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Posts Tagged ‘Central venous line’

PICC (Peripherally Inserted Central Catheter) Insertion Technique

Posted by Dr KAMAL DEEP on December 5, 2011

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1. The insertion site (below or above the antecubital fossa), 2. The sternocleidomastoid triangle at the medial third of the clavicle, and 3. The 3rd right costosternal junction of the sternum.

sum of the two linear distances measured between the three landmarks (with the inserted arm abducting laterally at 45-degree angle from the body) is the optimal PICC length.

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PICC INSERTION TECHNIQUE

 

1. Guidewire / SWG Insertion Techniques:

Kits/Sets are available with a variety of Guidewires/SWGs. Guidewires are provided in different diameters, lengths, and tip configurations for specific insertion techniques. Become familiar with the guidewire(s) to be used with the specific technique chosen, before beginning the actual PICC insertion procedure.

Image guidance may be used to gain initial venous access.

Catheter Insertion with an 80 cm Guide wire:

Use single 45 cm guidewire for venous access and 80 cm soft tip guidewire for catheter placement. Image guidance or fluoroscopy is used to gain initial venous access; catheter placement with 80 cm guidewire is done under fluoroscopy.

• Gain venous access with 45 cm guidewire and peel-away sheath.

• Load PICC onto 80 cm guidewire until soft tip of wire extends beyond tip of catheter.

• While maintaining control of distal end of guidewire, advance soft tip/catheter tip as a unit through peel-away sheath to desired depth.

• Once catheter is in desired location, remove guidewire.

Catheter Insertion with an 130 cm Guidewire:

Use single 45 cm guide wire for venous access and 130 cm soft tip guidewire for catheter placement. Image guidance or fluoroscopy is used to gain initial venous access; catheter placement with 130 cm guidewire is done under fluoroscopy.

• Gain venous access with 45 cm guidewire.

• Insert soft end of 130 cm guidewire through peel-away sheath to desired depth.

• Thread catheter over guidewire and advance catheter over guidewire through sheath into vessel into correct position.

• Once catheter is in desired location, remove guidewire.

NOTE: Some clinicians will gain access with 130 cm guide wire and thread catheter over guide wire once wire has been correctly positioned in the SVC. This technique is done under fluoroscopy.

Identify insertion vein:

• Apply tourniquet above anticipated insertion vein.

• Identify appropriate vein for insertion. Use direct visualization technologies, if available, and assess vein health.

5. Release tourniquet and leave in place beneath the arm.

6. Measure patient to assure placement of catheter in the SVC:

• Extend arm laterally 45 to 90 degrees from trunk.

• Measure distance from insertion site along presumed anatomical course of vessel to be catheterized.

• Catheter tip should lie in distal one-third of SVC above right atrium and parallel to SVC wall.

◊ If a catheter stabilization device will be used, add ½ to 1 inch (1.2 to 2.5 cm) to catheter measurement (STATLOCK®); if another device is used, check manufacturer recommendations.

◊ If using upper arm circumference assessment; for consistency in measurement, measure from an anatomical point and record.

7. Position patient as appropriate for insertion site:

• Extend arm laterally 45 to 90 degrees from trunk.

8. Prepare work area.

2. Prep Puncture Site:

1. Prep and drape peripheral puncture site.

2. Perform skin wheal with a local anesthetic as needed.

3. Gain Initial Venous Access:

See specific guidewire instructions, Guidewire Insertion Techniques (page 7) under Accessory Component Instructions section.

1. Insert soft tip of guidewire through introducer needle into vein. Advance guidewire to desired depth.

Warning: Do not insert stiff end of soft tip guidewire into vessel as this may result in vessel damage.

Warning: Do not cut guidewire to alter length.

Warning: Do not withdraw guidewire against needle bevel to minimize the risk of possible severing or damaging of guidewire.

2. Remove needle:

Hold guidewire in place while removing introducer needle.

Caution: Maintain firm grip on guidewire at all times.

