5. Pass the dilator over the wire and thread into the vessel

(Figure 3-3E). (For the Cordis catheter, the dilator and

catheter are inserted together.)

6. Remove the dilator and thread the triple lumen over the

wire, backing out the wire until it protrudes 2-3 em out

of the brown port.

7. Holding the free wire with one hand, thread the line

into the vein (Figure 3-3F).

8. Remove the wire and confirm placement with aspira ­

tion of blood (Figure 3-3G). Secure the catheter in

place with suture.

Internal jugular vein cannulation can be achieved by

multiple approaches. The central approach is described

here (Figure 3-4). Position the patient supine and in

slight Trendelenburg position, with the head rotated

75 degrees to the opposite side. Palpate the triangle

formed by the 2 heads of the sternocleidomastoid muscle.

Palpate the carotid artery pulse within this triangle. The

vein is lateral to the artery in this location and is widest

just below the level of the cricoid cartilage. Insert the

needle at the apex of the triangle, aiming toward the ipsilateral nipple with 30 degrees of angulation. The vein

should be entered within 2-3 em of needle advancement.

If unsuccessful, withdraw slowly, as the vessel, if punctured, may have been compressed during advancement

and will be pulled open on withdrawal. Do not palpate

the carotid pulse while attempting to cannulate the internal jugular vein. The slight compression that results can

compress the vein, making it more difficult to access.

Cannulation of the right internal jugular is preferred over

the left because of the straight line into the right atrium

CHAPTER 3

Figure 3-3. The Seldinger tech nique. (Reprod uced with permission from Reichman EF and Simon RR. Emergency

Medicine Procedures. New York: McGraw-Hill, 2004. Figure 38-1 0.)

CENTRAL VENOUS ACCESS

Figure 3-4. Internal jugular vein catheterization.

(Reproduced with permission from Dunphy JE, Way

LW. Current Surgical Diagnosis Er Treatment. 5th ed.

La nge, 1 981 .)

and the presence of the thoracic duct and a higher pleural

dome on the left side.

The subclavian vein can also be cannulated by multiple

approaches. The infraclavicular approach is described here

(Figure 3-5). Position the patient supine and in slight

Trendelenburg position. Place a rolled sheet or towel

between the patient's scapulas to allow the shoulders to fall

backward and flatten the clavicles. Insert the needle 1 em

inferior to the clavicle, at the junction of the middle and

medial thirds. Direct the needle under the clavicle and

toward the suprasternal notch, with the needle parallel to

the chest wall. The vein should be entered within 4 em of

needle advancement.