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Central venous access is essential in providing quality medical care to many patients for whom intensive therapy is required. In many situations, a semipermanent tunneled central line is preferred (see Indications). An anterior approach to the internal jugular vein (IJV) is the best option in this situation because it offers the easiest route with a low risk of complications.

In this procedure, a tunneled catheter is surgically inserted into a vein in the neck or chest and passed under the skin. Only the end of the catheter is brought through the skin; medicines and intravenous (IV) fluid can be administered through this catheter; other tasks, such as blood sampling, can also be performed. The fact that the catheter is passed under the skin helps secure the catheter, reduces the rate of infection, and permits free movement of the catheter port. The placement of a tunneled catheter should be carried out by practitioners with specific experience in the procedure.

Compared to femoral site access, internal jugular or subclavian access has been associated with a lower risk of catheter-related bloodstream infections (CRBSIs) in some studies, but subsequent studies have indicated that there is no difference in the rate of CRBSI between these three sites.^[1]Overall, the IJV is better suited, especially in children, although other factors such as interindividual vein size variation need to be kept in mind.

Indications

Indications for a tunneled approach to the IJV include the following:

Complex or critically ill patients who need continuous hemodynamic monitoring
Patients who require secure venous access for the infusion of agents that are very irritating or that have a very narrow therapeutic index, and which, therefore, require a very precise rate of delivery into the circulation (eg, cytotoxic drugs, inotropic agents)
Patients who require long-term venous access for parenteral nutrition, chemotherapy, or long-term prophylactic antibiotics
Patients in whom very frequent blood sampling or access to the circulation for other reasons is needed
Patients in whom venous access cannot be secured by any other route

Contraindications

This procedure has no absolute contraindications. Relative contraindications include the following:

Severe coagulopathy
Physical status unfit for anesthesia
Unavailability of a suitable access site
Thrombosed veins
Overlying skin infection

In patients who need long-term venous access (eg, patients with small bowel transplant), imaging of the neck veins may be necessary before the procedure.

Doppler ultrasonography (US), magnetic resonance (MR) venography, or both can be used to establish venous patency and anatomy, thus improving planning and anticipation of potential problems with access.^[3]

Particularly in patients with multiple medical problems, a complete blood count, clotting profile, and relevant renal and liver function tests should be included in the preoperative workup. Depending on the platelet count, platelet transfusion may be needed.

Periprocedural Care

Equipment

Materials required for the procedure include the following:

Central venous catheter tray (line kit; see the images below)
Sterile gloves
Antiseptic solution with skin swab
Sterile drapes or towels
Sterile gown
Sterile saline flush, approximately 30 mL
Lidocaine 1%
Gauze
Dressing
Scalpel, No. 11
Vascular forceps (DeBakey)
Needle driver
Polypropylene suture 4/0
Steri-Strips
Mepore adhesive tape

Patient preparation

Anesthesia

A local anesthetic agent is used before tunneling the catheter. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Positioning

Trendelenburg position with the head turned to the opposite side of the central venous line (CVL) insertion is optimal, as the internal jugular vein (IJV) distends in this position, providing a maximal cross-sectional area for access, as shown in the image below.The ipsilateral arm should be extended minimally at the axilla. In adults, neutral position of the neck has been shown to be equally safe

Source emedicine.com

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