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Cannulation of central veins
Intensive care
Cannulation of central veins
are now predominantly inserted percutaneously using a technique first described by Seldinger in 1953. The main indications for CVCs are listed in Table 1.
Michael Duffy
General preparation CVCs should be inserted whilst in an appropriate clinical area where full aseptic technique can be observed. A trained assistant is required and the patient must be monitored throughout the procedure. The equipment required for insertion is listed in Table 2. There is evidence that the use of a dedicated ‘lines trolley’ increases compliance with best practice. Chlorhexidine in alcohol is the preferred skin preparation as this has a greater effect on the risk of catheter colonization than iodine-based solutions.
Mark Sair
Abstract Central venous cannulation is a common procedure in anaesthesia and intensive care. The main indications for central venous catheters (CVCs) are to measure central venous pressure, administer vasoactive or cytotoxic drugs, and for renal replacement therapy. Common sites for catheterization are the internal jugular vein, the subclavian vein and the femoral vein. The internal jugular vein is the most frequently chosen site for insertion of CVCs. Complications occur in up to 10% of central venous cannulations and can be categorized according to mechanical, infectious and thromboembolic aetiologies. The rate of complications depends on a number of factors. These include the site chosen, the condition of the patient, the presence of atypical anatomy and the experience of the operator. The risk of pneumothorax is less common with internal jugular vein placement than with cannulations of the subclavian vein. Carotid artery puncture is uncommon and can be controlled with manual compression. The subclavian route may be preferred for long-term central venous access as there is less patient discomfort post placement and the risk of infection and other long-term complications is lower than at other insertion sites. The femoral route is particularly useful when urgent central venous access is required and the patient is coagulopathic. The femoral route is associated with a high risk of catheter-related infections and venous thrombosis in the long term. In the UK the National Institute for Clinical Excellence (NICE) recommends the use of ultrasonography for the elective insertion of CVCs into the internal jugular veins of adults and children.
General technique for all routes The most common method of insertion of CVCs is with a catheter over a guidewire (the Seldinger technique). The vein is punctured with a small-diameter needle (18 or 20G) attached to an empty syringe. The syringe should not be primed with saline as this makes the differentiation of venous and arterial blood more difficult. Blood is aspirated freely and a guidewire passed down the needle into the vein and the needle removed. The guidewire commonly has a flexible J-shaped tip to reduce risk of vessel perforation and to help negotiate tortuous vessels. The guidewire should be easy to advance and withdraw at all times. A dilator is passed over the guidewire and a small incision can be made in the skin at the site of entry to facilitate its passage. The dilator should be passed only a little beyond the depth of the vein because further passage along the vein may tear the wall or other distal structures. Gentle traction of the skin with the free hand whilst dilating using a twisting motion may help with the passage of the dilator and prevent kinking of the guidewire. Once the soft tissues have been dilated, the dilator is withdrawn and the catheter passed over the guidewire. The catheter is threaded over the guidewire until the end of the guidewire protrudes from the proximal end of the catheter. The guidewire is then held still whilst the catheter is advanced into the vein to the desired length. Care should be taken to ensure that the guidewire always protrudes from the end of the catheter and is not pushed further into the vein when advancing the catheter as this may precipitate arrhythmias. The guidewire is then removed and the catheter checked by aspirating blood freely from each lumen and then flushing with saline.
Keywords cannulation; catheterization; central veins; internal jugular; ultrasound
Central venous cannulation is a commonly performed procedure in anaesthesia and intensive care. An estimated 200,000 central venous access procedures are done in the UK per year. Historically, central venous access was gained by surgical cut-down onto an appropriate vessel, but central venous catheters (CVCs)
Indications for central venous catheterization • Measurement of central venous pressure • Infusion of irritant drugs and total parenteral nutrition • Difficult peripheral access or frequent blood sampling • Insertion of pacing wires or pulmonary artery catheters • Haemofiltration/haemodialysis • Monitoring of mixed venous and jugular bulb oxygen saturations • Replacement of circulating volume
Michael Duffy, FRCA, is Specialist Registrar in Anaesthesia and Intensive Care in the South West of England. He qualified from St Bartholomew’s and the Royal London Medical School, and has worked in Essex, London, and the South West. Mark Sair, PhD, MRCP, FRCA, is Consultant in Intensive Care at Derriford Hospital, Plymouth, UK. He qualified from the University of Bristol and trained in anaesthetics and intensive care in London. His research interests are the effects of sepsis on the circulation and tissue oxygenation.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
Table 1
17
© 2006 Elsevier Ltd. All rights reserved.
