Review of Critical Care Medicine

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Posted by Dr KAMAL DEEP on July 26, 2011

Internal Jugular Approach

The author wish to acknowledge the excellent guidance of Dr Harjit Singh Mahay , Sr. Intensivist in this topic.

Percutaneous Cannulation of The Internal Jugular Vein (ALL APPROACHES)

Jugular System
The anatomy of the IJ vein is relatively constant, regardless of body habitus. The vein drains the cranium, beginning as the superior jugular bulb, which is separated from the floor of the middle ear by a delicate bony plate. The IJ vein emerges deep to the posterior belly of the digastric muscle. At its origin the IJ vein courses adjacent to the spinal accessory, vagus, and hypoglossal nerves, as well as the internal carotid artery. Several tributary veins enter the IJ vein at the level of the hyoid bone. The IJ vein, the internal (and, later, the common) carotid artery, and the vagus nerve course together in the carotid sheath, with the IJ vein occupying the anterior lateral position.The only structure that maintains a fixed anatomic relationship with the IJ vein is the carotid artery. The vein invariably lies lateral and slightly anterior to the carotid artery, and the course of the artery serves as a guide to venous cannulation. At the level of the thyroid cartilage, the IJ vein can be found just deep of the sternocleidomastoid muscle .

The IJ vein emerges from under the apex of the triangle of the two heads of the sternocleidomastoid muscle and joins the subclavian vein behind the clavicle. As the vein approaches its supraclavicular junction with the subclavian vein, it assumes a more medial position in the triangle formed by the two heads of the sternocleidomastoid muscles, following the anterior border of the lateral head. In this lower cervical region, the common carotid artery assumes a deep paratracheal location. The brachial plexus is separated from the IJ vein by the scalenus anterior muscle. The phrenic nerve is anterior to the scalenus anterior muscle. Although quite deep, the stellate ganglion lies anterior to the lower brachial plexus.

Unlike the subclavian vein, the IJ vein is quite distensible. The vessel diameter is increased with performance of a Valsalva maneuver and the assumption of the head-down (Trendelenburg) tilt position. Prolonged palpation of the carotid pulse will decrease the diameter of the IJ vein.Rotating the head 90 degrees toward the opposite side or extending the neck will not change the size of the IJ vessel significantly. Severe rotation of the head will bring the sterno-cleidomastoid muscle anterior or medial to the IJ vein and may make cannulation impossible without first traversing the carotid artery. The diameter of the IJ vessel is largest below the cricoid ring, where it may reach 2 to 2.5 cm.




Neck anatomy showing the course of the internal jugular vein (IJV).















Diagram of external jugular line going up over the edge of the sternocleidomastoid muscle, the main landmark for the posterior approach. Identify the point of insertion for the introducer needle along the posterior edge of the sternocleidomastoid muscle at the level just superior to where the external jugular vein crosses the muscle. This is typically one third of the distance between the mastoid and the clavicle.

  • Typically, the vein is entered within 1-3 cm; if the vein is missed, draw the needle all the way back to the skin before redirecting it.
  • If the bevel of the introducer needle is swung back and forth in the deeper tissues, a vessel or nerve may be inadvertently lacerated. Redirecting the needle more lateral, toward the sternoclavicular joint as opposed to the notch, often allows the vein to be entered


Surface anatomy and various approaches to cannulation of the internal jugular vein. A: Surface anatomy. B: Anterior approach. C: Central approach. D: Posterior approach.




The anterior and posterior approaches are identical in technique, differing only in venipuncture site and plane of insertion. For the anterior approach (see Fig. )the important landmark is the midpoint of the sternal head of the SCM, approximately 5 cm from both the angle of the mandible and the sternum. At this point, the carotid artery can be palpated 1 cm inside the lateral border of the sternal head. The index and middle fingers of the left hand gently palpate the artery, and the needle is introduced 0.5 to 1 cm lateral to the pulsation. The needle should form a 45-degree angle with the frontal plane and be directed caudally parallel to the carotid artery toward the ipsilateral nipple. Venipuncture occurs within 2 to 4 cm, sometimes only while the needle is slowly withdrawn. If the initial attempt is unsuccessful, the next attempt should be at a 5-degree lateral angle, followed by a cautious attempt more medially, never crossing the plane of the carotid artery.

