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DOPS: ultrasound-guided internal jugular line, wire ectopy and air embolismDOPS: 66-year-old man, ventilated in ICU with septic shock, on noradrenaline via a peripheral cannula

DOPS: ultrasound-guided internal jugular line, wire ectopy and air embolism

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Ultrasound guidance is now standard for internal jugular access.
  • Maximal barrier precautions and chlorhexidine–alcohol prep reduce line infection.
  • Confirm venous placement by manometry or pressure before dilating; verify the tip position.
  • Arterial puncture is commoner than pneumothorax.
  • Air embolism: stop entry, 100% oxygen, left side down and head down, aspirate the line.

The patient

DOPS: 66-year-old man, ventilated in ICU with septic shock, on noradrenaline via a peripheral cannula. INR 1.3, platelets 140 × 10⁹/L. Vitals: BP 92/54 on noradrenaline, HR 104, SpO2 95% on FiO2 0.4. Task: insert a right internal jugular central venous catheter.

The examiner asks

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  1. Prepare

    How do you prepare?

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    • He lacks capacity: consent from his guardian, or the emergency two-doctor route if none is reachable. (Procedure step)
    • Clotting is near normal: INR 1.3, platelets 140.
    • Maximal barrier: hat, mask, sterile gown and gloves, and a full-length drape.
    • Chlorhexidine–alcohol skin prep; it lowers line infection compared with povidone–iodine.
    • Pre-scan: compressible vein, pulsatile carotid, and a patent vein without clot.

  2. Perform

    Talk me through insertion.

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    • Real-time ultrasound, keeping the needle tip in view until it is inside the vein. (Procedure step)
    • Wire through the needle, then scan to see the wire inside the vein, not the artery.
    • Before dilating, confirm venous placement by manometry or a pressure trace.
    • Dilate, railroad the catheter, never letting go of the wire, then remove it intact.
    • Aspirate, flush and cap every lumen; confirm the tip position before use.

  3. Crisis

    As the wire is advanced, runs of ventricular tachycardia appear. BP 84/50. What do you do?

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    • The wire is irritating the heart: pull it back until the rhythm settles. (Crisis)
    • Check for a pulse; pulseless VT means starting the arrest algorithm.
    • If VT persists with a pulse and low BP: synchronised cardioversion.
    • Re-advance only to the depth needed, watching the monitor.

  4. Crisis

    Later a hub is found open with the bed head-up. BP 70/40, HR 125, EtCO2 falls from 4.8 to 2.5 kPa, SpO2 88%.

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    • Venous air embolism: close the open hub immediately. (Crisis)
    • 100% oxygen.
    • Tilt him head-down, left side lowest, to move air out of the right ventricular outflow.
    • Aspirate air back through the central line.
    • Support the circulation with fluid and vasopressors; CPR if he arrests.

Scan · Internal jugular vein and carotid

Here is your image. Point to and name each structure, then say why it matters.

Real-time imaging across the vessel (short axis), or along it as an option (probe type and position not given in the corpus).

Transverse short axis, skin at top; IJV superficial and to the left, common carotid deeper and to the right; side of neck not stated

Internal jugular vein and carotid, labels covered, open the image full size
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Internal jugular vein and carotid, labelled, open the image full size

Labels VJI internal jugular vein · ACC common carotid artery

  • I scan before prepping to check the vein is a good size and not clotted.
  • This is the internal jugular; the right side is my usual choice.
  • This is the carotid, the thing I must not puncture.
  • I keep the beam just ahead of the tip until it sits inside the vein.
  • Before dilating I check pressure to exclude arterial placement.
  1. Right internal jugular vein Preferred side: predictable anatomy, reachable from the head end
  2. Carotid artery Accidental puncture is the classic danger; confirm venous by manometry
  3. Vein size and patency Pre-scan rules out a small or clotted vein
  4. Needle tip in lumen Follow the tip ahead of time until it sits mid-vessel
  5. Back wall of the vein Long-axis view helps avoid going through it

Checked against: Barash 9e · Miller 10e

Image: Kalina M et al., A novel "lateral approach short axis in-plane" technique vs. conventional "short-axis out-of-plane approach" for ultrasound-guided internal jugular vein access: a prospective randomized non-inferiority trial (Ultrasound J 2025; doi:10.1186/s13089-025-00405-9), Fig. 2, CC BY 4.0. Changes: Whole image kept, no crop. Question image: orange and green measurement lines and their 'a'/'b' letters covered with dark grey along the lines; 'VJI' and 'ACC' labels covered with boxes

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Fatal mistakes

  • Dilating the artery.
  • Losing the guidewire.
  • Leaving a hub open with the patient upright.

Checked against: Barash 9e · Miller 10e · Saudi Guidelines for Informed Consent, First Edition 1440H (2019)

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