Intensive care
sites for catheterization are the internal jugular vein, the sub clavian vein and the femoral vein.
Equipment required for central venous access
The internal jugular vein is most frequently chosen for insertion of CVCs. There are anatomical advantages with this route, and the risk of pneumothorax is less than for cannulation of the subclavian vein. Inadvertent puncture of the carotid artery can be controlled with manual compression. Cannulation of the internal jugular vein can be difficult in morbidly obese patients in whom the usual neck landmarks are often obscured. The right internal jugular vein is most frequently cannulated because it tends to be larger and straighter than that on the left side. It is more convenient for right-handed practi tioners and avoids the possibility of thoracic-duct injury. Approaches can be classified as high or low, which refers to the position of needle insertion in relation to the apex of the triangle formed by the two heads of sternomastoid and the clavicle. Techniques are classified as medial, lateral, or central, depending on their relation to the sternomastoid muscle. The patient is supine with both arms by his or her side. The table is tilted head down to distend the central veins and prevent air embolism. The patient’s neck can be extended by placing a small towel under the shoulders. The head is turned slightly away from the site of puncture. Extreme extension of the neck and rotation of the head are avoided as these manoeuvres tend to collapse the vein. In the high medial approach the needle is inserted along the medial border of the sternomastoid muscle at its midpoint just lateral to the carotid artery (Figure 2). It is directed caudally towards the ipsilateral nipple at an angle of 30–40° to the skin. The internal jugular vein is superficial and is usually within 2–3 cm of the skin’s surface. The operator should avoid exerting pressure on the carotid artery as this will compress the vein, reducing its diameter.
• Patient on tilting bed, trolley or operating table • Sterile hat, gown, gloves, mask • Large sterile drapes and gauze swabs • Chlorhexidine solution • Local anaesthetic with needle and syringe • Saline flush • Appropriate central venous catheter set (age/route/purpose) • Three-way taps • Scalpel blade • Sutures • Sterile dressing • Ultrasound machine available Table 2
The catheter should be secured in place with a suture and covered with a sterile non-occlusive dressing. Checks before using the line: it is important to confirm that the catheter has not been inadvertently placed in an artery rather than a vein. The emergence of dark blood under apparently low pressure is not always a reliable test of venous placement. Comparative synchronous arterial and venous blood gases can be performed, but wherever possible the pressure waveform should be transduced to confirm venous cannulation before the line is used. For catheters entering the chest, a chest radiograph is required to confirm correct positioning of the catheter and ensure there is no pneumothorax. The catheter tip should be above the carina, which indicates placement outside the right atrium. The tip should lie in the long axis of the superior vena cava without acute abutment to the vein wall.
The subclavian vein has a wide calibre (1–2 cm diameter in adults) and is believed to be held open by surrounding tissue, even in severe circulatory collapse. This may be the preferred route for long-term central venous access as there is less patient discomfort post placement and the risk of infection and other long-term complications is lower than at other insertion sites. The subclavian route may also be preferred in trauma patients with suspected cervical spine injury. This route is best avoided in
Sites for central venous catheterization Different surface landmarks are used to guide cannulation of individual veins (Figure 1) and successful catheterization relies on a thorough understanding of anatomy (see page 15). Common
Access sites of choice
f g 2
1 2 3 4 5
High internal jugular External jugular Low internal jugular Supraclavicular Infraclavicular
a
a
1
b c
3
4
c
d i
5
e
b
f h
d
k
g h
j
i j k
Clavicle 1st rib Suprasternal notch Sternal angle Right atrium External jugular vein Internal jugular vein Subclavian vein Left innominate vein Superior vena cava Suggested catheter tip positioning zone
e
Figure 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
18
© 2006 Elsevier Ltd. All rights reserved.
