Pediatric emergency medicine trisk 4332 4332

Equipment
See Procedure in Percutaneous Femoral Vein Catheterization section.

Procedure
Position the patient in 15 to 20 degrees of Trendelenburg with the head turned
over the bed or table edge. Mild hyperextension of the neck tenses the
sternocleidomastoid muscle to localize the landmarks. The medial approach uses
the apex of the triangle formed by the sternal and clavicular heads of the
sternocleidomastoid muscle as the entry site ( Fig. 130.6 ). Catheter length can be
estimated as the distance from the insertion site to the nipple line. The vein is
lateral to the artery and should be localized by palpation, with ultrasound, or both
before puncturing the skin. Using an introducer needle attached to a syringe,
advance at a 45-degree angle to the skin in the caudal direction. Aim toward the
ipsilateral nipple. Aspirate gently on the syringe as advancing; the vein should be
entered at a depth of 1 to 2 cm. If this fails, withdraw the needle slowly with
constant traction on the plunger of the syringe. If blood return does not signify
venous entry, reattempt cannulation by advancing the needle slightly lateral to the
initial attempt (do not advance the needle more medial to the ipsilateral nipple
line). After obtaining blood flow, introduce the guide wire and then the catheter,
as previously described. Check for blood return, and secure the line with suture
and tape. A radiograph of the chest should be examined for line position and for
pneumothorax. Ultrasound guidance is the preferred method of catheter insertion
into the internal jugular vein.