Internal Jugular "posterior" Approach

[jetproppilot]

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One of my colleagues routinely does his neck lines this way....swears by it....says its very simple, says carotid is "protected" by SVC.

I've watched him and he is indeed slick at them.

Looks cool. And is something different so I'm gonna have him watch me through a few, since I've never done one.

Have you guys done this approach?

Whatcha think?

 

[urge]

says carotid is "protected" by SVC.

For me it has worked well in really thin old ladies. Haven't tried it in pt's with a thick neck.

Carotid protected by SVC does not compute, thought. SVC is intrathoracic. I don't know how an intrathoracic vessel can protect a neck vessel.

I guess he is trying to say the IJ is lateral to the carotid so most of the time you will hit it first. You can accomplish the same from the anterior approach if you start lateral and work your way medial.

What I find interesting is a technique described in one of our journals (A+A or Anesthesilogy, I cannot remember) about 6-7 mo ago where you went supraclavical right where the subclavian and and the IJ meet. they claim the success rate is higher to any of the other approaches. I haven't tried it since old habits die hard and I have good success with the anterior approach.

 

[Planktonmd]

One of my colleagues routinely does his neck lines this way....swears by it....says its very simple, says carotid is "protected" by SVC.

I've watched him and he is indeed slick at them.

Looks cool. And is something different so I'm gonna have him watch me through a few, since I've never done one.

Have you guys done this approach?

Whatcha think?

Did you mean protected by SCM?
I always felt the the posterior approach was too close to the Brachial Plexus for my comfort but many older guys do it routinely.

 

[jetproppilot]

Did you mean protected by SCM?
I always felt the the posterior approach was too close to the Brachial Plexus for my comfort but many older guys do it routinely.

No Plank, he said SVC...so I guess he's misquoting a bit....

Regardless, in his hands the technique is slick looking!

 

[militarymd]

from ICU guy standpoint...seems more likely to have a line that is contaminated because you are coming from the side and down...near the dirty draps.

The other thing, when you U/S the IJ, it is really ANT to the carotid, not lateral.

 

[jetproppilot]

from ICU guy standpoint...seems more likely to have a line that is contaminated because you are coming from the side and down...near the dirty draps.

The other thing, when you U/S the IJ, it is really ANT to the carotid, not lateral.

Good points, MASTA OF FORCE UTILIZATION.

 

[urge]

Wish he wouldda put you in the driver's seat, Urge.

Cuz I'm bettin' after you watched a few, he couldda let you do a few, emulating his cool technique.

Lottsa cool s h it out here in PP I wish you resident studs could see.

Cuz it would increase your studstatus as a resident.....

better equipping you for your PP years.

THATS HOW WE ROLL OUT HERE, LADIES AND GENTLEMEN!!!!!

CDAZY FAST.

SMOOTH.

NO DRAMA.

 

[urge]

from ICU guy standpoint...seems more likely to have a line that is contaminated because you are coming from the side and down...near the dirty draps.

The other thing, when you U/S the IJ, it is really ANT to the carotid, not lateral.

I'll have to disagree on both.

Why would the drape be dirty? We use (we are all supposed to) full body (close to full body really) drapping. I don't see how it becomes dirty during the procedure.

Most of the time, I dare say >99%, the IJ is lateral IF YOU MAINTAIN THE HEAD MIDLINE. If you like to rotate the head a lot then the IJ rotates on top of the carotid quite often.

 

[militarymd]

I'll have to disagree on both.

Why would the drape be dirty? We use (we are all supposed to) full body (close to full body really) drapping. I don't see how it becomes dirty during the procedure.

Most of the time, I dare say >99%, the IJ is lateral IF YOU MAINTAIN THE HEAD MIDLINE. If you like to rotate the head a lot then the IJ rotates on top of the carotid quite often.

grab an U/S and look. Yes, there'll be parts of the IJ that is lateral to the carotid, but it'll be infront of the carotid.

like this

 

[militarymd]

and as for sterillity......it's just an opinion.

 

[dhb]

We do most of our IJ this way it's fairly easy: you go 2 finger width above the clavicule = approx where the external jug crosses the SCM aiming towards the sternal notch and you should find it 2-4 cm under the skin. I've had a couple of carotid punctures but i guess it's more related to my inexperience (N= 100).

I guess you have less risk of pneumo since you're not going down towards the pulmonary dome.

I've seen surgery residents go for the IJ-SC junction when they place a port-a-cath. They go under the SCM just above the clavicule the IJ must be pretty fat right there so it should be easy to find.

 

[VentdependenT]

grab an U/S and look. Yes, there'll be parts of the IJ that is lateral to the carotid, but it'll be infront of the carotid.

like this

Alas, here is how you cannulate the carotid after getting venous blood back. Through and through into the carotid.

Dexterity wins the day.

The relationship does change slightly with head rotation to the contralateral shoulder. It also changes the more inferiorly you do your stick (closer to the clavicle and the two vessels do tend to seperate a bit more).

I don't do mine posterior. I'm sure I go though the scm on some of my lines. Oh well. I always transduce.

 

[JayneCobb]

You guys use the supraclavicular subclavian approach? It looks just as easy as the infraclavicular approach.

 

[urge]

You guys use the supraclavicular subclavian approach? It looks just as easy as the infraclavicular approach.

That's the one I was talking about.

 

[JayneCobb]

That's the one I was talking about.

ah, I missed your post. I'm curious if anyone has the data on complication rates such as pneumo's compared to standard inf subclavians and IJs, it would seem that it might have the potential to be higher in the supraclavicular approach.

 

[urge]

Wish he wouldda put you in the driver's seat, Urge.

Cuz I'm bettin' after you watched a few, he couldda let you do a few, emulating his cool technique.

Lottsa cool s h it out here in PP I wish you resident studs could see.

Cuz it would increase your studstatus as a resident.....

better equipping you for your PP years.

THATS HOW WE ROLL OUT HERE, LADIES AND GENTLEMEN!!!!!

CDAZY FAST.

SMOOTH.

NO DRAMA.

Edited by jet

hey Jet, why did you choose to delete my post and replace it with this Pirvate practice ad?

 

[jetproppilot]

Edited by jet

hey Jet, why did you choose to delete my post and replace it with this Pirvate practice ad?

Uh oh.

Was responding to your post.

But accidently hit edit instead of quote.

Not used to the new moderator buttons, Urge.

I'm sorry.

Honest mistake.

Private practice add?

Not sure I understand that.

Just my response to your post which I accidentally deleted.

Again, I'm sorry.