Ultrasound Guided Internal
Jugular Lines
ER Lines
Subclavien Vein
 Femoral Vein
 Internal Jugular Vein

IJ is the BEST!!!
Lower risk of pneumothorax compared to
subclavian.
 Compressibility of the vessel in the event of
bleeding or arterial puncture (less likely with
use of ultrasound).
 Straight path from the right IJ to the SVC,
better for pacemaker insertion.
 Less line sepsis compared to femoral lines.

IJ with Ultrasound
Takes half as much time and half the
number of attempts compared with
landmark technique
 About 90% reduction in incidence of

Pneumothorax
 Hemothorax
 Carotid artery canulation
 Nerve injury

“Full Barrier Precautions”
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All central line insertions
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Mask for everyone in the room
Wash your hands first
Gown, gloves, hat
Broad draping—the entire bed should be covered
Use of this technique has led to a exceedingly
low rate of catheter related infections
 Chlorhexidine (aqueous) is the preferred
antiseptic
Terminal Positioning of the
Catheters
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Catheters should terminate in the distal innominate
vein or proximal SVC
3 to 5 cm proximal to the junction of the SVC and right
atrium to eliminate the risk of cardiac perforation.
The caval junction:
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Right side 14 to 16 cm from right-sided IJ or SC skin
punctures
Left side 16 to 18 cm
CVCs in IJ and SC veins should not be inserted to a depth of
>20 cm
Confirm catheter tip position with a CXR.
Ultrasound Tips
Know your probe
orientation.
 Optimize screen
position
 Prior to getting sterile,
check vein for
compressibility.

Optimize the Image
Probe Prep – the hardest part
You hold open sterile probe cover.
 Assistant dumps non-sterile gel inside
probe cover.
 Assistant puts non-sterile gel on probe.
 Using gravity, assistant puts probe into
cover.
 You put on the sterile rubber bands.
 Put sterile gel on outside of probe cover.

Cover and Rubber Band Probe
Visualizing and Cannulating

Transverse is easier,
longitudinal is better.
 Line up the vein so it is in the
middle of the screen, insert
the needle in the middle of
the probe.
 Gently bounce the needle
and manipulate the probe to
see the tip.
 Check the wire.
Transverse, Longitudinal
Post Line Placement CXR
Tip should be in
the Superior
Vena Cava, not
the right atrium.
 Ideally 2 cm
below the sternomanubrium
junction.

Pneumothorax

Subclavian line
placement
results in a
pneumothorax
Positive Lung Sliding Sign-No
Pneumothorax
Complications
Carotid artery
injury
 Nerve injury

Phrenic
 Brachial plexus

Seldinger
Maintain
control of the
wire.
 Make a big
enough nick,
avoid skin
bridge.

Cather Insertion Length
Formulas for Catheter Insertion Length Based on Patient Height and
Approach
Site
RSC
LSC
RIJ
LIJ
Formula In SVC (%)
(Hgt/10) – 2 cm 96
(Hgt/10) + 2 cm 97
Hgt/10 90
10
(Hgt/10) + 4 cm 94
In RA (%)
4
2
5
Thread the catheter to approximately 2 cm below the manubriosternal
junction
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http://dhmcsedation.com/CVC/index.asp