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Difficulty: MediumSurgical and Procedural Interventions

A 65-year-old woman is evaluated in the intensive care unit for refractory shock. She was admitted two days ago for severe community-acquired pneumonia and initially improved on broad-spectrum intravenous antibiotics. Over the past 4 hours, her condition has deteriorated. Her blood pressure is 70/40 mmHg despite the administration of 3 liters of intravenous isotonic crystalloids. The decision is made to initiate a continuous norepinephrine infusion via a central venous catheter. The physician prepares the right internal jugular vein site with chlorhexidine, applies sterile drapes, and utilizes ultrasound guidance for the procedure. Arrange the following procedural steps of the Seldinger technique for central venous catheter placement in the correct chronological sequence.

  1. 1Access the vessel with the introducer needle under direct ultrasound visualization.
  2. 2Advance the J-tip guidewire through the introducer needle into the lumen of the vein.
  3. 3Withdraw the introducer needle completely while maintaining continuous control of the guidewire.
  4. 4Advance a tissue dilator over the guidewire to enlarge the subcutaneous tract, then remove the dilator.
  5. 5Thread the central venous catheter over the guidewire into the vessel, and subsequently remove the guidewire.

Answer

The correct chronological sequence for the Seldinger technique is: 1) Access the vessel with the introducer needle, 2) Advance the guidewire through the needle, 3) Withdraw the introducer needle, 4) Advance and remove the tissue dilator over the guidewire, and 5) Thread the central venous catheter over the guidewire and remove the guidewire.
The Seldinger technique is the universal standard for establishing safe central venous access. The procedure follows a strict chronological order to maintain vascular access while minimizing trauma. The sequence begins with venous puncture using a small introducer needle. A guidewire is then passed through the needle to hold the place in the vessel. The rigid needle is removed, leaving the flexible wire. A dilator is temporarily advanced over the wire to enlarge the tissue tract, followed by the definitive central venous catheter. Once the catheter is securely in the vessel, the guidewire is completely removed.

Step-by-Step Solution

1
Venous Access
Target vessel punctured
To establish an initial tract into the vascular lumen under direct visualization.
2
Guidewire Insertion
Guidewire secured in vessel
To maintain access and establish a secure, flexible pathway into the vein.
3
Needle Removal
Needle removed, wire remains
To clear the pathway over the wire so larger instruments can be passed.
4
Tract Dilation
Subcutaneous tract enlarged
To accommodate the larger diameter of the central venous catheter without causing tissue trauma during insertion.
5
Catheter Placement
Catheter in place, wire removed
To position the catheter for fluid and medication infusion, followed by necessary wire removal to prevent embolism.

Key Concept

The Seldinger technique is the foundational method for safe, over-the-wire central venous catheter placement and other vascular procedures.
Estimated Time:1m 30s
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Topics

Surgical and Procedural Interventions

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