Chapter 32 ■ Central Venous Catheterization 203

15. Two small, curved mosquito hemostats

16. Dissecting scissors

17. 4-0 Vicryl suture on small, curved needle; 6-0 polypropylene on a tapered needle. This is used for a pursestring stitch as an alternative to ligation of the vessels.

18. Needle holder

19. Suture scissors

20. Appropriate materials for occlusive dressing of choice

Nonsterile

1. Cap and mask

2. Roll of 4- × 4-inch gauze

3. Tape measure

4. Adhesive tape

D. Techniques

In the neonate, the cervical veins are preferable to the

lower-extremity veins. The cervical veins are easily accessible and are a proportionately larger size. When the lower

extremities are used, the greater saphenous vein is often

selected in pediatric patients because of its large size and

consistent anatomy. It is not established whether femoral or

jugular sites have fewer complications in neonates (16,17).

1. Catheter placement via jugular veins

a. Immobilize infant in position similar to that for percutaneous insertion of subclavian venous catheter.

Make sure that the patient is in the Trendelenburg

position to minimize the risk of an air embolism.

b. If right side is to be catheterized, turn head to left

and extend neck. Care must be taken not to extend

the head too much, as this may result in occlusion

of the vein.

c. Estimate length of catheter to be inserted by measuring from a point midway between the nipple and

the midpoint of the clavicle to a point over the sternocleidomastoid muscle at the junction of the middle and lower third of the neck (Fig. 32.7).

d. Put on cap and mask.

e. Scrub as for major procedure and put on gown and

gloves.

f. Prepare neck and scalp area or right chest wall with

antiseptic solution such as iodophor and drape out

the sterile field.

g. Make small, transverse incision (1 to 2 cm) through

skin and platysma muscle low in the neck for the

external jugular and higher up for the facial vein.

h. Free external jugular or facial vein by blunt dissection with curved mosquito hemostat. If internal jugular vein is used, sternocleidomastoid muscle must

be split to locate vein.

i. Pass curved mosquito hemostat behind the vein,

and place proximal and distal ligatures of 4-0 absorbable suture loosely around vein (Fig. 32.8). Be careful not to twist the vessels as the suture is advanced.

j. Using a blunt tunneler, create a subcutaneous tract

from neck to exit on the chest wall medial to the

right nipple. In a baby girl, make sure that the tunnel is far from the breast bud (Figs. 32.9 and 32.10).

k. Thread the end of the catheter through the opening

in the tunneler, and guide the catheter gently

through the subcutaneous tract.

l. Fill the catheter system with heparinized flush

solution.

Fig. 32.7. The jugular veins in relation to major anatomic landmarks.

Fig. 32.8. Catheterization of the external jugular vein; venotomy has been performed prior to inserting the catheter.