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During setup for cardiac surgery, many anaesthetists use internal jugular vein cannulation. The internal jugular vein lies lateral to the carotid artery under the sternomastoid muscle. It is often palpable through the skin, but can be imaged using ultrasound.

  • Puncture of the artery with a fine needle - Digital pressure
  • Puncture with a dilator/sheath -
Heparinize and keep the sheath,complete the cardiac procedure and then repair the artery
  • Alternatives -
  • Remove sheath and defer the case.
  • Expose the artery, repair and keep open packed till the end of the case
  • Palpate the carotid
  • Ultrasound can be used
  • In doubt - Transduce the puncture needle

The main danger here is inadvertent cannulation of the artery with either a central venous catheter or a sheath through which a Swan Ganz catheter can be inserted. Techniques vary, but many use a fine needle to located the vein, and then pass a larger needle with a wire into the same place. (Seldinger technique). If this fine needle enters the artery, removal and local pressure usually suffices to prevent a large haematoma and the risk of compression whilst heparinised. Should a larger bore cannula enter the artery, (or even the Swan Ganz catheter), the risks for compromise of the carotid are much greater.

Inadverent Carotid puncture with Dilator: Another approach is to remove the sheath and Compress. Monitor the compressed Area, Continue with the surgery delaying heparinisation till fairly sure of hemostasis at compressed site.Like IABP insertion site, this puncture site would seal as well.Rarely local exploration and direct repair is warranted.

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