External Jugular Vein Cannulation 

Background

External jugular vein cannulation is an integral part of modern medicine and is practiced in virtually every health care setting. Venous access allows the sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.^[1]

This topic describes placement of an intravenous catheter into the external jugular vein. A similar technique can be used for placement of intravenous catheters in different anatomical sites.

Indications

Indications for external jugular vein cannulation include the following:

• Repeated blood sampling
• Intravenous fluid administration
• Intravenous medications administration
• Intravenous chemotherapy administration
• Intravenous nutritional support
• Intravenous blood or blood products administration
• Intravenous administration of radiological contrast agents (computed tomography, magnetic resonance imaging, nuclear imaging)

Note that many institutions will not allow administration of a high-pressure intravenous contrast agent into an external jugular vein.

Contraindications

No absolute contraindications exist for external jugular vein cannulation.

Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible.

Vesicant solutions can cause blistering and tissue necrosis if they leak into the tissue. Irritant solutions (pH < 5, pH >9, or osmolarity >600 mOsm/L, including sclerosing solutions, some chemotherapeutic agents, and vasopressors) also are more safely infused into a central vein. Therefore, these solutions should only be given through a peripheral vein in emergency situations or when a central venous access is not readily available.

Technical Considerations

Best Practices

Veins with high internal pressure become engorged and are easier to access. The use of dependent positioning, proximal compression with a finger, “pumping” via muscle contraction and the local application of heat or nitroglycerin ointment can contribute to venous engorgement.

The external jugular vein begins at the level of the mandible and it runs obliquely across and superficial to the sternocleidomastoid muscle. See the image below.

Some patients have double external jugular veins. Placing a patient in the Trendelenburg position, slightly tilting the head to the opposite side and application of light pressure above the clavicle will help to engorge the external jugular vein and assist its catheterization.^[2]

Complication Prevention

Use of an anesthetic cream 30 minutes prior to insertion attempt and/or subcutaneous infiltration of an anesthetic solution should be used prior to peripheral intravenous insertion whenever possible.

Collapse of the vein, inadequate skin traction, incorrect positioning, and incorrect angle of penetration can all lead to a failed attempt. Either attempt insertion at a different site or, if you believe that the selected vein should be accessible, withdraw the venous access device to just beneath the skin and reattempt insertion.

If blood stops flowing into the flashback chamber, vein collapse, venospasm, needle hub position against a venous valve, or penetration of the posterior wall of the vein might be the cause. Observation of a developing hematoma will necessitate removal of the catheter. Release and then reapply the venous tourniquet and attempt to gently stroke the vein to engorge it with blood and release venospasm. Finally, attempt to withdraw the needle a few millimeters to move it away from a valve.

If there is difficulty advancing the catheter over the needle and into the vein, failure to release the catheter from the needle before insertion, encountering a venous valve, removing the needle too far with the catheter being too soft to advance into the vein, poor skin traction, or venous collapse can all be the cause. Release the tourniquet and then reapply it to help engorge the vein. Connect a syringe with normal saline (0.9%) solution to the hub, then attempt to “float” the device in place by flushing the catheter and advancing it at the same time.

If there is difficulty flushing after the catheter was placed in a vein, the catheter tip positioned against a venous wall or a valve, a blood clot, or piercing of the venous wall might be the cause. Observation of a hematoma will necessitate removal of the catheter. Withdraw the catheter slightly to release it from a wall/valve and attempt to flush it back in.

Palpate the vein carefully before attempt to insert a venous access device to ensure that there is no palpable pulse in the vessel. Because the external jugular vein is superficial to the internal jugular vein and the carotid artery, make sure to enter the skin at a shallow angle of approximately 10 degrees. Maintain this angle or a lower angle as you advance the catheter. If an accidental arterial puncture occurs, as evident by arterial pulsation of blood out of the catheter, remove the catheter and apply direct pressure using gauze for at least 10 minutes.

Thrombophlebitis can be caused by either thrombus formation with subsequent inflammation and/or infection. Pain to the intravenous site of along the path of the catheter, skin erythema and/or induration, swelling, drainage from the skin puncture site, or presence of a palpable venous cord are the signs of thrombophlebitis. Remove the catheter and treat with appropriate antibiotics if you suspect an infectious etiology.

Regularly and at least daily inspect the site of insertion for signs of infections. Some sources recommend the routine replacement of peripherally inserted intravenous catheters every 3-4 days, while others suggest that proper antiseptic technique and at least daily monitoring of the insertion sites may allow for safe and less frequent replacement, as long as no signs of phlebitis are present.

Some vesicant and irritant solutions may cause severe soft tissue damage if the extravasate outside of the vein and into the surrounding tissue.

Equipment

This topic describes the use of the “over-the-needle” type of intravenous catheter, in which the catheter is mounted on the needle, as shown in the image below.

This device is available in various gauges, lengths, compositions, and designs. Gauges range from 16-24 G and lengths range from 25-45 mm (see the image below).

In general, the smallest gauge of catheter should be selected for the prescribed therapy to prevent damage to the vessel intima and ensure adequate blood flow around the catheter in order to reduce the risk of phlebitis.^[3]

In an emergency situation or when patients are expected to require large volumes infused over a short period of time, the largest gauge and shortest catheter that is likely to fit the chosen vein should be used. The catheter chosen should always be slightly smaller than the vein.

Necessary equipment includes the following:

• Nonsterile gloves
• Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol)
• Local anesthetic solution
• 1 mL syringe with a 30-G needle
• 2 × 2 gauze
• Venous access device
• Vacuum collection tubes and adaptor
• Saline or heparin lock
• Saline or heparin solution
• Transparent dressing
• Paper tape

Equipment is shown in the images below.

