Internal jugular line

One page, for the trolley. The reasoning is in the long version.

Adult, right internal jugular, real-time ultrasound. Tick down. The three red boxes are the ones that turn a routine line into a disaster, and none of them takes more than a few seconds.

Before you scrub

Indication still stands, and is not “to measure the CVP”
Consent — patient, person responsible, or section 37 emergency, and it is written down
Platelets and INR known; under 50 and elective, consider transfusing
Scan both sides undraped — patent, compressible, where is the carotid in this neck
Side chosen; avoid subclavian entirely if kidneys are failing
Monitoring on and visible; assistant present and staying
Everything open before you scrub; all lumens flushed
Position: head down 10–15°, head rotated as little as possible

Sterile set-up

Hat over all hair, mask, eye protection, sleeves up, bare hands and wrists
Surgical scrub, gown, gloves; assistant in hat and mask
Chlorhexidine in alcohol — allowed to dry
Full-body drape, puncture site only; sterile probe cover, gel inside and out

Doing it

Re-identify vein and artery; compress to be sure
Local anaesthetic, and wait for it
Puncture with the needle tip in view at all times
Wire passes with no resistance; stop if it does not
Wire in 15 cm, no further — watch for ectopy
Confirm venous. Twice. See the stop box
Nick with the blade away from the wire
Dilate held near the skin, skin and tissue only, never let go of the wire
Catheter to ~15 cm right, ~18–20 cm left
Wire out, and look at it
Aspirate and flush every lumen
Secure; chlorhexidine dressing over a clean, dry site

Stop 1 — before the dilator

Blood colour and the absence of pulsatility prove nothing. Two confirmations, at least one objective: see the wire in the vein on ultrasound in two planes, and/or transduce or run a manometry column. If you transduce, check the scale is arterial.

Stop 2 — if you have dilated an artery

Leave it in. Do not remove and press. Call vascular surgery or interventional radiology now. Removal and compression fails in the great majority and has killed people; leaving it in place while theatre is arranged does not.

Stop 3 — before anything is thrown away

Say the guidewire out loud and hold it up. Assistant confirms. Nothing goes in the bin until the wire is accounted for. This is an omission error that happens to careful people who were interrupted — being careful is not the control.

Afterwards

Tip to lower SVC or upper right atrium
Film if it was difficult, left-sided, or you are unsure — not routinely
A film cannot tell you the line is venous. Transduce
Check for pneumothorax if the patient changes

Document: indication, consent basis, site, supervision, ultrasound, passes, how venous position was confirmed, depth, wire accounted for
Ask tomorrow, and every day, whether it is still needed

Everything here is reasoned out, with the evidence and the numbers, in the long version. If you are learning this, read that once before you rely on this.

Challenge for you

Give one tip to somebody learning this.

The thing you actually do that is not in any guideline — a way of holding the probe, a trick for a neck that will not give you a vein, a near miss you still think about. I am collecting them, and publishing them anonymously unless you say otherwise. There is more about why in the long version.

Send me your tip

How you are credited is entirely your call — by name, by initials, or not at all — whether you write the piece or I do, and whether I quote you or simply say who sent something in; nothing of yours goes up with your name on it unless you have said yes.

The button opens a reply straight to me. If your device blocks it, write to icuandyou@icloud.com instead.