ACQUISITION TIPS AND TECHNIQUE
The technique and skills for ultrasound-guided CVC of the internal jugular (IJ) vein (or any other vessel) are the same as those in Chapter 3 for peripheral venous access.
In addition to the relative advantages of the two techniques described in Chapter 3 (in-plane and transverse), the probe footprint (transducer width) and anatomy (e.g., length of neck) will also influence choice of scanning plane.
To maintain the sterile field, for a CVC, a commercial probe cover that also covers at least 24 inches of the transducer wire should be used. Standard sterile prep of the insertion site will also be needed.
Position the patient as you would for a central line when doing your initial scan. Adjust the position of the US screen, the height of the bed, and the position of the table so that you are as comfortable as possible.
All scanning should be done with the linear (or vascular) probe.
Evaluate both sides of the body. Usually one side has an easier approach.
Choose a puncture site that gives direct access to the vessel with minimal potential to puncture the carotid artery (CA) (the IJ next to the CA, not in front of or behind it). Sliding the probe anteriorly or posteriorly at any level may move the CA out of the way.
The landmarks to identify the IJ are the heads of the sternocleidomastoid (SCM) muscle. Start at the apex of the triangle. For patient comfort, minimize the amount of SCM penetrated.
Check compressibility and anatomy prior to the procedure.
The probe should be perpendicular to the skin at all times.
Use light pressure on the skin and ample gel; too much pressure can collapse the vein.
Check for lung sliding before and after the procedure (see Chapter 6 for more details).
Compress the vessel above and below your intended insertion site to look for thrombus.
Confirmation of placement and absence of posterior-wall perforation can be performed using the linear probe to confirm placement inside the vein and cardiac ultrasound to visualize the right atrium.
US guidance for subclavian CVC has the advantage of allowing line placement using visualization of the axillary vein.