3. Enlarge puncture site, if necessary:

Use scalpel positioned away from the guidewire to enlarge cutaneous puncture site. Do not cut guidewire. Retract scalpel to the protected position.

4. Sheath Placement:

1. Thread tapered tip of peel-away sheath/dilator assembly over guidewire. Grasping near skin advance assembly with slight twisting motion to a depth sufficient to enter vessel. Dilator may be partially withdrawn to further facilitate advancement of sheath into the vessel. A slight twisting motion of the peel-away might help sheath advancement.

Caution: Do not withdraw tissue dilator until the sheath is well within the vessel to minimize the risk of damage to sheath tip. Sufficient guidewire length must remain exposed at hub end of sheath to maintain a firm grip on guidewire.

2. Check sheath placement by holding sheath in place, withdraw guidewire and dilator sufficiently to allow venous blood flow. Holding sheath in place, remove guidewire and dilator as a unit.

Warning: Do not leave the dilator in place as an indwelling catheter to minimize the risk of possible vessel wall perforation.

Warning: Do not apply undue force on guidewire to minimize the risk of possible breakage.

5. Catheter Advancement:

Advance catheter according to the guidewire used. Review detailed instructions for 80 cm and 130 cm guidewire usage (page 7) under Accessory Component Instructions section.

Warning: Do not apply excessive force in placing or removing catheter. Failure to do so can result in catheter breakage. If placement or withdrawal cannot be easily accomplished, an x-ray should be obtained and further consultation requested.

1. Retract catheter guard.

2. Insert catheter through peel-away sheath.

• If resistance is met while advancing catheter, retract and/or gently flush while advancing.

3. Stop advancing catheter 5 inches (13 cm) before reaching pre-established insertion length.

4. Withdraw peel-away sheath over catheter until free from venipuncture site.

5. Grasp tabs of peel-away sheath and pull apart, away from catheter, until sheath splits down entire length.

6. Advance catheter to final indwelling position.

Placement Wire (where provided):

Caution: To minimize the risk of placement wire kinking, do not clamp extension line(s) when placement wire is in catheter.

1. Complete catheter insertion.

2. Remove placement wire.

Warning: Remove placement wire and Luer-Lock sidearm assembly as a unit (see Figure 24). Failure to do so may result in wire breakage.

6. Dressing:

Replace dressing according to organizational policies, procedures, and practice guidelines. Change immediately if the integrity becomes compromised e.g. dressing becomes damp, soiled, loosened, or no longer occlusive.

• Consult manufacturer’s recommendations for dressing specifics.

• Transparent semipermeable membrane dressing should be changed every 7 days.

• Gauze and tape should be changed every 48 hours.

• Label dressing with type, size, and length of catheter; date and time; and initials of the clinician performing dressing change.

7. Maintain Catheter Patency:

Maintaining central venous catheter patency shall be done in accordance with organizational policies, procedures, and practice guidelines. All personnel who care for patients with central venous catheters must be knowledgeable about effective management to prolong catheter’s dwell time and prevent injury.

Perform hand hygiene as required.

1. Solution and frequency of flushing a venous access catheter should be established in hospital/agency policy.

2. Catheter patency is established and maintained by:

• flushing intermittently via syringe with heparinized saline or preservative-free 0.9% sodium chloride (USP)

• continuous drip

• positive pressure device

3. The amount of heparin:

• depends on physician preference,

• hospital/agency protocol,

• patient condition

Caution: Assess patient for heparin sensitivity. Heparin-induced thrombocytopenia (HIT) has been reported with the use of heparin flush solutions.

The volume of flush solution should be:

• equal to at least twice the priming volume of the catheter and any add-on devices

Catheter priming volume is printed on product packaging.

5. When using any central venous catheter for intermittent infusion therapy, proper flushing (heparinization) using a positive-pressure flushing technique will help prevent occlusion. Neutral as well as positive displacement valve systems have also been shown to help prevent occlusion.

