A 62-year-old man is transferred to the intensive care unit due to distributive shock secondary to a severe soft tissue infection. Peripheral intravenous access is insufficient, and the critical care team determines that a central venous catheter is required for continuous vasopressor infusion. The physician opts to cannulate the right internal jugular vein using the ultrasound-guided Seldinger technique. The patient is placed in the Trendelenburg position, the neck is prepped and draped in a sterile fashion, and local anesthetic is infiltrated.
Arrange the subsequent critical steps of the Seldinger technique in the correct chronological order to safely complete the procedure.
- 1Insert the introducer needle into the target vein under ultrasound guidance and confirm intravascular placement by aspirating venous blood.
- 2Advance the flexible guidewire gently through the introducer needle into the venous lumen.
- 3Withdraw the introducer needle completely over the guidewire while maintaining firm control of the wire.
- 4Pass the tissue dilator over the guidewire to expand the skin and subcutaneous tract, then remove the dilator.
- 5Thread the central venous catheter over the guidewire into its final intravascular position, and subsequently remove the guidewire.
Answer
The correct sequence is: 1) Insert the introducer needle and aspirate blood, 2) Advance the guidewire through the needle, 3) Withdraw the introducer needle over the wire, 4) Pass the tissue dilator over the wire and remove it, 5) Thread the central venous catheter over the wire and remove the wire.
The Seldinger technique is a fundamental procedural sequence for achieving safe central venous access. Following sterile preparation and local anesthesia, the target vessel is initially cannulated with an introducer needle. Once intravascular placement is confirmed by aspiration of venous blood, a flexible guidewire is threaded through the needle and into the vein. The introducer needle must then be carefully withdrawn over the guidewire; the operator must maintain constant control of the wire to prevent its unintended loss into the bloodstream. Because the definitive central venous catheter is relatively large and blunt, a rigid tissue dilator is temporarily passed over the guidewire to enlarge the subcutaneous tract and the puncture site in the vessel wall. After the dilator is removed, the multi-lumen central venous catheter is threaded over the guidewire into its proper position. Finally, the guidewire is completely removed so the catheter can be secured to the skin and utilized for therapy.
Step-by-Step Solution
Key Concept
The chronological procedural steps of the Seldinger technique for safe central venous catheterization.