Intensive care
The large diameter of the femoral vein allows infusion and removal of large volumes of fluid, and because of this it is commonly used in the ICU for placement of short-term haemofiltration catheters. Femoral catheters are more appropriate in ventilated, sedated patients as movement may cause mechanical problems and kinking of the lines. In ventilated patients, values of central venous pressures obtained through femoral catheters correlate well with measurements obtained via thoracic veins. The risk of infections in the medium and long term is higher with femoral catheters compared with subclavian and internal jugular lines. This is because of the greater degree of bacterial colonization of the groin compared with the shoulder or the neck. There is also an increased risk of thromboembolism compared with subclavian and internal jugular routes. Femoral catheters should ideally be removed or replaced within 48–72 hours of insertion. The patient is positioned supine and a pillow is placed under the patient’s buttocks to thrust the groin upwards. The thigh is abducted and externally rotated. The pulsation of the femoral artery is palpated 2 cm caudal to the inguinal ligament. The needle is inserted 1 cm medial to the pulsation, aiming medially towards the head at an angle of 20–30° to the skin. In adults, the vein is normally found 2–4 cm from the skin’s surface. Cannulation can be difficult because of a lack of anatomical landmarks, especially in obese patients.
High medial approach to the internal jugular vein
Complications Complications occur in up to 10% of CVCs and they can be categorized according to mechanical, infectious and thrombo embolic aetiologies. Common complications are listed in Table 3. The rate of complications depends on a number of factors, which include the site chosen, the condition of the patient, the presence of atypical anatomy, and the experience of the operator.
Figure 2
patients requiring long-term renal replacement therapy, as there is a significant risk of venous stenosis, which may cause problems with existing or future arteriovenous fistulae. Serious immediate complications are uncommon but occur more frequently than with other routes. Pneumothorax is one of the most common major complications with an overall incidence between 1% and 2%. This figure increases to 10% if multiple attempts are made. Subclavian vein puncture should be avoided in patients with abnormal clotting because it is difficult to apply pressure in the event of inadvertent subclavian artery puncture. The right subclavian vein is preferred because this approach avoids damage to the thoracic duct. However, in the presence of unilateral lung pathology, subclavian catheterization is performed on the ipsilateral side. Various approaches to the subclavian vein have been described. The patient is positioned as for cannulation of the internal jugular vein. In the frequently used infraclavicular approach the needle is inserted into the skin just below the lower border of the clavicle at the junction of the medial and middle thirds. The needle is kept in the horizontal plane and advanced medially and posteriorly to the clavicle, aiming for the sternal notch. The needle should not pass further than the sternal head of the clavicle.
Complications of central venous catheterization Mechanical • Arterial puncture • Haematoma • Pneumothorax • Haemothorax • Haemorrhage • Arrhythmias during procedure • Cardiac tamponade • Respiratory obstruction • Thoracic duct damage • Brachial plexus damage Infectious • Local infection • Bacteraemia, sepsis Thromboembolic • Thrombosis of vessel • Thrombus formation • Venous air embolism • Catheter/guidewire embolism
The femoral vein may be cannulated with low risk of serious short-term complications. This route is useful when urgent central venous access is required and the patient is coagulopathic.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
Table 3
19
© 2006 Elsevier Ltd. All rights reserved.
Intensive care
CVC insertion is necessary in elective and emergency situations. Figure 3 shows a transverse view of the right internal jugular vein obtained using ultrasound. The ultrasound image provides information about the patency of the vessel and confirms that it is in the predicted anatomical location. In approximately 10% of cases, the internal jugular vein is either absent, small, or medial or lateral to its usual position. Ultrasound guidance can be performed in real-time enabling the operator to monitor the passage of the needle throughout the procedure as the needle enters the vein. ◆
Further reading Hall A P, Russell W C. Towards safer central venous access: ultrasound guidance and sound advice. Anaesthesia 2005; 60: 1–4. Hind D, Calvert N, McWiliams R et al. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ 2003; 327: 361–4. Latto I P, Ng W S, Jones P L, Jenkins B J. Percutaneous central venous and arterial catheterisation. 3rd ed. London: WB Saunders, 2000. McGee D C, Gould M K. Preventing complications of central venous catheterizations. New Engl J Med 2003; 348: 1123–33. The National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters (NICE technology appraisal No. 49). London: NICE, 2002.
Figure 3 Transverse view of right internal jugular vein. (a) Carotid artery; (b) internal jugular vein.
Ultrasound guidance for placing central venous catheters The National Institute for Clinical Excellence (NICE) recommends the use of ultrasonography for the elective insertion of CVCs into the internal jugular veins in both adults and children. Ultra sonography should be considered in most circumstances where
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
20
© 2006 Elsevier Ltd. All rights reserved.
