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Central Venous Catheter Kit:
Most of the instruments and materials needed for placing a central venous catheter come in a prepackaged, sterile “kit.” Opening one of these kits for the first time can be overwhelming – there are many different needles and hubs and tubes, and knowing what each piece in the kit does what may help before describing the exact technique.
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Sharps holder (E, below) : This provides a place to stick the needles when you are done using them, thus lessening the chance of sticking yourself with a contaminated needle, and without having to go to the sharps box every time a needle has been used. Note that once a needle has been stuck into the “foam” of the holder, it should not be used again, because the plastic reside can stick to the needle and lodge inside the needle tip.
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A 25 or 26 gauge (remember bigger numbers mean smaller needles!) needle with a small syringe attached and a vial of 1% lidocaine (A, below) : This smallest needle is used with the lidocaine to numb the area to be cannulated. 
- A 22 gauge “finder needle” with 5ml syringe (B, right) : This needle does just that; it is used to find the internal jugular vein initially- its small size makes it safer to use when in the process of locating the vein. If the carotid artery is inadvertently punctured with this needle, there is a decreased risk of a large hematoma forming, and other complications arising.
- An 18 gauge IV needle with a catheter hub attached to a 10 ml syringe (syringe C with catheter D, right) :This is basically an IV set that is used to create an opening in the vein large enough to pass the guide-wire through. The soft plastic IV catheter around the needle is left in the vein while the needle is withdrawn.
- Tubing ("D" in main photo at top of page): This long clear tubing is used to test the venous access. The tubing is filled with sterile saline, attached to the IV catheter lying within the vein and is lifted straight up. If the column of water drops, the hub is successfully within the vein.
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Guide wire (below) : This is a long, soft, flexible wire that is mounted in a plastic loop in order to ease the insertion into the hub of the IV catheter; the wire helps to direct the central venous catheter the vein. It has a “J” shaped bend on one end to protect the vein once it is inserted. The central venous catheter will be fed into the vein using this wire as a lead.
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A #11 scalpel (below) : This is used to enlarge the entry into the vein while the guide wire lies within the vein.
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Suture (below): This is used to attach the body of the catheter to the skin after insertion. It acts as an added safety measure to prevent the catheter from being inadvertently pulled out.
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Multiple lumen catheter (below on left, top device): This is the catheter that will be inserted into the vein. This catheter has three ports, two that open on the side of the cathter tip, and one that opens at the very end of the catheter.
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Vessel dilator (above on left, bottom device): This is the blue length of firm plastic that is part of the body of the catheter while the catheter is being inserted. As its name implies, it dilates the vein and helps the catheter pass smoothly into the vein. It is removed after insertion.
The Procedure:
After reviewing these steps, you may want to view the movie to see the procedure in its entirety.
- The first step will be to place the supine patient in Trendelenburg position. This head down position will make the internal jugular vein more prominent, and therefore, easier to stick. It also will help prevent against dangerous air emboli which could occur during the procedure.
- Make sure you have everything you will need for the procedure, including a non-sterile assistant to help you if the need arises – remember that you will be masked and wearing sterile gloves and gown for the entire procedure!
- First acquaint yourself with the anatomical landmarks you will be using during the procedure before the patient is sterile and draped.
- Ask the patient to turn their head to the left; this will open up the right side of the neck which you will be working on. A popular technique for ascertaining where the vein lies begins by first locating the two heads of the SCM. You can ask the patient to try to lift their head up off the table, (while facing to the left!) and then look for the clavicular and sternal heads while the muscle is tense. Once you have located both heads of the SCM, you will trace them back to where they form the superior apex of the “triangle” discussed earlier. This superior corner formed by the two heads of the SCM will be where you will attempt cannulation of the internal jugular vein. You will insert the needle here at a 45 angle and point it towards the ipsilateral nipple of the patient.
- Now that you have familiarized yourself with the landmarks, the next step is to put on sterile gloves, prep a wide area of the neck with an aseptic solution, and then drape the area completely (the landmarks are harder to see with everything covered, aren’t they?) A sterile gown should also be worn during this procedure.
- With everything draped and sterile, you must re-acquaint yourself with the anatomical landmarks and again locate the “V” where the two heads of the SCM meet. Palpate the carotid artery to reassure yourself it is medial to where you plan on cannulating the patient. Draw up the 1% lidocaine with the 25 gauge needle to anesthetize the area. Start by creating a wheal right under the skin, and then continue to inject the lidocaine deeper, pulling back on the syringe before injecting at each depth, to make sure you have not hit a vessel. Make the initial wheal large enough to anesthetize the area you will be suturing later as well!
