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Jugular Veins, Internal: Central Approach

- See: SG cath

- Technique:
    - prepare the patient as for subclavian approach;
    - right side of the neck is preferred for venipuncture for three reasons:
          - dome of the right lung and pleura is lower than left;
          - there is more or less a straight line to the atrium;
          - the large thoracic duct is not endangered; 
    - locate the triangle formed by the clavicle and the two heads of the sternocleidomastoid muscle;
          - internal jugular vein runs deep to the sternocleidomastoid muscle and then through this triangle before it enters into the subclavian vein;
    - patient is placed in Trendelenburg's position with the head rotated 45 degrees away from the insertion site;
    - strict sterile technique;
    - use a 25 gauge needle and 1% lidocaine to raise a small skin wheal in the center of this triangle;
    - finder needle:
          - use one hand to palpate the carotid artery;
          - 22 gauge needle to anesthetize the deeper layers, and then use gentle aspiration, with the same needle, to initially locate internal jugular vein;
                 - needle is inserted immediately lateral to the carotid pulse and slightly superior to the apex of the triangle.
          - needle is inserted past the apex of the triangle, towards the ipsilateral nipple, at an angle of 20 deg;
          - vein is located near the skin surface and often is less than 1.5 cm from the skin surface;
          - if the attempt is unsuccessful, then the needle is aimed more medially on the next insertion attempt;
    - attach a thin walled 18 gauge cannula-over-needle or 16 gauge intracath needle to a 10-20 ml syringe;
    - direct the needle thru the skin wheal caudally, directed toward the ipsilateral nipple and at a 30 deg angle to the frontal plane;
          - if vein is not entered, withdraw the needle and slightly redirect it 10-15 degrees more laterally;
          - apply constant back pressure;
    - if bright red blood forcibly fills the syringe, you have punctured the carotid artery;
          - remove the needle and apply firm pressure for 10 min;
    - follow the proceedure for subclavian vein approach;

- Cautions:
    - this approach is contraindicated with coagulopathy because pressure cannot be applied if expanding hematoma occurs

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