6. All valves need to be properly cleansed with an appropriate antiseptic before being accessed.

7. The SASH or SAS method of flushing will help eliminate occlusions due to incompatible solutions:

• Saline • Administer drug • Saline • Heparin (if used)

8.Catheter Removal Procedure

1. PICC removal shall be performed:

• following order of authorized prescriber

• in accordance with organizational policies, procedures, and practice guidelines

2. A PICC shall be removed immediately upon patient assessment for:

• suspected contamination

• unresolved complication

• discontinuation of therapy

3. As indicated, place patient in supine position to minimize the risk of potential air embolism.

4. Remove dressing.

Warning: Do not use scissors to remove dressing, to minimize the risk of cutting catheter.

5. Open catheter stabilization device retainer wings and remove catheter from catheter stabilization device posts.

6. Remove catheter by slowly pulling it parallel to skin. If resistance is met when removing the catheter, catheter should not be forcibly removed and the physician should be notified.

Caution: Do not exert excessive force while removing the catheter; to minimize the risk of catheter breakage.

7. Upon removal of catheter:

• measure and inspect

• ensure entire catheter length has been removed

8. Direct pressure should be applied at site until hemostasis is achieved.

9. Apply alcohol swab to catheter stabilization device adhesive and gently lift pad off of skin (if applicable).

10. Dress insertion site. Sterile occlusive dressing should be applied and site assessed every 24 hours until site is epithelialized. Residual catheter track may remain an air entry point until completely sealed (usually 24 to 72 hrs); dependent upon amount of time catheter was indwelling.

11. Document catheter removal procedure on patient’s chart per hospital/agency protocol.

Include:

• catheter condition

• length of catheter removed

• patient’s tolerance of the procedure

• any nursing interventions needed for removal

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NOTE: These “standard” insertion sites were defined to correspond to the catheter lengths determined by the formulas. Any deviation from the defined site requires appropriate adjustment of catheter length. For example, a PICC inserted 2.5 cm above the antecubital fossa would be 5 cm shorter than the value from the chart, based on the patient’s height

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These recommended lengths should always be critically appraised prior to use in the individual patients. For patients with unusual proportions, e.g. short or long neck, lengthy arm or upper body proportions, case-by-case decision-making is important.

 

Catheter Trimmer:

NOTE: There should be very limited resistance when cutting catheter with supplied trimmer. Any greater resistance is likely to be caused by the placement wire – which has not been sufficiently retracted. If so, do not use catheter.
Catheter Trimmer is a one time use trimming device.
• To trim catheter with Catheter Trimmer, retract placement wire 1-1/2 inches minimum (4 cm) behind where catheter is to be cut. The placement wire is to be withdrawn through septum (see Figure 4).

 

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Kink proximal end of placement wire at connector with side-port (see Figure 5). This minimizes the risk of placement wire extending beyond distal tip of catheter during insertion. (Do not attempt to advance placement wire through septum.)

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Peel back contamination guard exposing catheter portion to be trimmed. Using trimming device, cut catheter straight across (90° to catheter cross-section) to maintain a blunt tip. Warning: Do not cut placement wire when trimming catheter to minimize the risk of foreign embolism. Caution: Check that there is no wire in cut catheter segment, after trimming catheter. If there is any evidence that placement wire has been cut or damaged, catheter should not be used.

Trim Catheter:
If necessary, review detailed instructions for Catheter Trimmer device under Accessory Component Instructions section.
1. Identify catheter type:
• BFT (Blue FlexTip®)
• Non-BFT
2. Peel back contamination guard exposing catheter portion to be trimmed.
3. Review catheter marking pattern below. The catheter is marked so clinician can easily identify desired amount of catheter to be trimmed; length of catheter that remains or as with BFT catheter – both.

