Central Venous Access Via External Jugular Vein Technique
- Author: Rick McPheeters, DO, FAAEM; Chief Editor: Vincent Lopez Rowe, MD more...
Central venous access via the external jugular vein (EJV) is depicted in the video below.
Puncture of External Jugular Vein
Place the patient in supine position, preferably in the Trendelenburg position. Tilt the head contralaterally from the vein being cannulated. Position for maximal venous distention.
The second operator may place a forefinger parallel and immediately superior to the clavicle, where the EJV dives into cervical fascia for vessel occlusion. A stethoscope may be positioned to occlude the vein. The patient should be instructed to perform a Valsalva maneuver.
After landmarks and the EJV are optimally visualized, decontaminate the area by painting it widely with povidone-iodine or chlorhexidine solution. Apply full sterile technique by donning gown, mask, cap, and sterile gloves. Apply sterile drape.
The EJV begins at the level of the mandible and it runs obliquely across and superficial to the sternocleidomastoid (SCM). Taking care not to obscure the vein, place a wheal of anesthetic at planned venipuncture and suture sites.
Stabilize the vein using your nondominant hand (thumb), applying traction to the skin distal to the chosen site of insertion to prevent the vein from rolling away from needle. Stabilization should be maintained throughout the procedure.
The EJV is usually superficial and is best accessed at a 10-25° angle. 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). After obtaining flash, the angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should be gently and smoothly advanced an additional 2-3 mm into the vein.
While maintaining skin traction with the nondominant hand after the hub of the venous access device is lowered to the skin level, slide the hub of the catheter over the needle and into the vein.
While using the 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 the dominant hand to withdraw the needle and secure it in its safety cover, a dedicated biohazard sharps container, or both.
Since its first description in 1953 by Seldinger as a method of vascular access for percutaneous arteriography, the Seldinger technique has become the most widely used technique for virtually all vascular access. The method has proved to be reliable and easily mastered, with an acceptable safety profile.
Appropriate patient and practitioner preparation and positioning are carried out as described. With the catheter in place, thread the flexible J-tip wire through the lumen of the catheter to lie inside the vein lumen. Gently advance the guide wire until approximately one fourth to one third of its length is within the lumen of the vein.
If resistance is encountered in advancing the guide wire, rotate it and then advance. Do not force it. If the wire will not advance, several measures can be tried. The wire can be withdrawn a few millimeters and rotated 90-180° before reinsertion. If the wire is not passing the junction of the EJV and the superior vena cava, an attempt to advance the triple-lumen catheter can be made. Anteriorly manipulate the shoulder. If none of these measures are successful, a catheter can be left in place and secured for use as peripheral access.
With the wire in place, remove the catheter by threading it backward over the wire. The skin and soft tissue adjacent to wire can be anesthetized at this time, if this has not already been done.
A nick made adjacent to wire with a No. 11 blade may permit easier passage of the dilator. Thread the dilator over the wire and use it to create a tract in skin and soft tissue to allow easy passage of catheter.
Remove the dilator and thread the catheter over the wire until wire emerges from the distal end of the catheter. Grasp the distal end of the wire and thread the catheter forward into the vein. Once the catheter is in place, remove the wire completely. Confirm intraluminal placement by aspirating venous blood from each port, and flush with sterile saline solution.
Secure with sutures or staples. Apply sterile dressing. Obtain a chest radiograph to confirm proper placement.
J-wire Through Needle Technique
With this technique, once the needle is in the lumen and confirmed by aspiration, the J-tip wire is advanced through the needle. The needle is then removed, and subsequent steps are essentially the same as those described above.
Byth PL. Evaluation of the technique of central venous catheterisation via the external jugular vein using the J-wire. Anaesth Intensive Care. 1985 May. 13(2):131-3. [Medline].
Uvelin A, Kolak R, Putnik D. External jugular cannulation is irreplaceable in many situations. Resuscitation. 2010 Jun. 81(6):773; author reply 774. [Medline].
Cho SK, Shin SW, Do YS, Park KB, Choo SW, Choo IW. Use of the right external jugular vein as the preferred access site when the right internal jugular vein is not usable. J Vasc Interv Radiol. 2006 May. 17(5):823-9. [Medline].
Blitt CD, Wright WA, Petty WC, Webster TA. Central venous catheterization via the external jugular vein. A technique employing the J-WIRE. JAMA. 1974 Aug 12. 229(7):817-8. [Medline].
Dailey RH. External jugular vein cannulation and its use for CVP monitoring. J Emerg Med. 1988 Mar-Apr. 6(2):133-5. [Medline].
Segura-Vasi AM, Suelto MD, Boudreaux AM. External jugular vein cannulation for central venous access. Anesth Analg. 1999 Mar. 88(3):692-3. [Medline].
Sparks CJ, McSkimming I, George L. Shoulder manipulation to facilitate central vein catheterization from the external jugular vein. Anaesth Intensive Care. 1991 Nov. 19(4):567-8. [Medline].
Mitre CI, Golea A, Acalovschi I, Mocan T, Caea AM, Ruta C, et al. Ultrasound-guided external jugular vein cannulation for central venous access by inexperienced trainees. Eur J Anaesthesiol. 2010 Mar. 27(3):300-3. [Medline].
Nishihara J, Takeuchi Y, Miyake M, Nagahata S. Distribution and morphology of valves in the human external jugular vein: indications for utilization in microvascular anastomosis. J Oral Maxillofac Surg. 1996 Jul. 54(7):879-82. [Medline].
Jaroch M, Steiger E. Rapid identification of the external jugular vein. Cleve Clin J Med. 1990 Jan-Feb. 57(1):95-6. [Medline].
Kato K, Taniguchi M, Iwasaki Y, Sasahara K, Nagase A, Onodera K, et al. Central venous access via external jugular vein with CT-venography using a multidetector helical 16-section CT. J Invest Surg. 2014 Jun. 27(3):176-82. [Medline].
Chakravarthy M, Krishnamoorthy J, Nallam S, Kolur N, Faris A, Reddy K, et al. External jugular venous route for central venous access: our experience in 563 surgical patients. J Anesth Clin Res. 2011. 2(6):1-5. [Full Text].