Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA

Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, intravascular device delivery (pacing wires, Swann-Ganz catheters), volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy.

Safe reliable placement of a central venous catheter (CVC) in the internal jugular (IJ) vein using ultrasound guidance has become the standard of care. It is therefore imperative to understand the anatomy, the relationship between the IJ and the carotid artery, and their appearance on ultrasound. It is also necessary to have the psychomotor skills of vessel cannulation under ultrasound guidance.

Seldinger technique is an introduction of a device into the body over a guide wire, which is inserted through a thin-walled needle. In the case of CVC insertion, the device is an intravascular catheter and the target vessel is a central vein. First, the target vessel is cannulated with an 18 gauge thin-walled needle. A guide wire is then passed thought the needle until it is appropriately positioned within the vessel. The needle is removed, and a dilator is passed over the wire to dilate the skin and soft tissue to the level of the vessel. The dilator is then removed, and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, the guide wire is removed.

Successful placement of a CVC using ultrasound consists of a working understanding of the target anatomy, facility with procedural ultrasound, and fluidity in Seldinger technique. An IJ CVC can be placed in either the right or the left IJ vein. In general, however, the right IJ vein is preferred because of its straight route to the superior vena cava (SVC), which makes malposition of the catheter less likely.

There are several types of CVC kits commonly available marketed by different manufacturers. CVCs may a single lumen, a double lumen, or a triple lumen. For purposes of this discussion, we will place a triple-lumen CVC, as this is commonly needed when multiple different medications need to be delivered simultaneously. The procedure for placing any type of CVC is the same.