4. Using the trimming device, cut catheter straight across (90° to catheter cross-section) to maintain a blunt tip. NOTE: There should be very limited resistance when cutting catheter with supplied trimming device. If using a catheter with a placement wire, any greater resistance is likely to be caused by the placement wire which has not been sufficiently retracted. If so, do not use catheter. 5. Inspect cut surface for clean cut and no loose material. Warning: Do not cut placement wire when trimming catheter to minimize the risk of foreign embolism. Caution: Check that there is no wire in cut catheter segment, after trimming catheter. If there is any evidence that placement wire has been cut or damaged, catheter should not be used

     BFT double numbering pattern:

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◊ First number designates centimeters from tip of catheter.
◊ Second number designates centimeters from hub of catheter.
◊ This double numbering pattern permits clinician to easily identify centimeters of catheter to be trimmed and also identifies centimeters of catheter remaining.
◊ Record both numbers.

         Non-BFT numbering pattern:

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Raulerson syringe

Number designates centimeters of catheter to be trimmed and also gives amount of catheter remaining

Reducing Risks: There are two key benefits to using the Raulerson syringe. First, it lessens the exposure to blood and can lower the risk of air embolism. Second, it enables you to place the catheter in fewer steps, with less risk of dislodging needle from vessel.

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verify Catheter tip position
Based on hospital policy, utilize
one of the following methods for tip
placement verification:
• Radiographic imaging (Chest Film,
Fluoroscopy)
• Physiological Feedback such as EKG
• Other approved methods.
Appropriate tip placement for Central
Venous Catheters other than Dialysis
Catheters is in the lower one-third
of the Superior Vena Cava or at the
Cavoatrial Junction.
If catheter tip is malpositioned,
reposition and reverify tip position.

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The following designations are examples for port usage and do not represent the
only way the lumens can be used:

Proximal: Blood Sampling
Medications
Blood Administration

Medial: Total Parenteral Nutrition
Medications (only if TPN use is not
anticipated)

Distal: CVP Monitoring
Blood Administration
High Volume or Viscous Fluids
Colloids
Medication
4th Lumen: Infusion
Medication

                                                                       ANATOMY OF ARM VEINS

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A, Anatomy of vessels in the anticubital fossa, noting

the brachial artery (BA), basilic vein (BAV), and deep brachial vein

(DBV). B, Corresponding ultrasound image. The vein collapses with

probe pressure to distinguish it from the artery.

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Posted in Medical | Tagged: , , , | 6 Comments »

CENTRAL VENOUS ACCESS

Posted by Dr KAMAL DEEP on July 26, 2011

Internal Jugular Approach

The author wish to acknowledge the excellent guidance of Dr Harjit Singh Mahay , Sr. Intensivist in this topic.

Percutaneous Cannulation of The Internal Jugular Vein (ALL APPROACHES)

Jugular System
The anatomy of the IJ vein is relatively constant, regardless of body habitus. The vein drains the cranium, beginning as the superior jugular bulb, which is separated from the floor of the middle ear by a delicate bony plate. The IJ vein emerges deep to the posterior belly of the digastric muscle. At its origin the IJ vein courses adjacent to the spinal accessory, vagus, and hypoglossal nerves, as well as the internal carotid artery. Several tributary veins enter the IJ vein at the level of the hyoid bone. The IJ vein, the internal (and, later, the common) carotid artery, and the vagus nerve course together in the carotid sheath, with the IJ vein occupying the anterior lateral position.The only structure that maintains a fixed anatomic relationship with the IJ vein is the carotid artery. The vein invariably lies lateral and slightly anterior to the carotid artery, and the course of the artery serves as a guide to venous cannulation. At the level of the thyroid cartilage, the IJ vein can be found just deep of the sternocleidomastoid muscle .

The IJ vein emerges from under the apex of the triangle of the two heads of the sternocleidomastoid muscle and joins the subclavian vein behind the clavicle. As the vein approaches its supraclavicular junction with the subclavian vein, it assumes a more medial position in the triangle formed by the two heads of the sternocleidomastoid muscles, following the anterior border of the lateral head. In this lower cervical region, the common carotid artery assumes a deep paratracheal location. The brachial plexus is separated from the IJ vein by the scalenus anterior muscle. The phrenic nerve is anterior to the scalenus anterior muscle. Although quite deep, the stellate ganglion lies anterior to the lower brachial plexus.

