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OSCE 081: Internal Jugular CVC Insertion

Introduction

You are assisting with the insertion of an internal jugular central line…

Question No. 2

Q: Which side of the patients neck is this image of? (1 marks)

Answer No. 2

This is the right side 1 of the neck
The thyroid gland can be identified medially
The internal jugular vein lies laterally to the carotid artery

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Question No. 3

Q: Why do we use right side in preference to left side? (1 marks)

Answer No. 3

Right IJV preferred due to straighter course to the SVC 1

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Question No. 4

Q: Other than the internal jugular vein what are the contents of the carotid sheath? (3 marks)

Answer No. 4

Vagus nerve 1
Carotid artery 1
Deep cervical lymph nodes 1

Contents of the carotid sheath

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Question No. 5

Q: What are the classical landmarks for insertion of an IJV CVC using the landmark technique? (3 marks)

Answer No. 5

Technique

Classical (Central)

Insertion point is apex of Sedillot's triangle 1
- Sternal head of sternocleidomastoid 1
- Clavicular head of sternocleidomastoid 1
- Superior border of medial 3rd of the clavicle 1
Needle angled at a 45° to the skin 1
Aiming toward the ipsilateral nipple 1

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Question No. 6

Q: What do you need to do before commencing the insertion procedure for an internal jugular line? (3 marks)

Answer No. 6

Risk Assessment

Assess and correct coagulopathy 1
If evidence of coagulopathy:
- Consider correction based upon the clinical situation
- Consider femoral insertion site
- Should be inserted by an experienced operator with ultrasound guidance

Consent

Explain the risks of the procedure and complete a consent form 1)

Monitoring

AAGBI Monitoring 1
ECG (to monitor for arrhythmias with guidewire) and pulse oximetry essential

Patient Positioning Upper body lines:

Flat with head-down tilt (Trendelenburg) 1

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Question No. 7

Q: Why do we lie the patient head down for central line insertion? (2 marks)

Answer No. 7

Assists with distension of the vein to maximise the target area 1
Helps reduce the incidence of air embolism 1

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Question No. 8

Q: What needs to be done post-procedure? (3 marks)

Answer No. 8

Confirm position of line within the vein before use 1
Review chest x-ray to confirm position and exclude complications 1
Document procedure including details of lines, operator and complications 1

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Question No. 9

Q: Name 3 techniques you can use to confirm your catheter is in the internal jugular vein? (3 marks)

Answer No. 9

CVP trace observed 1
Ultrasound visualisation of line within vein 1
Blood gas sample showing venous blood 1
Position consistent with venous site on chest x-ray 1
Echocardiographical confiramtion 1

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Question No. 10

Q: Where is the appropriate position for an internal jugular CVC tip on CXR? (1 marks)

Answer No. 10

The most commonly used x-ray landmark is the level of the carina 1:
- Origin of the Superior vena cava 1-2cm above
- Pericardial reflection lies 1-2cm below
- Tip should lie within the boundaries
Cavo-atrial junction usually lies two vertebral bodies below the carina:
- Above this may be an acceptable position for L sided lines to ensure they lie parallel or haemodialysis catheters to optimise flow

Correct positioning for tip of central line (CVC) on chest x-ray (CXR)

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