- Begin by using the 22 gauge “finder needle” attached to a 5 ml syringe. Insert the needle at a 45 degree angle in the corner formed by the two SCM heads, pointing towards the ipsilateral nipple of the patient. Gently pull back on the syringe as you advance the needle deeper. A stream of dark red blood into the syringe indicates that you’ve hit the internal jugular vein. If the needle does not hit the vessel, withdraw the needle a bit and then advance it again in a slightly more lateral course. DO NOT INITIALLY DIRECT THE NEEDLE IN A MORE MEDIAL DIRECTION! Why not? Remember that the carotid artery lies more medial, and it is really best to avoid puncturing the carotid artery. Continue to advance the needle in a more lateral direction, gently pulling back on the syringe until you hit the vein. At this point, keep the finder needle where it lies in the vein, and proceed to the next step.
- Sometimes, due to certain factors (a very long or very thick neck) it may be difficult to find the internal jugular vein by landmarks alone. When finding the IJ proves difficult, often it is helpful to use ultrasound guidance to place the finder needle. Using a small, portable ultrasound device (a “site-right” as it is sometimes referred to at UVA) can be done either before the patient has been prepped and draped, or can be done afterwards using a sterile technique. If done as aseptically, a sterile, clear plastic sheath is filled at the end with ultrasound gel, the sheath slides over the probe, and sterile ultrasound gel is placed at the site where the vein is thought to lie. The probe should be held perpendicular to the course of the vein along the neck. On the screen, the vein will appear as a large vessel which is easily collapsed with a bit of pressure applied to the neck. Slightly posterior and medial to the vein, the carotid artery should appear as a slightly smaller vessel that does NOT collapse under the same pressure. After locating the exact position of the vein, you can either 1. try to place the needle while the probe is resting over the vein, or 2. make note of the exact location of the internal jugular, remove the probe and try again without concurrent visualization.
- Once the finder needle has been placed within the vein, take the larger 18 gauge IV catheter and attached syringe, and insert it in the same location and course that the finder needle was in when it punctured the vein. Advance the needle slowly while gently pulling back on the syringe. Due to the larger size of this needle, sometimes it will poke through both sides of the vein, compressing the vein as it goes in. Pulling back slightly on the needle may put the tip back into the lumen. Once the needle is within the lumen of the vein (as evidenced by a stream of dark red blood into the syringe), the catheter can be advanced into the vein, and the needle is withdrawn. Care should be taken to cover the end of the IV catheter hub with a finger to prevent venous air embolism.
- At this point the long plastic tubing, filled with sterile saline or aspirated bood, can be connected to the hub within the vein, and raised straight up. The column of water should fall slowly, indicating that the needle hub is successfully within the lumen of the vein. Remove the tubing, and keep your finger covering the hub.
- Take the guide wire in the hand that is not capping the catheter hub, and using your thumb, slowly advance the wire into the needle hub, and into the vein. The wire should advance easily, without resistance. When the wire is about 15cm into the vein, it is safe to remove the needle hub over the wire. THE OPERATOR SHOULD NOW HAVE A HOLD ON THE GUIDEWIRE AT ALL TIMES! It is poor technique to lose the guidewire into the vein, and it may require surgery to remove- if it doesn’t kill the patient first. ALWAYS HAVE CONTROL OF THE GUIDEWIRE!
- With the #11 scalpel, make a small incision right along the guidewire into the skin to increase the size of the opening through which the much larger catheter will have to pass. The blade should be pointed away from the carotid artery, either laterally or inferiorly, while making the incision.
- With the dilator in place in the body of the introducer, thread the catheter over the guidewire (while always controlling the wire!) into the neck. You may want to warn the patient that they may feel some intense pressure as the catheter is going in. The catheter should slide into the vein, and at this point the dilator and the guidewire can be removed. To check for proper placement of the catheter, be sure the ports of the catheter flush and draw easily.
- Using the suture provided, loosely secure the catheter to the skin and finish with a square knot. Suturing the catheter too tightly may cause the skin underlying the suture to necrose.
- At this time, a sterile dressing (such as Tegrederm) can be applied to cover the catheter and secure it to the neck.
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