Unlike the subclavian vein, the IJ vein is quite distensible. The vessel diameter is increased with performance of a Valsalva maneuver and the assumption of the head-down (Trendelenburg) tilt position. Prolonged palpation of the carotid pulse will decrease the diameter of the IJ vein.Rotating the head 90 degrees toward the opposite side or extending the neck will not change the size of the IJ vessel significantly. Severe rotation of the head will bring the sterno-cleidomastoid muscle anterior or medial to the IJ vein and may make cannulation impossible without first traversing the carotid artery. The diameter of the IJ vessel is largest below the cricoid ring, where it may reach 2 to 2.5 cm.

 

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Neck anatomy showing the course of the internal jugular vein (IJV).

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POSTERIOR APPROACH

Diagram of external jugular line going up over the edge of the sternocleidomastoid muscle, the main landmark for the posterior approach. Identify the point of insertion for the introducer needle along the posterior edge of the sternocleidomastoid muscle at the level just superior to where the external jugular vein crosses the muscle. This is typically one third of the distance between the mastoid and the clavicle.

  • Typically, the vein is entered within 1-3 cm; if the vein is missed, draw the needle all the way back to the skin before redirecting it.
  • If the bevel of the introducer needle is swung back and forth in the deeper tissues, a vessel or nerve may be inadvertently lacerated. Redirecting the needle more lateral, toward the sternoclavicular joint as opposed to the notch, often allows the vein to be entered

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Surface anatomy and various approaches to cannulation of the internal jugular vein. A: Surface anatomy. B: Anterior approach. C: Central approach. D: Posterior approach.

MIDDLE

ANTERIOR

POST

The anterior and posterior approaches are identical in technique, differing only in venipuncture site and plane of insertion. For the anterior approach (see Fig. )the important landmark is the midpoint of the sternal head of the SCM, approximately 5 cm from both the angle of the mandible and the sternum. At this point, the carotid artery can be palpated 1 cm inside the lateral border of the sternal head. The index and middle fingers of the left hand gently palpate the artery, and the needle is introduced 0.5 to 1 cm lateral to the pulsation. The needle should form a 45-degree angle with the frontal plane and be directed caudally parallel to the carotid artery toward the ipsilateral nipple. Venipuncture occurs within 2 to 4 cm, sometimes only while the needle is slowly withdrawn. If the initial attempt is unsuccessful, the next attempt should be at a 5-degree lateral angle, followed by a cautious attempt more medially, never crossing the plane of the carotid artery.

The posterior approach (see Fig. )uses the EJV as a surface landmark. The needle is introduced 1 cm dorsally to the point where the EJV crosses the posterior border of the SCM or 5 cm cephalad from the clavicle along the clavicular head of the SCM. The needle is directed caudally and ventrally toward the suprasternal notch at an angle of 45 degrees to the sagittal plane, with a 15-degree upward angulation. Venipuncture occurs within 5 to 7 cm. If this attempt is unsuccessful, the needle should be aimed slightly more cephalad on the next attempt.

DSC01597DSC01599DSC01600DSC01602DSC01603DSC01604DSC01605DSC01606_2DSC01607_2DSC01608DSC01609DSC01610DSC01611DSC01612DSC01613_2DSC01614DSC01615_2DSC01616_2DSC01618DSC01619DSC01620DSC01621_2DSC01632DSC01633DSC01634DSC01635DSC01636DSC01637DSC01638DSC01639DSC01640DSC01647DSC01649DSC01648DSC01650DSC01641DSC01642DSC01643DSC01644DSC01645DSC01646DSC01651_2DSC01652DSC01653DSC01654DSC01655DSC01656IJ line triangle

