Scenario:

A 60-year-old male patient arrives in ED ICU with septic shock and refractory hypotension despite adequate fluid resuscitation. You've decided to start vasopressor support. Before initiation, you need reliable central venous access. Describe your approach for securing an IJv central line.

Questions:

1.  What are the indications and contraindications for central line placement via IJv?

2. How do you choose between IJv, subclavian, and femoral routes?

3. What complications could occur with IJv insertion, and how can they be mitigated?

Checklist:

Preparation:

1. Verify patient identity and indication.

2. Briefly explain the procedure to the simulated patient.

3. Hand hygiene and apply appropriate PPE (sterile gown, gloves, mask, cap).

4. Gather necessary equipment:

   1. Central line insertion kit

   2. Ultrasound machine with sterile sleeve

   3. Sterile drapes, syringes, needles, scalpel, sutures, chlorhexidine solution, lidocaine

Procedure Steps:

1. Patient Positioning: Trendelenburg position (~10–15 degrees) with head slightly rotated opposite to insertion site.

2. Ultrasound-Guided IJv Identification: Identify IJ vein and carotid artery clearly with ultrasound.

3. Skin Preparation: Clean site with chlorhexidine solution, maintain sterile field.

4. Local Anaesthesia: Inject local anaesthetic (lidocaine: 5mg/kg max) at insertion site.

5. Needle Insertion (Seldinger Technique):

   1. Insert needle at ~45-degree angle, guided by ultrasound.

   2. Confirm venous entry by blood aspiration and ultrasound visualisation.

   3. Guidewire Placement: Advance guidewire gently without resistance.

   4. Confirm guidewire placement in vein via ultrasound.

   5. Dilator and Catheter Placement:

   6. Make small skin incision with scalpel.

   7. Advance dilator carefully over guidewire (remove dilator afterwards).

   8. Insert catheter over guidewire to appropriate depth.

   9. Confirmation and Securing: Aspirate all ports, flush with saline, and ensure smooth flow.

   10. Secure catheter with sutures and apply sterile dressing.

   11. Post-Procedure Confirmation:

   12. Order chest X-ray to confirm placement and rule out complications (pneumothorax).

   13. Document everything