Monday, December 12, 2016

How To Perform Jugular Venous Access

Accessing the jugular vein is the first step of a wide range of procedures, performed by interventional radiologists as well as intensivists, anesthesiologists, and other proceduralists. The vast majority of central lines, port placements, dialysis catheter placements, and other venous procedures begin with this step. Although common, jugular venous access is a critical step, with serious complications if not performed appropriately.
  • Under ultrasound, visualize the right internal jugular vein which should be compressible (unless thrombosed). The pulsatile carotid should medial/posterior.
    • If partially thrombosed, may be possible to push needle through. 
  • Anesthetize the skin. 
  • Advance the 21G micropuncture needle (green hub) into the jugular vein. 
    • While access can be performed either in plane with the needle or transverse to it, the in-plane approach has the benefit of seeing the entire length of the needle.
    • If the vein is large enough, one can also visualize the tip of the needle within the vein. 
    • If there is spontaneous venous return, advance 0.018 inch microwire into SVC-RA under fluoro 
    • If no return but likely in vessel, attach connection tubing and aspirate. 
    • If bright red / pulsatile return, withdraw needle and hold pressure for 2-5 minutes. 
  • Once access is gained, make a skin incision along the needle and then blunt dissect using the curved Kelly. 
  • Exchange the needle for the 5Fr micropuncture sheath and hub it. 
  • Remove the inner 3Fr stylet and the micropuncture wire, holding your finger over the 5Fr lumen. 
  • Insert 0.035 in J wire and advance into the inferior vena cava. Take care not to irritate the atrium (will cause PVCs). If difficult, ask patient take deep breath and hold, then advance. Make sure the J is facing right/posterior (take-off of IVC from RA). 
    • This step is not actually necessary, but confirms venous access more definitively.
    • If access to the IVC is needed for the procedure and difficulty is encountered, switch the 5 Fr sheath for a Kumpe catheter, and use that to direct the wire into the IVC (which often has a posterior and rightward take-off). 

For more details on interventional radiology procedures, check out the Handbook of Interventional Radiologic Procedures: