Pragmatic risk-mitigation strategies for aseptic internal jugular vein cannulation in resource-limited emergency settings

Dear Editor,

Central venous catheterisation is a cornerstone of care in critically ill and trauma patients. Current guidelines and expert consensus recommend maximal aseptic precautions during central venous catheter insertion, including hand hygiene and the use of sterile gloves, gown, mask, cap, and large full-body drapes.[1,2,3] While large-bore peripheral intravenous cannulation remains the appropriate first-line intervention for immediate crisis management, certain clinical scenarios necessitate central access even when standard resources are limited. These include patients in profound shock with collapsed peripheral veins where emergency access is unattainable, the mandatory initiation of potent inotropes or vasopressors in patients awaiting intensive care unit (ICU) transfer, or cases with exhausted peripheral access, such as in intravenous drug users. Although randomised data comparing maximal barrier precautions with limited barriers show varied results, it is well established that bundled aseptic practices including full sterile barriers are consistently associated with significantly reduced central line-associated bloodstream infections (CLABSIs) and remain the non-negotiable standard of care.[2,3,4]

In contrast, high-volume emergency triage areas and temporary holding zones for patients awaiting ward or ICU transfer frequently lack the infrastructure required for full guideline adherence. Space constraints, limited assistance, and restricted sterile supplies are common, and in many such settings, the only readily available sterile option for urgent internal jugular vein cannulation is a basic central line set comprising a small fenestrated drape and minimal instruments, without access to sterile gowns, full-body drapes, or dedicated ultrasound probe covers. Recognising that no adaptation should take precedence over established safety standards, we describe context-specific risk-mitigation strategies aimed at minimising breaches in sterility when ideal resources are physically unavailable. These pragmatic manoeuvres are designed to maintain a ‘zone of asepsis’ by physically preventing equipment from contacting unsterile surfaces. While we acknowledge that the impact of such bedside innovations on the true incidence of CLABSI remains to be validated through structured clinical research, they serve as a necessary safety bridge for clinicians balancing the urgency of access against the constraints of a resource-limited environment [Table 1, Figure 1a and b].

Table 1.

Pragmatic adaptations for aseptic internal jugular vein cannulation

Procedure Step	Limitation in Resource-Poor Setting	Risk Mitigation Strategy	Clinical rationale for Change
Equipment Stability	Non-locking trolleys with no adjustable height	Prior manual stabilisation by the available attendant.	Prevents accidental trolley shifting and contamination during procedure[5]
Workflow Logistics	Lack of assistance to open/handover equipment; cramped workspace	Pre-flight staging: Pre-position all hardware (USG, sutures, kits) within arm’s reach before scrubbing.	Minimises movement-induced breaches by reducing the need to reach across unsterile zones[5]
Site Preparation	Absence of full-body sterile drapes.	Static Ultrasound Pre-marking: Identify vein location first	Ensures precise placement of the small sterile fenestrated drape over the target vessel.[5]
Patient Ergonomics	Fixed-height gurneys; lack of specialised headrests	Use saline bottles/towels for neck extension; position patient at trolley edge.	Better vein visualisation; positioning the patient on the edge keeps the guidewire suspended in mid-air away from the bed surface as no full body drapes.
USG Probe Asepsis	Lack of dedicated sterile probe covers and gels.	Sterile Glove “sleeve” used to cover the probe alone; the assistant holds the probe “mid-air” from the cable as it is not in the camera cover.	Maintains probe sterility for re-confirmation without needing a sterile docking station. Cautionary Note: Improvised covers are not validated for acoustic clarity or perforation resistance. However, they provide a physical barrier against gross contamination when dedicated covers are unavailable.[5]
Guidewire/central venous catheter control	No sterile gowns; high risk of wire touching the operator’s unsterile arms/chest.	The “coiling” technique: Stabilise the catheter between thumb/index; hold it coiled within the palm when railroading over guidewire [Figure 1a/b].	Keeps the long guidewire “contained” within the sterile hand rather than touching unsterile surfaces.
Suture management	Long suture tails often drag on unsterile bedsheets.	“Short-loop” suturing: Roll excess thread in the palm; shorten tail length after each pass prior to tying knots.	Eliminates the “tail” contact with unsterile surfaces beneath the small drape[5]

USG: Ultrasonography

Figure 1.

Improvised sterile handling technique for catheter: The Coiling technique: (a) When holding the central venous catheter; (b) When railroading the central venous catheter over the guidewire

Presentation at conferences/CMEs and abstract publication

Nil.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

Nil.

Declaration of use of permitted tools

Nil.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.