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catheter

                                                                                                 

 

 

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 Sandwich Technique
For multi-lumen catheters, bulky catheter hubs or difficult to dress areas
1.
Use two 3M™ Tegaderm™ Transparent Film Dressings. Fold one dressing across the
width with the printed liner facing outward. The location of the fold may vary
depending on the distance between the catheter exit site and the hub, but typically
would be near the centre of the dressing.
2. Remove the printed liner. Keeping the dressing folded, gently lift the catheter and slip
the dressing underneath, positioning the fold at the exit site (or sutures). Secure one
half to the skin; and lay the catheter on top of the exposed adhesive of the other half.
(Figure 1) Smooth down the portion of the dressing on the skin. Do not remove the
frame.
3. Remove the printed liner from the second dressing and place it on top of the catheter.
Smooth one half over the exposed adhesive of the first dressing, and the remaining half
over the skin above the exit site. (Figure 2) Firmly smooth both dressings from the exit
site outward to enhance adhesion.
4. Pinch the dressings together around the catheter and remove the frame
from both dressings, smoothing down the edges as the frames are removed. (Figure 3)

sandwitch

A sandwich, loop-line, or bridge technique was used to apply each of the dressings. Two mechanisms of displacement were tested: dressing adherence to skin and dressing adherence to line. Dressing to skin adherence was tested on a relatively hairless part of the upper arm. Weights were added sequentially until the dressing peeled off. Dressing to line adherence was tested by applying the dressing to a 7F Dual Lumen Bard Hickman line passing through a piece of foam (measuring 13 × 12 cm). Weights were attached to the line until the cuff was pulled through the foam.

Dressing to skin adherence was poorest for the clear dressings, followed by Mefix and Sleek, and greatest for a combination of Tegaderm and Mefix. Dressing to line adherence was improved using a sandwich technique instead of a loop-line technique and most secure when a bridge technique was used to the thicker shaft of the line.

The dressings used for securing Hickman lines are not all equally secure. The least effective is the IV 3000 loop-line dressing. Tegaderm-Mefix bridge and Tegaderm-Mefix-Sleek combination dressings are the most secure and cost effective.

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Infraclavicular Sub

IJV3

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Patient positioning for subclavian cannulation. B: Cannulation technique for supraclavicular approach

Capture

needle

2

  • Needle insertion site options include the following:
    • One centimeter inferior to the junctions of the middle and medial third of the clavicle
    • Inferior to the clavicle at the deltopectoral groove
    • Just lateral to the midclavicular line, with the needle perpendicular along the inferior lateral clavicle
    • One fingerbreadth lateral to the angle of the clavicle
  • Sternal notch: Direct the insertion needle toward this target in the coronal plane.

The 18-gauge thin-wall needle is preferable for SV cannulation .The patient is placed in a 15- to 30-degree Trendelenburg position, with a small bedroll between the shoulder blades. The head is turned gently to the contralateral side and the arms are kept to the side. The pertinent landmarks are the clavicle, the two muscle bellies of the SCM, the suprasternal notch, the deltopectoral groove, and the manubriosternal junction. For the infraclavicular approach, the operator is positioned next to the patient’s shoulder on the side to be cannulated. For reasons cited earlier, the left SV should be chosen for pulmonary artery catheterization; otherwise, the success rate appears to be equivalent regardless of the side chosen. Skin puncture is 2 to 3 cm caudal to the clavicle at the deltopectoral groove, corresponding to the area where the clavicle turns from the shoulder to the manubrium. Skin puncture should be distant enough from the clavicle to avoid a downward angle of the needle in clearing the inferior surface of the clavicle, which also obviates any need to bend the needle. The path of the needle is toward the suprasternal notch. After skin infiltration and liberal injection of the clavicular periosteum with 1% lidocaine, the 18-gauge thin-wall needle is mounted on a 10-mL syringe. Skin puncture is accomplished with the needle bevel up, and the needle is advanced in the plane described above until the tip abuts the clavicle. The needle is then “walked” down the clavicle until the inferior edge is cleared. In order to avoid pneumothorax, it is imperative the needle stay parallel to the floor and not angle down toward the chest. This is accomplished by using the operator’s left thumb to provide downward displacement in the vertical plane during needle advancement, until the needle advances under the clavicle.