The posterior approach (see Fig. )uses the EJV as a surface landmark. The needle is introduced 1 cm dorsally to the point where the EJV crosses the posterior border of the SCM or 5 cm cephalad from the clavicle along the clavicular head of the SCM. The needle is directed caudally and ventrally toward the suprasternal notch at an angle of 45 degrees to the sagittal plane, with a 15-degree upward angulation. Venipuncture occurs within 5 to 7 cm. If this attempt is unsuccessful, the needle should be aimed slightly more cephalad on the next attempt.

DSC01597DSC01599DSC01600DSC01602DSC01603DSC01604DSC01605DSC01606_2DSC01607_2DSC01608DSC01609DSC01610DSC01611DSC01612DSC01613_2DSC01614DSC01615_2DSC01616_2DSC01618DSC01619DSC01620DSC01621_2DSC01632DSC01633DSC01634DSC01635DSC01636DSC01637DSC01638DSC01639DSC01640DSC01647DSC01649DSC01648DSC01650DSC01641DSC01642DSC01643DSC01644DSC01645DSC01646DSC01651_2DSC01652DSC01653DSC01654DSC01655DSC01656IJ line triangle

Click To Enlarge






 Sandwich Technique
For multi-lumen catheters, bulky catheter hubs or difficult to dress areas
Use two 3M™ Tegaderm™ Transparent Film Dressings. Fold one dressing across the
width with the printed liner facing outward. The location of the fold may vary
depending on the distance between the catheter exit site and the hub, but typically
would be near the centre of the dressing.
2. Remove the printed liner. Keeping the dressing folded, gently lift the catheter and slip
the dressing underneath, positioning the fold at the exit site (or sutures). Secure one
half to the skin; and lay the catheter on top of the exposed adhesive of the other half.
(Figure 1) Smooth down the portion of the dressing on the skin. Do not remove the
3. Remove the printed liner from the second dressing and place it on top of the catheter.
Smooth one half over the exposed adhesive of the first dressing, and the remaining half
over the skin above the exit site. (Figure 2) Firmly smooth both dressings from the exit
site outward to enhance adhesion.
4. Pinch the dressings together around the catheter and remove the frame
from both dressings, smoothing down the edges as the frames are removed. (Figure 3)


A sandwich, loop-line, or bridge technique was used to apply each of the dressings. Two mechanisms of displacement were tested: dressing adherence to skin and dressing adherence to line. Dressing to skin adherence was tested on a relatively hairless part of the upper arm. Weights were added sequentially until the dressing peeled off. Dressing to line adherence was tested by applying the dressing to a 7F Dual Lumen Bard Hickman line passing through a piece of foam (measuring 13 × 12 cm). Weights were attached to the line until the cuff was pulled through the foam.

Dressing to skin adherence was poorest for the clear dressings, followed by Mefix and Sleek, and greatest for a combination of Tegaderm and Mefix. Dressing to line adherence was improved using a sandwich technique instead of a loop-line technique and most secure when a bridge technique was used to the thicker shaft of the line.

The dressings used for securing Hickman lines are not all equally secure. The least effective is the IV 3000 loop-line dressing. Tegaderm-Mefix bridge and Tegaderm-Mefix-Sleek combination dressings are the most secure and cost effective.


Infraclavicular Sub



Patient positioning for subclavian cannulation. B: Cannulation technique for supraclavicular approach




  • Needle insertion site options include the following:
    • One centimeter inferior to the junctions of the middle and medial third of the clavicle
    • Inferior to the clavicle at the deltopectoral groove
    • Just lateral to the midclavicular line, with the needle perpendicular along the inferior lateral clavicle
    • One fingerbreadth lateral to the angle of the clavicle
  • Sternal notch: Direct the insertion needle toward this target in the coronal plane.

