Ultrasound-guided internal jugular CVC insertion

Prepare equipment

Open your equipment in a sterile fashion. Flush each lumen of the catheter and then close off the line so the flush is retained within it. Finally, arrange your equipment so that each item is easy to reach in the order you’ll need it.

Prepare sterile field

If a beard will interfere with the procedure or dressing, consider shaving or trimming the area first.

Remove overlying dressings, tube ties, ECG dots from area.

Clean the skin with 2% chlorhexidine, and apply sterile drapes. Most drapes have an orientation and a transparent window, which can reduce the feeling of claustrophobia for the patient.

Scan and identify vessels

Scan the neck to identify the vessels, paying particular attention to distinguishing the internal jugular vein from the carotid artery — use Doppler if there is any uncertainty. Also look for overlying superficial vessels, such as the external jugular vein, before choosing your approach.

Inject local anaesthetic

Once you have selected your site, infiltrate with small volumes of 1% lidocaine subcutaneously (this step may not be necessary if the patient is heavily sedated). Keep the volume modest, as too much can distort the local anatomy and make the vessels harder to identify.

Access vessel

Attach the syringe to the needle or cannula and insert through the skin. Holding the probe with your non-dominant hand, insert the needle under direct visualisation towards the vein. Aspirate as you’re advancing through the wall to know when you’re within the lumen itself as opposed to the wall.

Insert guidewire

Insert the guidewire through the needle or cannula, keeping hold of it at all times.

There are markings on the guidewire to know how far you have inserted it. A distance of 15–18 cm is standard.

Ensure you are not forcing the wire at any point, as this may indicate that it has kinked or is abutting a vessel wall.

Have your assistant keep an eye on the cardiac monitor during guidewire insertion to assess for ectopic beats, which may indicate the wire has advanced too far into the right heart.

Confirm guidewire position

Use ultrasound to confirm the wire lies within the IJV and is moving freely, scanning as far caudally as possible to check it stays within the lumen along its course. Both in-plane and out-of-plane views are worth using. Remove the needle or cannula, leaving the guidewire in place.

Dilate skin and vessel

Decide whether to make a small skin incision or to dilate without cutting.

Insert the dilator at the same angle as your original needle insertion. Throughout dilation, check that the guidewire continues to move smoothly; resistance may mean it is kinking or that a false passage is being created. When withdrawing the dilator, press gauze over the insertion site to hold the guidewire in place.

Some bleeding is common after dilation, so it’s worth leaving gauze over the site to control this.

Insert catheter and remove guidewire

Hold the guidewire with one hand while threading the catheter over it with the other, feeding it into the insertion site — expect some bleeding at this stage.

Secure catheter

Attach the catheter clamp and place four sutures to secure the catheter to the skin.

Aspirate and flush lumens

Fit bungs or injection ports onto each lumen to protect the line, then aspirate and flush each one. Use a 10 mL syringe for flushing, as smaller syringes generate higher pressures that risk damaging the vessel wall.

Apply dressing

Apply a dressing over the site, choosing between a chlorhexidine-impregnated dressing or a standard dressing according to local policy.