What information should be included in a note for Internal Jugular Vein (IJV) catheter insertion?

Documentation for Internal Jugular Vein (IJV) Catheter Insertion

Your procedure note for IJV catheter insertion must document the six-step ultrasound-guided approach, patient positioning, sterile technique, confirmation of placement, and any complications encountered. 1

Essential Pre-Procedure Documentation

Patient Information and Indication

• Document the specific indication for central venous access (hemodynamic monitoring, medication delivery, hemodialysis, parenteral nutrition) 2
• Record relevant comorbidities and risk factors including coagulopathy, previous catheter insertions in the same vein, or poor compliance 3
• Note contraindications assessed, particularly for coagulopathy (platelet count should be documented if <50 × 10⁹/L) 1

Informed Consent

• Document discussion of risks including arterial puncture, pneumothorax, bleeding, infection, catheter malposition, and thrombosis 3, 4
• Record patient or surrogate understanding and agreement to proceed

Procedural Documentation Requirements

Site Selection and Rationale

• Document why the right IJV was chosen as the preferred site (more direct route to caval-atrial junction, lower complication rates) or justify alternative site selection 1, 5
• Record assessment of alternative sites if right IJV was not used 1

Pre-Procedure Ultrasound Assessment (Step 1)

• Document static ultrasound findings performed before prepping and draping 1, 5
• Record vessel identification in both short-axis (transverse) and long-axis (longitudinal) views 1
• Note anatomic variations, vessel size, depth from skin, and relationship between IJV and carotid artery 1
• Document vein patency confirmed by compression ultrasound 1
• Record use of color Doppler imaging to differentiate venous from arterial flow if performed 1

Patient Positioning

• Document Trendelenburg positioning (head-down) to increase IJV filling 1, 5
• Record degree of head rotation (noting that excessive rotation increases IJV-carotid overlap) 1

Sterile Technique (Step 3)

• Document maximal sterile barrier precautions: cap, mask, sterile gown, sterile gloves, and large sterile full-body drape 1, 5
• Record skin preparation with 2% chlorhexidine gluconate in 70% isopropyl alcohol with complete air drying 5
• Note sterile probe cover and sterile ultrasound gel used 1

Catheter Specifications

• Record catheter type, size (French), length (15 cm for right IJV is standard minimum for adults), and number of lumens 1, 5
• Document selection of smallest appropriate diameter to reduce vein trauma 5

Real-Time Procedural Steps Documentation

Venipuncture Technique (Steps 3-4)

• Document real-time ultrasound guidance approach: short-axis/out-of-plane versus long-axis/in-plane 1
• Record number of needle passes (average should be 1-2 attempts) 3, 4
• Note whether single-wall or double-wall puncture technique was used 3
• Document confirmation that needle tip was visualized centrally in the vein before guidewire advancement 1

Guidewire Placement (Step 5)

• Record confirmation of guidewire position in vein using both short-axis and long-axis ultrasound views 1
• Document ease of guidewire passage and any resistance encountered 2

Catheter Insertion (Step 6)

• Document dilation performed over guidewire
• Record confirmation of catheter position in vein using ultrasound in both planes 1
• Note catheter secured at skin with sutures (document number and type)

Post-Procedure Confirmation and Documentation

Immediate Verification of Placement

• Document confirmation of venous access using ultrasound, manometry, pressure-waveform analysis, or venous blood gas 5
• Record that blood color alone was NOT used as sole confirmation of venous placement 5
• Document blood return from all lumens 6

Chest X-Ray Confirmation

• Document that chest X-ray was obtained to confirm catheter tip position at caval-atrial junction or lower SVC and to exclude pneumothorax 1, 5
• Record final catheter tip position (should be in lower SVC or upper right atrium, parallel to vessel wall) 1
• Note any catheter malposition requiring adjustment 1

Post-Procedure Orders

• Document catheter care instructions and dressing type applied
• Record heparin or saline lock concentration for each lumen

Complications Documentation

Immediate Complications

• Document any arterial puncture (occurs in 1.8% with ultrasound guidance) 3
• Record any bleeding, hematoma formation, or oozing around catheter site 3
• Note pneumothorax if occurred (should be rare with ultrasound guidance at 0.4%) 3
• Document catheter malposition requiring repositioning 6

Absence of Complications

• Explicitly state "no immediate complications" if procedure was uncomplicated 4

Time Documentation

• Record total procedure time from skin preparation to final catheter securement 3, 4
• Document time to venipuncture (average 138 seconds with ultrasound) 4
• Note any delays and reasons

Operator Information

• Document operator name, training level, and experience with ultrasound-guided IJV catheterization 3, 6
• Record supervisor present if trainee performed procedure 6

Common Documentation Pitfalls to Avoid

• Never document that landmark technique was used as primary approach—ultrasound guidance is the standard of care and reduces complications by 12.3% 4
• Never omit documentation of the six-step ultrasound approach—this is the recommended systematic method 1
• Never document catheter use before chest X-ray confirmation for subclavian or IJV insertions 1, 5
• Never fail to document why an alternative site was chosen if right IJV was not used 1, 5
• Do not document reliance on blood color or pulsatility alone to confirm venous placement 5