Presentation
Urosepsis, central line indicated for vasopressor administration.
Patient Data
Cine-loop 1: Two vessels deep to the sternocleidomastoid identified at the lateral neck; larger, thin walled, superficial vessel which is compressible with light probe pressure and subtly varies with respiration represents the internal jugular vein. The deeper, thicker walled vessel with a characteristic pulsation, no respiratory variation, and higher resistance to collapse represents the common carotid artery.
Image 1: skin and subcutaneous tissue (SQ), sternocleidomastoid (SCM), internal jugular vein (IJV), common carotid artery (CCA)
Cine-loop 2: begins with initial needle insertion, visible when through the skin and subcutaneous tissue, and in the body of the SCM, demonstrating acoustic shadowing characteristic of the needle shaft. Enters internal jugular vein and secured in the mid-lumen.
Image 2: echogenic needle shaft (red circle) casts a characteristic acoustic shadow (parallel white lines)
Image 3: the needle tip (red circle) is located prior to puncture of the anterior wall of the internal jugular vein.
Cine-loop 3: right hemithorax, third intercostal space. + lung sliding, no pneumothorax.
Cine-loop 4: left hemithorax, third intercostal space. + lung sliding, no pneumothorax.
Case Discussion
This case demonstrates the out-of-plane technique (alternatively the "short-axis" or "transverse" approach) for cannulation of the internal jugular vein under ultrasound guidance. Some studies suggest that use of this technique, as opposed to the in-plane "long-axis" approach, offers the following advantages 2:
- superior visualization of surrounding neurovascular structures, including the common carotid artery
- lower rate of inadvertent carotid puncture 1
- more favorable learning curve for less experienced operators
Other studies suggest, however, the longitudinal approach is more favorable, providing the following benefits:
- decreased incidence of posterior wall puncture 3
- decreased procedural time
Regardless of approach, the following principles must be upheld to avoid complications and successfully cannulate the target vessel 4:
- the vein should be distinguished from the artery
- using compressibility, as well as color and/or spectral Doppler
- the needle tip should be distinguished from the shaft
- the tip will lack the acoustic shadow characteristic of the shaft
- after cannulation, the needle tip should remain in the center of the lumen
- the presence or absence of complications should be sought promptly
- lack of lung sliding with pneumothorax
- an extravascular fluid collection with a hematoma
- an incompressible vessel with vascular thrombosis
Unable to process the form. Check for errors and try again.