the angle of the mandible so I can fully understand its course.
And I know this is the internal jugular because it is lateral and superficial to that other vessel which must be the carotid. You can convince yourself further by doing some compression testing. The vein will compress and the artery will remain plump and pulsatile.
Well with that out of the way, let's grab some PPE and get the supplies we need for the procedure. Central line kits are awesome and have most of what you need, but there's always something missing so you have to know what you're getting in the kits. In this case, I also know I'll need an ultrasound, a sterile ultrasound probe cover, and a dressing.
I also brought a compass pressure transducer to show you guys. I open up the kit and put on the rest of the included PPE. Alright, let's familiarize ourselves with the rest of the contents of the kit. There's the drape, the prep stick, there's the lidocaine syringes and needles we need to inject, here are a few finder needles, one is long one is short and one has a small catheter attached to it, here's the guide wire in its sheath, here's the dilator for the skin, knife, sterile saline flushes, caps for the catheter, suture needle driver and catheter fastener, some places to hold sharps, sterile dressing and probe cover that we opened earlier, and the catheter itself. We're using a triple lumen here, if you want a follow-up video discussing the different types of catheters, leave a comment below.
leave a comment below. And I wanna show you the compass pressure transducer. It measures the pressure in the vessel you cannulate. Some hospitals have them, some don't. I won't do the procedure with it, but wanted to show you in case you have them available.
All right, let's start the procedure. Prep and drape in the usual sterile fashion. Make sure you orient the drape according to the arrows.
We have to prime some of our equipment. So take the catheter and attach the blue caps to the two side ports. Leave the middle port uncapped because the wire will need to emerge from there. Flush each of the three ports generously with saline.
Thumb the guide wire back and forth to ensure it glides smoothly, then leave the wire so it is just about to emerge from the cheater cone. Attach the finder needle to the syringe, I used the long one, and then drop some lidocaine. Have your assistant put gel on the tip of the ultrasound probe while you ready the probe cover. Put your hand through the poochy tip of the probe cover and then reach out and grab the probe.
Use your fingers to snug the probe cover up against the probe removing any folds in the plastic. You also want to massage any air bubbles in the gel away from the tip of the probe. Remember air is the nemesis of ultrasound. Then apply the rubber bands to secure the cover.
Next I slap some sterile gel onto the patient and have a look with the probe again. So let's see... yep looks like my site. Having confirmed where I plan to make the puncture, I inject lidocaine subcutaneously.
It's important to remember that you will be sewing the line in, so you also need to inject where you anticipate. the suture needle will be passing. Now you'll want to wait at least a couple minutes for the local to take effect and while I'm waiting one of my favorite things to do is to stage all the equipment I'll be using in the order I'll be using them.
I really love doing this for two reasons. Number one, it forces you to mentally rehearse the steps of the procedure in order before you even get started. And number two, especially if you don't have an assistant, the tool you need next in the procedure will always be the one coming up.
And so as you'll soon be learning, the order should be the same. should be the finder needle attached to the syringe, the guide wire, a knife, the dilator, the catheter, saline flushes, and then finally the things you need to sew it in. So the needle drivers, the suture, and the catheter fastener. Personally, I really like staging on the sterile field itself next to the patient.
It leaves the tools within arm's reach and I don't have to look away to grab them. The MayoStand would be just fine too, especially if the patient is squirrelly and you're afraid they may bump your equipment. Place the ultrasound back on target and then wield the finder needle.
Use the ultrasound to guide the finder needle into the lumen of the jugular, applying negative suction pressure on the syringe as you advance it. I cover the ins and outs of ultrasound guided access in this other video which I'll link here. You should definitely watch it now if you haven't already. And once you're done, come back to this video. Once the needle is in the lumen of the jugular and you are able to draw back venous blood, very carefully remove the syringe from the finder needle.
Stabilize that needle while you're doing this. Don't let it move. If you're using the compass pressure transducer, you can feed a wire through it so you don't have to remove the syringe. Now grab that wire and start feeding it through the needle.
The wire should advance fairly smoothly. If it does not, something is wrong. You should stop and reassess.
You only need to feed as much wire as the catheter is long. Any more is unnecessary. If your guide wire is like mine, The second or two line marking on the wire identifies 20 centimeters, and so I advance until that mark is at the skin. And as you advance, watch the monitors for signs of ectopy. If you see that, then you are too deep and you should withdraw the wire a couple centimeters.
From here on out, one hand should always be controlling the wire until it is out of the body. Otherwise, there is the rare chance it gets totally sucked into the vein, and that will be an embarrassing call to vascular or cardiothoracic surgery. Speaking of embarrassing calls, now is a good time to confirm placement of the wire.
If you accidentally wired up the carotid, it's not too late. You can still remove it and hold pressure for several minutes and see if you can get away with it. But if you go to the next step and you dilate the carotid artery, you will need to call vascular.
Here is how I am confident that I put the wire in the right spot. 1. The initial flash was dark venous appearing blood. 2. Under ultrasound, I saw the tip of the needle entering the vein and not the artery.
See the ultrasound-guided axis video for more info. 3. The compass pressure transducer, if I'm using it, was reading a non-pulsatile venous-level pressure. And 4. I see the wire traveling down the jugular on ultrasound. So number 4 is what I do next.
