Cannulation of the internal jugular vein

The internal jugular vein (IJV) is accessible, so cannulation of this vein is associated with a lower complication rate than with other approaches. Hence, it is the vessel of choice for central venous cannulation.

Anatomy of the IJV (click for larger images)

The vein originates at the jugular foramen and runs down the neck, to terminate behind the sternoclavicular joint, where it joins the subclavian vein. It lies alongside the carotid artery and vagus nerve within the carotid sheath. The vein is initially posterior to, then lateral and then anterolateral to the carotid artery during its descent in the neck. The vein lies most superficially in the upper part of the neck.

Relations of the IJV (click for larger image)

Anterior
Internal carotid artery and vagus nerve.

Posterior
C1, sympathetic chain, dome of the pleura. On the left side, the IJV lies anterior to the thoracic duct.

Medial
Carotid arteries, cranial nerves IX-XII

Technique

Place the patient in a supine position, at least 15 degrees head-down to distend the neck veins and to reduce the risk of air embolism. Turn the head away from the venepuncture site. Cleanse the skin and drape the area. Sterile gloves and a gown should be worn (see catheter-related sepsis).

a) Ultrasound guided technique
b) Landmark technique using Seldinger

Landmark technique

If the patient is awake, use local anaesthetic to numb the venepuncture site. Introduce the large calibre needle, attached to an empty 10 ml syringe, into the centre of the triangle formed by the two lower heads of the sternocleidomastoid muscle and the clavicle. Palpate the carotid artery and ensure that the needle enters the skin lateral to the artery. Direct the needle caudally, parallel to the sagittal plane, at a 30 degree posterior angle with the frontal plane, aiming towards the ipsilateral nipple. Once blood is aspirated, cannulate the vein using the Seldinger technique. The catheter tip should lie in the superior vena cava above the pericardial reflection. Perform check chest X-ray to confirm position and exclude pneumothorax.

Complications

 Pneumothorax/haemothorax - a high approach minimises this risk.
 Air embolism - ensure head-down position.
 Arrhythmias - avoid passing guidewire too far, observe rhythm on cardiac monitor during insertion.
 Carotid artery puncture/cannulation - palpate artery and ensure needle is lateral to it, use ultrasound-guided placement, transduce needle before dilating and passing central line into vessel, or remove syringe from needle and ensure blood is venous.
 Chylothorax - use a high approach and avoid left side wherever possible.
 Infection - see section on catheter related sepsis.