Cannulation of central veins
are now predominantly inserted percutaneously using a technique first described by Seldinger in 1953. The main indications for CVCs are listed in Table 1.
Michael Duffy
General preparation CVCs should be inserted whilst in an appropriate clinical area where full aseptic technique can be observed. A trained assistant is required and the patient must be monitored throughout the procedure. The equipment required for insertion is listed in Table 2. There is evidence that the use of a dedicated ‘lines trolley’ increases compliance with best practice. Chlorhexidine in alcohol is the preferred skin preparation as this has a greater effect on the risk of catheter colonization than iodine-based solutions.
Mark Sair
Abstract Central venous cannulation is a common procedure in anaesthesia and intensive care. The main indications for central venous catheters (CVCs) are to measure central venous pressure, administer vasoactive or cytotoxic drugs, and for renal replacement therapy. Common sites for catheterization are the internal jugular vein, the subclavian vein and the femoral vein. The internal jugular vein is the most frequently chosen site for insertion of CVCs. Complications occur in up to 10% of central venous cannulations and can be categorized according to mechanical, infectious and thromboembolic aetiologies. The rate of complications depends on a number of factors. These include the site chosen, the condition of the patient, the presence of atypical anatomy and the experience of the operator. The risk of pneumothorax is less common with internal jugular vein placement than with cannulations of the subclavian vein. Carotid artery puncture is uncommon and can be controlled with manual compression. The subclavian route may be preferred for long-term central venous access as there is less patient discomfort post placement and the risk of infection and other long-term complications is lower than at other insertion sites. The femoral route is particularly useful when urgent central venous access is required and the patient is coagulopathic. The femoral route is associated with a high risk of catheter-related infections and venous thrombosis in the long term. In the UK the National Institute for Clinical Excellence (NICE) recommends the use of ultrasonography for the elective insertion of CVCs into the internal jugular veins of adults and children.
General technique for all routes The most common method of insertion of CVCs is with a catheter over a guidewire (the Seldinger technique). The vein is punctured with a small-diameter needle (18 or 20G) attached to an empty syringe. The syringe should not be primed with saline as this makes the differentiation of venous and arterial blood more difficult. Blood is aspirated freely and a guidewire passed down the needle into the vein and the needle removed. The guidewire commonly has a flexible J-shaped tip to reduce risk of vessel perforation and to help negotiate tortuous vessels. The guidewire should be easy to advance and withdraw at all times. A dilator is passed over the guidewire and a small incision can be made in the skin at the site of entry to facilitate its passage. The dilator should be passed only a little beyond the depth of the vein because further passage along the vein may tear the wall or other distal structures. Gentle traction of the skin with the free hand whilst dilating using a twisting motion may help with the passage of the dilator and prevent kinking of the guidewire. Once the soft tissues have been dilated, the dilator is withdrawn and the catheter passed over the guidewire. The catheter is threaded over the guidewire until the end of the guidewire protrudes from the proximal end of the catheter. The guidewire is then held still whilst the catheter is advanced into the vein to the desired length. Care should be taken to ensure that the guidewire always protrudes from the end of the catheter and is not pushed further into the vein when advancing the catheter as this may precipitate arrhythmias. The guidewire is then removed and the catheter checked by aspirating blood freely from each lumen and then flushing with saline.
Keywords cannulation; catheterization; central veins; internal jugular; ultrasound
Central venous cannulation is a commonly performed procedure in anaesthesia and intensive care. An estimated 200,000 central venous access procedures are done in the UK per year. Historically, central venous access was gained by surgical cut-down onto an appropriate vessel, but central venous catheters (CVCs)
Indications for central venous catheterization • Measurement of central venous pressure • Infusion of irritant drugs and total parenteral nutrition • Difficult peripheral access or frequent blood sampling • Insertion of pacing wires or pulmonary artery catheters • Haemofiltration/haemodialysis • Monitoring of mixed venous and jugular bulb oxygen saturations • Replacement of circulating volume
Michael Duffy, FRCA, is Specialist Registrar in Anaesthesia and Intensive Care in the South West of England. He qualified from St Bartholomew’s and the Royal London Medical School, and has worked in Essex, London, and the South West. Mark Sair, PhD, MRCP, FRCA, is Consultant in Intensive Care at Derriford Hospital, Plymouth, UK. He qualified from the University of Bristol and trained in anaesthetics and intensive care in London. His research interests are the effects of sepsis on the circulation and tissue oxygenation.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
Table 1
17
© 2006 Elsevier Ltd. All rights reserved.
