Tips for IJ placement

jwk · Dec 31, 2005

Just wondering if anyone has any good tips for IJ line placement. I find myself successful a little over half the time using the standard anatomical landmarks.

More lateral perhaps?

Do you have access to ultrasound? A lot of folks are swearing by it, plus there are some with the opinion that it should be the standard of care (not me). If you're in the learning process anyway, I'd get some exposure to that if you can.

WntrMute2 · Jan 2, 2006

Actually, the answer is probably more medial. If you don't find the IJ as you probe laterally you must move medially. Consider that the carotid A. lies medial to the IJ, so probing increasingly medial SHOULD result in IJ cannulation before sticking a needle in the carotid. Tips: don't turn the head excesivally, just enough for access, locate the 2 heads of the SCM, find the carotid pulse, find the cricoid cartilage. I place my fingers on the carotid pulse, and insert my needle at the level of the cricoid cart. just lateral to my fingers that remain over the carotid pulse. I find that the IJ is encountered just medial to that angle that is often reccomended, towards the ipsilateral nipple. Don't be afraid of sticking the carotid if you maintain your fingers over the pulse. This procedure takes practice, I've done hundreds and still occasionally (although infrequently) need to call for help. BTW, there are at least 15 different approaches to the IJ. The book Handbook of Percutaneous Central Venous Catheterisation by Rosen, Platto and Ng covers the topic completly.

athomas91 · Jan 3, 2006

i was initially taught to also feel the carotid and leave my fingers there - and i continue to do that even though some say that i shouldn't - but there are cases where you can't turn the patients head or while they are asleep you can't ask them to lift the head to identify your scm landmarks as easily - so the carotid pulse is sure-fire.... and thank God i haven't hit bright red yet....

jwk · Jan 3, 2006

Actually, the answer is probably more medial. If you don't find the IJ as you probe laterally you must move medially. Consider that the carotid A. lies medial to the IJ, so probing increasingly medial SHOULD result in IJ cannulation before sticking a needle in the carotid. Tips: don't turn the head excesivally, just enough for access, locate the 2 heads of the SCM, find the carotid pulse, find the cricoid cartilage. I place my fingers on the carotid pulse, and insert my needle at the level of the cricoid cart. just lateral to my fingers that remain over the carotid pulse. I find that the IJ is encountered just medial to that angle that is often reccomended, towards the ipsilateral nipple. Don't be afraid of sticking the carotid if you maintain your fingers over the pulse. This procedure takes practice, I've done hundreds and still occasionally (although infrequently) need to call for help. BTW, there are at least 15 different approaches to the IJ. The book Handbook of Percutaneous Central Venous Catheterisation by Rosen, Platto and Ng covers the topic completly.

Thanks, I understand the anatomy very well. The OP didn't specify exactly what his problem was with IJ placement. When I've been observing students, it seems there is more of a problem hitting the carotid than not hitting anything, which is why I said try more lateral.

London88 · Jan 6, 2006

I seem to have more of a problem threading the guide wire more than anything else. The last couple of times of I have placed a central line in the IJ, I have had to restick the pt to locate the IJ again. Hopefully with time my technique will be smoother. Thankfully, I work at a place that give me plenty of opportunities to insert IJs and improve my technique. I use Wntrmutes2 technique and for most part have been successful in locating the IJ.

WntrMute2 · Jan 7, 2006

When encountering difficulty threading the wire, try dropping the needle more and more parallel to the patient as you try and thread. If you still have trouble SLIGHTLY withdraw the needle as you try and thread the wire, just sort of enough to tug on the vein wall I imagine. This almost always allows me to avoid a second stick.

London88 · Jan 7, 2006

When encountering difficulty threading the wire, try dropping the needle more and more parallel to the patient as you try and thread. If you still have trouble SLIGHTLY withdraw the needle as you try and thread the wire, just sort of enough to tug on the vein wall I imagine. This almost always allows me to avoid a second stick.

Thanks for the tip!

miloisstinky · Jan 14, 2006

two words....ULTRA SOUND

athomas91 · Jan 15, 2006

ultrasounds are great - but i don't agree with learning by using them - it just disables you when you are on your own - you can't always count on having one available at all institutions...and when you are called to the ER in an emergency and need to place the line - waiting on an u/s isn't a viable option.

jwk · Jan 16, 2006

ultrasounds are great - but i don't agree with learning by using them - it just disables you when you are on your own - you can't always count on having one available at all institutions...and when you are called to the ER in an emergency and need to place the line - waiting on an u/s isn't a viable option.

I agree - you need to learn how to use them since they're the new hot toy at the moment, but you shouldn't learn to depend on them.

That goes for lots of things really. I occasionally turn off the monitors or cover up the numbers so students can't see them. Some do fine, some freak. :rotfl: It's just like flying partial-panel when you're learning how to fly (for those so inclined). Airplane instruments can and do go out occasionally - ya better know how to fly without them! The same goes for patient monitors.