Bilateral Internal Jugular Veins Ultrasound Scanning Prior to CVC Placement

Central venous catheter placement is a common procedure in the intensive care unit and is a
required skill for all residents working in the critical care setting. Central venous
catheters (CVC) are placed for a variety of reasons including administration of caustic
medications, administration of fluids or blood products for rapid resuscitation, access for
hemodynamic monitoring or transvenous pacing, temporary vascular access for dialysis, or
inability to obtain peripheral IV access.

The 2011 CDC Guidelines for Prevention of Intravascular Catheter-Related Infections
recommends placement of a CVC in the subclavian vein rather than the internal jugular vein
to minimize infection risk. However, due to lack of experience with placement in the
subclavian vein, in the Vanderbilt MICU, it is most common for residents to place catheters
in the internal jugular vein. Placement of the CVC under ultrasound guidance has become
standard of care and is also recommended by the aforementioned CDC guidelines (CDC
guidelines).

Ultrasound guidance for CVC placement has improved patient safety by reducing the rate of
complications, improving success rates, and decreasing number of attempts and time for
successful insertion (Brass). The benefit of ultrasound guidance in reducing complications
is especially important when less experienced operators such as residents are placing a CVC
(Rando, Airapetian, Dodge). The addition of an ultrasound machine to an otherwise sterile
procedure does not increase the rate of catheter associated blood stream infections
(Cartier).

Placement of the IJ CVC on the right instead of the left is commonly preferred due to the
more direct path to the superior vena cava. However, placement in the left IJ may be
necessary for a variety of reasons. Depending on head position, the degree of overlap
between the right IJ and the right carotid artery may make right sided placement precarious
due to risk of arterial puncture (Ozbek, Maecken). Previously undetected IJ thrombus on the
right may also prevent CVC placement, requiring a switch to the contralateral side (Goel).
Ultrasound guidance could also reveal a unilateral vascular anatomic anomaly that would
otherwise complicate CVC insertion (Benter, Rossi).

For these reasons, the investigators intend to compare the standard practice of residents
placing IJ CVC in the medical ICU against mandatory screening of the right and left IJ prior
to selection of the CVC placement site.

The benefits of ultrasound guidance for IJ CVC placement are well established. However, the
benefits of ultrasound guidance may be extended by more fully evaluating both the left and
right IJ prior to choosing a side for placement. As mentioned previously, several factors
could make placement of the CVC on a particular side either more successful or precarious.
These factors include possible asymmetric diameter of the IJ vein, unfavorable relationship
of the IJ to the carotid artery, pre-existing IJ thrombus, or other aberrant vascular
anatomy.

This study will begin with a 4 month period of data collection on the standard practice of
IJ CVC placement by residents in the medical intensive care unit. Data will be collected on
the success rate of CVC insertion as measured by "first stick" placement of the catheter.
The study will also record how often placement of the CVC must be aborted in favor of an
attempt on the contralateral side. Any incidental detection of pre-existing conditions that
could complicate CVC placement, including IJ thrombus or aberrant anatomy, will also be
recorded. Finally, the investigators will record rates of immediate complication of CVC
placement, including pneumothorax, hemothorax, and arterial placement or puncture of the CVC
catheter.

In the medical ICU of the institution where this study will occur, nurse practitioners
perform similar duties to residents on a separate but similarly operating ICU team. Data on
central line placement by nurse practitioners will also be collected.

The specific aims will be threefold:

Specific Aim 1: To assess the first pass and overall success rates when both IJ veins are
evaluated by ultrasound compared to standard IJ CVC placement by ultrasound.

Specific Aim 2: To assess the rate of aborted procedures between the two study periods, as
defined by failure of catheter placement at the side of first needle puncture site or
failure of catheter placement overall.

Specific Aim 3: To assess the rate of complications when IJ central venous catheters are
placed after evaluation of bilateral IJ sites compared to current practice of placing IJ
catheters under ultrasound guidance.

Inclusion Criteria:

- Patient admitted to the medical intensive care unit on the 8th floor

- Central venous catheter placed by a resident or nurse practitioner working in the
medical intensive care unit

- Central venous catheter placed in the right or left internal jugular vein

- Central venous catheter placed with ultrasound guidance

Exclusion Criteria:

- Line placed outside the MICU

- Placed in the subclavian or femoral vein

- Placed by a fellow in training or attending physician

- Placed under emergent or time-sensitive conditions

- Placed during a code

- Placed under non-sterile conditions