Intensive care
sites for catheterization are the internal jugular vein, the sub clavian vein and the femoral vein.
Equipment required for central venous access
The internal jugular vein is most frequently chosen for insertion of CVCs. There are anatomical advantages with this route, and the risk of pneumothorax is less than for cannulation of the subclavian vein. Inadvertent puncture of the carotid artery can be controlled with manual compression. Cannulation of the internal jugular vein can be difficult in morbidly obese patients in whom the usual neck landmarks are often obscured. The right internal jugular vein is most frequently cannulated because it tends to be larger and straighter than that on the left side. It is more convenient for right-handed practi tioners and avoids the possibility of thoracic-duct injury. Approaches can be classified as high or low, which refers to the position of needle insertion in relation to the apex of the triangle formed by the two heads of sternomastoid and the clavicle. Techniques are classified as medial, lateral, or central, depending on their relation to the sternomastoid muscle. The patient is supine with both arms by his or her side. The table is tilted head down to distend the central veins and prevent air embolism. The patient’s neck can be extended by placing a small towel under the shoulders. The head is turned slightly away from the site of puncture. Extreme extension of the neck and rotation of the head are avoided as these manoeuvres tend to collapse the vein. In the high medial approach the needle is inserted along the medial border of the sternomastoid muscle at its midpoint just lateral to the carotid artery (Figure 2). It is directed caudally towards the ipsilateral nipple at an angle of 30–40° to the skin. The internal jugular vein is superficial and is usually within 2–3 cm of the skin’s surface. The operator should avoid exerting pressure on the carotid artery as this will compress the vein, reducing its diameter.
• Patient on tilting bed, trolley or operating table • Sterile hat, gown, gloves, mask • Large sterile drapes and gauze swabs • Chlorhexidine solution • Local anaesthetic with needle and syringe • Saline flush • Appropriate central venous catheter set (age/route/purpose) • Three-way taps • Scalpel blade • Sutures • Sterile dressing • Ultrasound machine available Table 2
The catheter should be secured in place with a suture and covered with a sterile non-occlusive dressing. Checks before using the line: it is important to confirm that the catheter has not been inadvertently placed in an artery rather than a vein. The emergence of dark blood under apparently low pressure is not always a reliable test of venous placement. Comparative synchronous arterial and venous blood gases can be performed, but wherever possible the pressure waveform should be transduced to confirm venous cannulation before the line is used. For catheters entering the chest, a chest radiograph is required to confirm correct positioning of the catheter and ensure there is no pneumothorax. The catheter tip should be above the carina, which indicates placement outside the right atrium. The tip should lie in the long axis of the superior vena cava without acute abutment to the vein wall.
The subclavian vein has a wide calibre (1–2 cm diameter in adults) and is believed to be held open by surrounding tissue, even in severe circulatory collapse. This may be the preferred route for long-term central venous access as there is less patient discomfort post placement and the risk of infection and other long-term complications is lower than at other insertion sites. The subclavian route may also be preferred in trauma patients with suspected cervical spine injury. This route is best avoided in
Sites for central venous catheterization Different surface landmarks are used to guide cannulation of individual veins (Figure 1) and successful catheterization relies on a thorough understanding of anatomy (see page 15). Common
Access sites of choice
f g 2
1 2 3 4 5
High internal jugular External jugular Low internal jugular Supraclavicular Infraclavicular
a
a
1
b c
3
4
c
d i
5
e
b
f h
d
k
g h
j
i j k
Clavicle 1st rib Suprasternal notch Sternal angle Right atrium External jugular vein Internal jugular vein Subclavian vein Left innominate vein Superior vena cava Suggested catheter tip positioning zone
e
Figure 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
18
© 2006 Elsevier Ltd. All rights reserved.