As the needle is advanced further, the inferior surface of the clavicle should be felt hugging the needle. This ensures that the needle tip is as superior as possible to the pleura. The needle is advanced toward the suprasternal notch during breath holding or expiration, and venipuncture occurs when the needle tip lies beneath the medial end of the clavicle. This may require insertion of the needle to its hub. Blood return may not occur until slow withdrawal of the needle. If venipuncture is not accomplished on the initial effort, the next attempt should be directed slightly more cephalad. If venipuncture does not occur by the third or fourth attempt, another site should be chosen, as additional attempts are unlikely to be successful and may result in complications

When blood return is established, the bevel of the needle is rotated 90 degrees toward the heart. The needle is anchored firmly with the left hand while the syringe is detached with the right. Blood return should not be pulsatile, and air embolism prophylaxis is necessary at all times. The guidewire is then advanced through the needle to 15 cm and the needle withdrawn. To increase the success rate of proper placement of the catheter, the J-wire tip should point inferiorly .The remainder of the procedure is as previously described. Triple-lumen catheters should be sutured at 15 to 16 cm on the right and 17 to 18 cm on the left to avoid intracardiac tip placement .

For the supraclavicular approach  the important landmarks are the clavicular insertion of the SCM muscle and the sternoclavicular joint. The operator is positioned at the head of the patient on the side to be cannulated. The site of skin puncture is the claviculosterno-cleidomastoid angle, just above the clavicle and lateral to the insertion of the clavicular head of the SCM. The needle is advanced toward or just caudal to the contralateral nipple just under the clavicle. This corresponds to a 45-degree angle to the sagittal plane, bisecting a line between the sternoclavicular joint and clavicular insertion of the SCM .The depth of insertion is from just beneath the SCM clavicular head at a 10- to 15-degree angle below the coronal plane. The needle should enter the jugulosubclavian venous bulb after 1 to 4 cm, and the operator may then proceed with catheterization.

Table 2. Common Errors in Technique

Error Percent of Failures (n = 277)
Inadequate landmark identification 14.7
Improper insertion position 32.3
Insertion of needle through periosteum 21.9
Taking too shallow a trajectory with needle 16.1
Aiming the needle too cephalad 7.5
Failure to keep needle in place for wire passage 7.5

Q:-Why is air embolism a complication of a lacerated wall
of the internal jugular vein?

Ans:- Air embolism is a serious complication of a lacerated
wall of the internal jugular vein. Because the wall of
this large vein contains very little smooth muscle, its injury
is not followed by contraction and retraction (as
occurs with arterial injuries). Moreover, the outer coat
of the vein is attached to the fascia of the carotid sheath,
which hinders the collapse of the vein.

 

Q:-In subclavian vein catheterization using the infraclavicular
approach, the following problems may occur, even
when great care is exercised: (a) The needle may hit the
clavicle; (b) the needle may hit the first rib; (c) the needle
may hit the subclavian artery. How would you deal
with these problems?

Ans:- When performing a subclavian vein catheterization
using the infraclavicular approach, the clavicle may
be hit by the advancing needle. The needle may then
be “walked” along the lower surface of the clavicle until
its posterior edge is reached and then inserted into
the subclavian vein. The needle may hit the first rib.
This is due to the fact that the needle is pointing downward
and not upward. The needle may hit the subclavian
artery. This is recognized by feeling the pulsatile
resistance to the advancing needle and the presence of
bright red blood in the catheter. It indicates that the
needle has passed too deeply posterior to the scalenus
anterior muscle and perforated the wall of the subclavian
artery .The needle should be
partially withdrawn and the vein approached again.

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