Patient Preparation

Anesthesia

Both intradermal injection of a topical anesthetic agent just prior to intravenous insertion,^[4] as well as topical application of a local anesthetic cream^[5] about 30 minutes prior to intravenous insertion, have been shown to significantly reduce the pain associated with intravenous catheterization. They should be used unless in an emergent situation^[6] .

Positioning

Make sure there is adequate light and that the room is warm enough to encourage vasodilation. Adjust the height of the bed to make sure you are comfortable and to prevent unnecessary bending.

Make sure the patient is in a comfortable position. Most of the time, the pillow will have to be removed in order to help visualization of the engorged external jugular vein.

Place the patient in the Trendelenburg position, slightly tilting the head to the opposite side.

Application of light pressure above the clavicle (proximal to the vein entry point) will help to engorge the external jugular vein and assist in its catheterization.

The patient’s skin should be washed with soap and water if visibly dirty.

Because infants and young children are unlikely to cooperate, it is recommended that an assistant aids in stabilizing the head and body during the procedure.

Intravenous Catheter Insertion

Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes.

Place the patient in the Trendelenburg position, slightly tilting the head to the opposite side, as shown in the image below.

Note that the external jugular vein tends to collapse during the patient's inspiration, especially in patients who are volume depleted (see the image below).

In this case, the application of mild pressure over the vein just above the patient's clavicle might aid in engorging the vein, as shown in the image below.

Select a proximal site for intravenous catheter insertion, preferably as far away as possible from the clavicle in order to avoid accidental lung puncture.

If difficulty is encountered in finding an appropriate vein, one of the following techniques may be used: inspection of the opposite side, gravity (increased Trendelenburg), gentle tapping or stroking of the site, or applying heat (warm towel/pack).

Ultrasound guidance has been shown to facilitate peripheral venous placement in emergency department patients with difficult intravenous access. It should be used when appropriate veins are not readily visualized or palpable.^[7]

Apply an antiseptic solution such as 2% chlorhexidine solution or 70% alcohol with friction for 30-60 seconds, as shown in the image below.

Allow it to air dry for up to 1 minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin. Once cleaned, do not touch or repalpate the skin.

While the skin is allowed to dry, flush the saline or heparin lock with the appropriate solution. The syringe may be left attached to the tubing. If blood sampling via a syringe is planned, do not flush the saline/heparin lock, but an empty syringe may be connected to it.

Unless in an emergent situation and if the patient is interested in local anesthesia, infiltrate 0.5-1 mL of a local anesthetic using a 25- or 30-G needle to raise a wheal at the site of catheter insertion.

Stabilize the vein using your nondominant hand (thumb), applying traction to the skin distal to the chosen site of insertion. This will prevent the vein from rolling away from the needle. Stabilization should be maintained throughout the procedure. See the image below.

Hold the venous access device in your dominant hand with the bevel up. This will ensure smoother catheterization because the sharpest part of the needle will penetrate the skin first. Release the needle from the catheter and replace it, ensuring the catheter was not damaged or fragmented. This will ensure smooth advancement once the venous access device is inside the vein.

The angle of the needle entry into the skin will vary according to the device used and the depth of the vein. As the external jugular vein is usually very superficial, it is best accessed at a 10- to 25-degree angle, as shown in the image below.

Upon entry into the vein, the practitioner might feel a “giving way” sensation and blood should appear in the chamber of the venous access device (ie, flashback). See the image below.

The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should be advanced gently and smoothly an additional 2-3 mm into the vein.

If no blood is observed in the flashback chamber, the device should be withdrawn to just beneath the skin level and another attempt to recatheterize the vein should take place. Flashback may stop if the device punctured the posterior wall of the vein or in extremely hypotensive patients. If swelling develops, withdraw the device, release the tourniquet, and apply direct pressure for 5 minutes as a hematoma developed.

If venous catheterization is unsuccessful, the needle should never be reintroduced into the catheter because this could result in catheter fragmentation and embolism.

While maintaining skin traction with your nondominant hand after the hub of the venous access device was dropped to the skin, hold the needle grip portion of the venous access device in place between your dominant thumb and middle finger, while using your dominant index finger to slide the hub of the catheter over the needle and into the vein. See the image below.

While using your nondominant middle finger to apply pressure over the catheter to prevent blood spill and holding the hub in place using your nondominant index and thumb fingers, use your dominant hand to withdraw the needle and secure it in either its safety cover and/or a dedicated biohazard sharps container.

If blood sampling is needed, use a syringe or attach an adaptor or a syringe to the hub and obtain the required samples.

While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before, disconnect the blood sampling adaptor or syringe and securely attach the preflushed saline or heparin lock to the hub of the venous access device. See the image below.

Using the saline or heparin flush syringe, withdraw a small amount of blood to verify that the catheter is still inside the vein and immediately flush the tubing with the remaining solution. Slide the plastic tubing lock and continue to lock the tubing, if such a lock is available. See the image below.

Secure the venous access device to the skin using the transparent dressing and tape, as shown in the image below.

Finish securing the tubing to the skin using tape (see the image below).

Place a label indicating date, time, and other facility-required information over the transparent dressing.

The video below demonstrates an example of external jugular vein cannulation

Intravenous Catheter Removal

Stop the infusion solution and disconnect the tubing, leaving just the saline/heparin lock tubing connected to the venous access device.

Release the adhesive tape and transparent dressing from the skin.

Withdraw the catheter outside of the vein and apply direct pressure with gauze for at least 5 minutes.

Inspect the catheter for fragmentation and document in the patient’s chart the date, time, and reason for catheter removal and the integrity of the catheter as inspected.

Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the intravenous insertion site and instruct the patient to continue manual pressure for 10 more minutes to minimize hematoma formation.