Intensive care
The large diameter of the femoral vein allows infusion and removal of large volumes of fluid, and because of this it is commonly used in the ICU for placement of short-term haemofiltration catheters. Femoral catheters are more appropriate in ventilated, sedated patients as movement may cause mechanical problems and kinking of the lines. In ventilated patients, values of central venous pressures obtained through femoral catheters correlate well with measurements obtained via thoracic veins. The risk of infections in the medium and long term is higher with femoral catheters compared with subclavian and internal jugular lines. This is because of the greater degree of bacterial colonization of the groin compared with the shoulder or the neck. There is also an increased risk of thromboembolism compared with subclavian and internal jugular routes. Femoral catheters should ideally be removed or replaced within 48–72 hours of insertion. The patient is positioned supine and a pillow is placed under the patient’s buttocks to thrust the groin upwards. The thigh is abducted and externally rotated. The pulsation of the femoral artery is palpated 2 cm caudal to the inguinal ligament. The needle is inserted 1 cm medial to the pulsation, aiming medially towards the head at an angle of 20–30° to the skin. In adults, the vein is normally found 2–4 cm from the skin’s surface. Cannulation can be difficult because of a lack of anatomical landmarks, especially in obese patients.
High medial approach to the internal jugular vein
Complications Complications occur in up to 10% of CVCs and they can be categorized according to mechanical, infectious and thrombo embolic aetiologies. Common complications are listed in Table 3. The rate of complications depends on a number of factors, which include the site chosen, the condition of the patient, the presence of atypical anatomy, and the experience of the operator.
Figure 2
patients requiring long-term renal replacement therapy, as there is a significant risk of venous stenosis, which may cause problems with existing or future arteriovenous fistulae. Serious immediate complications are uncommon but occur more frequently than with other routes. Pneumothorax is one of the most common major complications with an overall incidence between 1% and 2%. This figure increases to 10% if multiple attempts are made. Subclavian vein puncture should be avoided in patients with abnormal clotting because it is difficult to apply pressure in the event of inadvertent subclavian artery puncture. The right subclavian vein is preferred because this approach avoids damage to the thoracic duct. However, in the presence of unilateral lung pathology, subclavian catheterization is performed on the ipsilateral side. Various approaches to the subclavian vein have been described. The patient is positioned as for cannulation of the internal jugular vein. In the frequently used infraclavicular approach the needle is inserted into the skin just below the lower border of the clavicle at the junction of the medial and middle thirds. The needle is kept in the horizontal plane and advanced medially and posteriorly to the clavicle, aiming for the sternal notch. The needle should not pass further than the sternal head of the clavicle.
Complications of central venous catheterization Mechanical • Arterial puncture • Haematoma • Pneumothorax • Haemothorax • Haemorrhage • Arrhythmias during procedure • Cardiac tamponade • Respiratory obstruction • Thoracic duct damage • Brachial plexus damage Infectious • Local infection • Bacteraemia, sepsis Thromboembolic • Thrombosis of vessel • Thrombus formation • Venous air embolism • Catheter/guidewire embolism
The femoral vein may be cannulated with low risk of serious short-term complications. This route is useful when urgent central venous access is required and the patient is coagulopathic.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
Table 3
19
© 2006 Elsevier Ltd. All rights reserved.
Intensive care
CVC insertion is necessary in elective and emergency situations. Figure 3 shows a transverse view of the right internal jugular vein obtained using ultrasound. The ultrasound image provides information about the patency of the vessel and confirms that it is in the predicted anatomical location. In approximately 10% of cases, the internal jugular vein is either absent, small, or medial or lateral to its usual position. Ultrasound guidance can be performed in real-time enabling the operator to monitor the passage of the needle throughout the procedure as the needle enters the vein. ◆
Further reading Hall A P, Russell W C. Towards safer central venous access: ultrasound guidance and sound advice. Anaesthesia 2005; 60: 1–4. Hind D, Calvert N, McWiliams R et al. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ 2003; 327: 361–4. Latto I P, Ng W S, Jones P L, Jenkins B J. Percutaneous central venous and arterial catheterisation. 3rd ed. London: WB Saunders, 2000. McGee D C, Gould M K. Preventing complications of central venous catheterizations. New Engl J Med 2003; 348: 1123–33. The National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters (NICE technology appraisal No. 49). London: NICE, 2002.
Figure 3 Transverse view of right internal jugular vein. (a) Carotid artery; (b) internal jugular vein.
Ultrasound guidance for placing central venous catheters The National Institute for Clinical Excellence (NICE) recommends the use of ultrasonography for the elective insertion of CVCs into the internal jugular veins in both adults and children. Ultra sonography should be considered in most circumstances where
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
20
© 2006 Elsevier Ltd. All rights reserved.