Healthcare and Medicine Reference
Box 11.3 Use of US probe
Box 11.4 Surface landmarks for needle insertion
The vein will usually be larger and lateral to the artery which will
have a visible arterial pulsation. Compress the neck with the probe;
the vein should be compressible and the artery will retain its shape.
Right internal jugular vein
Identify the sternocleidomastoid and look for where the sternal and
clavicular heads divide. The IJV runs directly beneath the apex formed
by the bifurcation of the two muscle bellies. The internal carotid artery is
palpated and gently lifted medially. The vein now lies lateral to the artery.
In a healthy well-hydrated subject lying on a trolley tipped head
down, the IJV pulsation may be visible and the vein fi lls and empties.
The JVP waveform is different to the carotid pulsation because it
is more complex, present in diastole, of lower amplitude and non-
Insert the needle at 30° to the skin aiming for the ipsilateral
nipple as shown in the step-by-step guide. The vein lies less than
1 cm below the skin in a slim subject.
Internal jugular vein
Right subclavian vein
Neither the subclavian artery or vein can be directly visualised or
palpated. The key surface landmark is the clavicle. Palpate it along
its entire length and establish the point between the medial third
and the middle third. This lies on the most curved part of the clavicle
where it turns to run posteriorly.
The needle is introduced at this point and passed under the
clavicle. It is essential to keep a mental image of where the tip of
the needle lies. When it is under the clavicle, fl atten the syringe to
the skin and aim for the suprasternal notch. The SCV should be
reached at approximately 4 cm.
Trasnsverse internal jugular
Figure 11.5 An ultrasound view showing the landmarks for internal jugular
Right femoral vein
Identify the femoral triangle at the top of the thigh below the
inguinal ligament. To do this fi nd the pubic tubercle and palpate
laterally until the femoral artery pulsation is felt. The vein lies 2 cm
medial to the femoral artery. Approach the skin one fi nger's breadth
medial to the artery at 30° aiming for the contralateral shoulder.
If using ultrasound the probe should be covered with a sterile
cover (Figure 11.4c). Single-use sterile ultrasound transmission
gel should be applied to provide contact between the probe and
the plastic cover and also between the sheath and the patient.
Identify the site of skin puncture. Local anaesthetic (e.g. 1%
lidocaine) should be infi ltrated around this site (Figure 11.4d).
The ultrasound probe can now be placed over the anaesthetised
guidewire passes too far and touches the endocardium, atrial
or ventricular ectopics can be observed. If this occurs withdraw
the wire immediately.
area and the vein and artery can be visualised (Box 11.3 and
Move the probe up and down the neck slightly to fi nd the
14 When the guidewire has been inserted to an appropriate length
(look for marker) the needle can be withdrawn (Figure 11.4h).
position where the vein is largest and most lateral to the artery
(or use the landmark techniques described in Box 11.4).
15 It is essential that one hand keeps hold of the guidewire through-
out the rest of the procedure, until the wire is removed .
10 Use the introducer needle attached to a 10-mL syringe,
approaching the skin at a 30° angle. Begin to aspirate as soon as
you pierce the skin (Figure 11.4e). If using USS insert the needle
just proximal to the probe and watch the screen at all times. The
needle will appear as a bright white, echo-dense, spot which you
can angle towards the vein until it deforms the wall of the vein
as it pierces it.
16 If using USS place the probe over the vein, the guidewire will be
visible in the vein lumen.
17 Use a scalpel to make a small nick in the skin around the
insertion point of the guidewire (Figure 11.4i).
18 Pass the dilator over the wire and dilate the skin and
subcutaneous tissue only, keeping hold of the wire at all times
11 As soon as blood is aspirated stop advancing the needle.
USS can be used to confi rm the location of the needle in
19 Remove the dilator while holding a sterile swab over the
insertion site. Place the central line over the wire and pass the
line into the vein (Figure 11.4k,l).
12 Remove the syringe, and keep hold of the needle; the blood
should fl ow gently rather than with a pulsatile spurt (this
suggests arterial puncture).
20 Stop advancing the cannula at a depth of 15 cm and remove the
wire, keeping hold of the central line (Figure 11.4m).
13 The guidewire should be inserted into the introducer needle
(Figure 11.4f,g). It should pass freely without resistance. During
insertion of the guidewire the ECG should be observed. If the
21 Use a syringe fi lled with saline to check that you can aspi-
rate blood from each lumen and that they each fl ush freely