The 18-gauge thin-wall needle is preferable for SV cannulation .The patient is placed in a 15- to 30-degree Trendelenburg position, with a small bedroll between the shoulder blades. The head is turned gently to the contralateral side and the arms are kept to the side. The pertinent landmarks are the clavicle, the two muscle bellies of the SCM, the suprasternal notch, the deltopectoral groove, and the manubriosternal junction. For the infraclavicular approach, the operator is positioned next to the patient’s shoulder on the side to be cannulated. For reasons cited earlier, the left SV should be chosen for pulmonary artery catheterization; otherwise, the success rate appears to be equivalent regardless of the side chosen. Skin puncture is 2 to 3 cm caudal to the clavicle at the deltopectoral groove, corresponding to the area where the clavicle turns from the shoulder to the manubrium. Skin puncture should be distant enough from the clavicle to avoid a downward angle of the needle in clearing the inferior surface of the clavicle, which also obviates any need to bend the needle. The path of the needle is toward the suprasternal notch. After skin infiltration and liberal injection of the clavicular periosteum with 1% lidocaine, the 18-gauge thin-wall needle is mounted on a 10-mL syringe. Skin puncture is accomplished with the needle bevel up, and the needle is advanced in the plane described above until the tip abuts the clavicle. The needle is then “walked” down the clavicle until the inferior edge is cleared. In order to avoid pneumothorax, it is imperative the needle stay parallel to the floor and not angle down toward the chest. This is accomplished by using the operator’s left thumb to provide downward displacement in the vertical plane during needle advancement, until the needle advances under the clavicle.

As the needle is advanced further, the inferior surface of the clavicle should be felt hugging the needle. This ensures that the needle tip is as superior as possible to the pleura. The needle is advanced toward the suprasternal notch during breath holding or expiration, and venipuncture occurs when the needle tip lies beneath the medial end of the clavicle. This may require insertion of the needle to its hub. Blood return may not occur until slow withdrawal of the needle. If venipuncture is not accomplished on the initial effort, the next attempt should be directed slightly more cephalad. If venipuncture does not occur by the third or fourth attempt, another site should be chosen, as additional attempts are unlikely to be successful and may result in complications

When blood return is established, the bevel of the needle is rotated 90 degrees toward the heart. The needle is anchored firmly with the left hand while the syringe is detached with the right. Blood return should not be pulsatile, and air embolism prophylaxis is necessary at all times. The guidewire is then advanced through the needle to 15 cm and the needle withdrawn. To increase the success rate of proper placement of the catheter, the J-wire tip should point inferiorly .The remainder of the procedure is as previously described. Triple-lumen catheters should be sutured at 15 to 16 cm on the right and 17 to 18 cm on the left to avoid intracardiac tip placement .

For the supraclavicular approach  the important landmarks are the clavicular insertion of the SCM muscle and the sternoclavicular joint. The operator is positioned at the head of the patient on the side to be cannulated. The site of skin puncture is the claviculosterno-cleidomastoid angle, just above the clavicle and lateral to the insertion of the clavicular head of the SCM. The needle is advanced toward or just caudal to the contralateral nipple just under the clavicle. This corresponds to a 45-degree angle to the sagittal plane, bisecting a line between the sternoclavicular joint and clavicular insertion of the SCM .The depth of insertion is from just beneath the SCM clavicular head at a 10- to 15-degree angle below the coronal plane. The needle should enter the jugulosubclavian venous bulb after 1 to 4 cm, and the operator may then proceed with catheterization.

Table 2. Common Errors in Technique

Error Percent of Failures (n = 277)
Inadequate landmark identification 14.7
Improper insertion position 32.3
Insertion of needle through periosteum 21.9
Taking too shallow a trajectory with needle 16.1
Aiming the needle too cephalad 7.5
Failure to keep needle in place for wire passage 7.5

Q:-Why is air embolism a complication of a lacerated wall
of the internal jugular vein?

Ans:- Air embolism is a serious complication of a lacerated
wall of the internal jugular vein. Because the wall of
this large vein contains very little smooth muscle, its injury
is not followed by contraction and retraction (as
occurs with arterial injuries). Moreover, the outer coat
of the vein is attached to the fascia of the carotid sheath,
which hinders the collapse of the vein.


Q:-In subclavian vein catheterization using the infraclavicular
approach, the following problems may occur, even
when great care is exercised: (a) The needle may hit the
clavicle; (b) the needle may hit the first rib; (c) the needle
may hit the subclavian artery. How would you deal
with these problems?

Ans:- When performing a subclavian vein catheterization
using the infraclavicular approach, the clavicle may
be hit by the advancing needle. The needle may then
be “walked” along the lower surface of the clavicle until
its posterior edge is reached and then inserted into
the subclavian vein. The needle may hit the first rib.
This is due to the fact that the needle is pointing downward
and not upward. The needle may hit the subclavian
artery. This is recognized by feeling the pulsatile
resistance to the advancing needle and the presence of
bright red blood in the catheter. It indicates that the
needle has passed too deeply posterior to the scalenus
anterior muscle and perforated the wall of the subclavian
artery .The needle should be
partially withdrawn and the vein approached again.


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