Hemostats around the surgical field rostral to the incision. Use the position with the hemostat to apply slight tension on the vein, that will help in elevating the jugular vein. If required location the closed fine scissors beneath the vein to compress any interfering tissue. Re-wet vein liberally with sterile saline. 20. Insert a second ten cm section of 4-0 braided suture below the vein. Execute the first double throw required to produce a further surgeon’s knot but do not pull the knot tight. As an alternative form a loose 0.five cm diameter loop. Position the loop as far caudally as possible on exposed section of jugular vein.watermark-text watermark-text watermark-textCurr Protoc Neurosci. Author manuscript; obtainable in PMC 2013 October 01.Beardsley and SheltonPageThis loop will later be pulled tight to anchor the catheter firmly inside the jugular vein. 21. Position the catheter using the attached flush syringe around the surgical field such that the tip is close towards the incision and inside the appropriate orientation to be quickly grasped and inserted inside the jugular vein. 22. Make a small nick inside the top in the jugular vein amongst the rostral knot and caudal loop applying a pair of ball-tipped Bonn artery scissors or Vannas spring scissors. The size of your nick is critical. The optimal nick is around 1/3?/2 in the vein diameter. A nick that is too smaller might not completely penetrate the vein wall and as a result prevent venous access by the catheter. A nick that is definitely also substantial may possibly lead to the remaining jugular vein to element and retract in to the underlying tissue, which can be generally an unrecoverable error requiring catheterization on the opposing jugular vein. Initially erring around the side of caution is warranted as an more deeper nick might be created far more caudally on the vein when the first attempt was of insufficient depth. 23. Hold the needle with the catheter introducer parallel towards the vein and insert the needle of your catheter introducer by way of the nick and in to the vein. After introduced, slightly angle the handle with the catheter introducer to open the nick inside the vein such that a hole into which the catheter could be inserted is apparent. At times a small “flash” of blood will accompany this operation, which is an further indication that the introducer is adequately inserted within the vein. 24. Applying the opposite hand, grasp the catheter roughly five mm in the tip together with the Dumont forceps. Slide the catheter beneath the introducer and in to the hole inside the vein. Continue advancing the catheter in to the vein utilizing the forceps until inserted to the depth from the initial cuff. Eliminate the catheter introducer. 25. Verify that the catheter is adequately positioned by drawing back slightly on the attached syringe plunger. Blood ought to flow into the catheter tubing. Push the syringe plunger forward to expel the blood back in to the vein. Based upon the positioning of the catheter it may PubMed ID:http://www.ncbi.nlm.nih.gov/pubmed/21114274 not be possible to pull blood back into the catheter. If no blood might be withdrawn, gradually flush 0.3?.4 ml of saline in the syringe in to the catheter and appear for pooling in the incision. If no pooling of saline is noted the catheter is probably positioned properly. 26. Grasp the catheter working with the thumb and PD-166866 site forefinger of 1 hand and together with the help of your Dumont forceps inside the other hand to manipulate the vein, work the initial cuff in the catheter absolutely into the vein. A gentle back and forth twisting motion from the catheter between the thumb and forefinger is normally useful. 27. Tighten the uncompleted.