Pick up the ultrasound and put it just over the wire. In short axis view, follow the wire down the jugular as it meets the subclavian. Then I do the same thing in long axis view. Unfortunately, our model doesn't have a subclavian, so the demonstration here isn't perfect.
Leave a comment if you thought Dr. Franco should have let me put a centerline in him for educational purposes. Next, grab the 11 blade and slide it down the wire, inserting just the tip right into the puncture site, with the sharp edge facing away from the wire. Apply pressure away from the wire as you pull the knife out of the skin to make a small nick at the skin which you can fit the dilator through. Now grab that dilator and feed it over the wire to get it to the skin. Applying firm but steady pressure and with a bit of a twisting motion, dilate the skin and the subcutaneous tract.
A couple notes about dilation. One, you only need to insert the dilator up to the anticipated depth of the jugular vein, which is usually no more than three to four centimeters. And two, you need to prevent pinking of the guide wire as it emerges from the tip of the dilator. which can happen when you try to force the dilator over the wire. A kinked wire can tear the vein.
To prevent this, I gently oscillate the wire back and forth to ensure it continues to glide smoothly as I advance the dilator. Okay, now withdraw that dilator and pick up the central line catheter itself. Feed the catheter over the wire, keeping control of the wire at the skin.
As you advance the catheter, at some point the wire will poke out of the middle port. If the catheter gets all the way to the skin and the wire is not yet poking out of the port, you need to back the wire up until there is enough length for it to poke out of the port. Once the wire is poking out of the port, you can now control the wire from behind the catheter.
With that control, push the catheter through the skin into the vein until you reach your desired depth. In a right-sided IJ, I typically insert to about 16 centimeters. If you stick around, I will discuss appropriate insertion depths for the other sites. Remember you left the middle port without a blue cap so the wire could poke through? Well now you'll want to place that last blue cap onto the middle port.
We now need to draw back from and then flush each of the three ports. Take the sterile saline syringe and attach it to one of the ports. Aspirate from the syringe just enough until you see red appear in the line tubing.
Don't pull back so far that blood begins to enter the syringe. When you see red begin to enter that tubing, push the plunger and flush a little bit of that saline through the line. And now do the same thing for the remaining two ports.
All that's left is to suture this thing in place, so confirm the catheter depth is correct, then take the white, soft part of the catheter fastener and affix it around the catheter, right up against the skin. Lock the white part in place by snapping the hard, red part of the fastener over it. Sew this in, and then sew in the fixed white holes as well. Put the sterile dressing on, call for x-ray to confirm placement, and call it a job well done. Ugh, doesn't stick to the mannequin very well.
As promised, I want to briefly discuss the other potential central line access sites. They all use the same Seldinger technique, so you don't have to learn too much more. We just demonstrated the right internal jugular.
You could also access the left IJ with the same landmarks, but there is a greater chance of malposition because the catheter will need to make a sharper turn down the superior vena cava. Subclavian lines are also an option. The advantages of the subclavian are increased patient comfort and decreased risk of infection, but downsides are that this site is difficult to compress and the patient is more likely to have a stroke.
if you encounter bleeding and there is an increased risk of pneumothorax. Subclavian lines are sometimes obtained blind but ultrasound is becoming much more popular. Still the blind subclavian is very fast to put in.
In a trauma situation if a fem line is not possible the subclavian is my next choice. For the blind landmark guided approach put your index or third finger on the sternal notch and then put your thumb on the prominent bump of the clavicle where it starts to bend toward the shoulder. Insert the needle next to your thumb and aim the needle at the finger on the sternal notch. Aspirate as you advance and you'll hit the vein. Here's the infraclavicular short axis view of the subclavian vein, and here's long axis.
You can also get a supraclavicular approach by following the jugular down until it meets the subclavian, and then following the subclavian from there. I won't go to too much more depth about this, but leave a comment if you want to know more. But speaking of depths, for insertion depths of neck catheters, I place right-sided neck catheters 16 centimeters deep and left-sided catheters I place 19 centimeters deep. I adjust if the patient is very short or very tall.
There are formulas that predict optimal depth based on height, but I don't bother with them. Remember if a line is too deep you can withdraw it, but if a line is too shallow you can't advance it further without replacing it. In my experience I rarely put lines in too deep.
Finally, the femoral line is the archetypical crash line. This line has the highest rate of infection and is not comfortable to have in, but you can place it while people are crowding around the top of the patient. Remember, the vein is medial to the artery, so if you can feel a pulse, aim medial to the pulsation.
But often these patients are crashing and do not have a pulse, and in that case, my favorite landmark to use is the pubic tubercle. That's the bony prominence off of the lateral aspect of the pubic bone. Measure two finger widths lateral and one finger width inferior to the tubercle and that's where you should stab. Hub the line when you insert it.
That was a lot of information and yet there's still so much more to talk about. And I know some of you guys are out there furiously typing in the comments section about something that I missed or didn't cover. Well by all means keep typing those comments, we love to read them.
Tell us about your personal tips for doing the central line or leave any questions that you may have had from the video. We do read the comments and I promise that one day in the near future I plan on revisiting these topics and making videos about the things you guys are commenting on. But until next time, dominate the day.