Central Venous Access via Posterior Approach to the Internal Jugular Vein 

In caring for patients who are critically ill, access to the central venous circulation is important. Central venous access allows the placement of various types of intravenous lines to facilitate the infusion of fluids, blood products, and drugs and to obtain blood for laboratory analysis. It is also an essential procedure in patients in whom placement of a line in a peripheral vein is impossible. A central line may be the only means of venous access in such cases. Subclavian and internal jugular lines can allow the measurement of central venous pressure (CVP), an important parameter to gauge if a patient has been given an adequate amount of fluids.

Three central veins are typically used for venous access: the internal jugular vein (IJ), subclavian vein, and femoral vein. The capacity to place a line in the internal jugular vein is an important skill, as it is the preferred vein for placement of a transvenous pacemaker because it is a straight line down the vein to the right side of the heart.^[1] Given the fact that it can be compressed, the internal jugular vein can be used for central venous access in patients who have impaired blood clotting. However, in such patients, the femoral vein is most often used.

The 3 traditional approaches to the internal jugular vein are the anterior, posterior, and central approaches. The central and posterior approaches are most commonly used and are less apt to result in a puncture of the carotid artery. This article describes the posterior approach to cannulation of the internal jugular vein.

Indications for the posterior approach to the internal jugular vein are the same as for any of the indications for a central line. They include the following:

• Fluid resuscitation needing a large-bore intravenous line for medical or trauma resuscitation
• Need of a multilumen intravenous line
• Lack of peripheral access
• Measurement of central venous pressure (CVP)
• Access via the superior vena cava to the right ventricle for passage of a venous pacemaker
• Access to the pulmonary artery via the right ventricle for passage of a Swan-Ganz catheter
• Access to a large vein for temporary renal dialysis
• Access to a large vein for administration of hypertonic solutions such as total parenteral nutrition

• No absolute contraindications exist to placement of a central line in the internal jugular vein using the posterior approach.
• Relative contraindications include the following:

  • Relative contraindications revolve around mechanical problems of access to the neck. Skin infection, abscess, trauma, scarring, or mass along the side of the neck would make cannulation of the internal jugular vein difficult and hazardous. In addition, obesity may obscure landmarks and increase the risk of complications.
  • A coagulopathy, regardless of etiology, is a relative contraindication even though, unlike the subclavian vein, the internal jugular vein is compressible. The ability to compress the internal jugular vein allows it to be used for central line placement in a patient with a clotting disorder.
  • While not essential, the ability to turn the head away from the side where the line is being placed is helpful with the posterior approach to the internal jugular vein. In a patient with limited neck mobility, such as trauma patients who do not have the cervical spine cleared, the posterior approach can be quite difficult.
  • Finally, cooperation of the patient is essential because the lung and carotid artery are nearby and the risk of injury is excessive if the patient moves during the procedure.

• The most common means of anesthesia for placement of an intravenous line in the internal jugular vein is use of a local anesthetic (eg, lidocaine). Generous administration of a local anesthetic in the area just posterior to the mid portion of the sternocleidomastoid muscle is typically sufficient for the patient's comfort before tunneling the catheter.

  • Care must be taken not to inject the anesthetic into either the internal jugular vein or the carotid artery.
  • Additional local anesthetic is used on the skin for the sutures that secure the catheter to the skin.
• In certain patients, the pain of the procedure is such that additional sedation, pain control, or both might be prudent. Titrated doses of midazolam, fentanyl, or both are useful because these are agents with relatively short durations of action and minimal cardiovascular effects.
• For more information, see Local Anesthetic Agents, Infiltrative Administration and Procedural Sedation.

A preassembled kit for central line cannulation is used. The kit contains the following equipment:

• Local anesthetic (eg, lidocaine 1%) with needles and syringes
• Thin-walled 14- to 18-gauge introducer needle
• J-wire configured guidewire and semirigid dilator
• Central line catheter
• Antiseptic solution and applicator (eg, povidone-iodine [Betadine], chlorhexidine [Hibiclens])
• Sterile drapes, gloves, and gown, and nonsterile mask and cap
• Gauze pads, No. 11 blade scalpel
• Suture (commonly, 3-0 silk on a straight cutting needle)
• Antibiotic ointment for the dressing
• Plastic occlusive dressing such as Tegaderm

• A key part of placing a central line in the internal jugular vein is proper positioning of the patient.

  • Putting the patient in the Trendelenburg position dilates the internal jugular vein and makes cannulation easier.
  • In addition, this position makes the external jugular vein more prominent. The point at which the vein crosses the sternocleidomastoid muscle is a key landmark in the posterior approach.
• Some patients cannot tolerate having their head lower than their feet. In such patients, laying them down as flat as possible is important to the success of the procedure.
• The patient’s head should be turned away from the side of the internal jugular vein being accessed to provide access to the side of the neck.

  • Having an assistant hold the patient’s head in that position is often necessary.
  • Turning the patient’s head to the side also makes the sternocleidomastoid muscle more prominent and makes the landmarks easier to identify.

Internal jugular vein cannulation via the posterior approach

The most common method to place a cannula in the internal jugular vein is the Seldinger wire technique. Various catheters can be placed in the internal jugular vein, including single lumen, multiple lumen, large-bore sheaths, and dialysis catheters such as the Quinton catheter.

The posterior approach does not lend itself as easily to ultrasonographic guidance as does the anterior approach. However, the use of ultrasonography can allow visualization of the internal jugular vein and carotid artery and is often helpful regardless of the approach to the internal jugular vein.^{[2, 3]}

When placing an internal jugular or subclavian central line, the Trendelenburg position distends the veins in the patient's neck, making them easier to cannulate. Either side of the neck can be used, but the right internal jugular vein is most often used.

• To begin the procedure, inspect the neck to identify landmarks, including the posterior edge of the sternocleidomastoid muscle, shown below, and the external jugular vein, and palpate the carotid artery to ascertain its position. Also look for any skin infections or neck masses. See the image below. Diagram of external jugular line going up over the edge of the sternocleidomastoid muscle, the main landmark for the posterior approach.
• Place the patient in the Trendelenburg position, 10-15^o, and turn the patient’s face to the contralateral side.
• Drape with sterile sheets or towels as with any sterile procedure. The use of large sterile sheets to cover the patient and the use of a cover over the hair, a mask, and a sterile gown and gloves for the practitioner have been shown to decrease the rate of line infection.^{[4, 5]}
• Clean the skin of the patient’s neck down to the clavicle and upper chest with the antiseptic solution, and apply the drape to allow visualization of the middle of the neck.
• 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.
• Anesthetize the skin and subcutaneous tissue at this point, aspirating so lidocaine is not injected directly into a vessel.

  • Typically, a 25-gauge needle is used to administer the local anesthetic. This same needle can be used to localize the internal jugular vein to determine how deep and at what angle to the skin the vein might be.
  • Even a long 25-gauge needle may not have sufficient length to reach the internal jugular vein. However, hunting for the vein with a smaller gauge needle tends to be less traumatic than using the introducer needle.
• Place the introducer needle at the area of anesthetized skin aiming down toward the sternal notch.
• Advance the needle while aspirating; the easy flow of venous blood assures that the needle is in the internal jugular vein.

  • 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.^{[6, 7]}
• Once venous blood is free flowing in the syringe, carefully remove the syringe so that the needle remains in the internal jugular vein.
• Introduce the guidewire down the needle, with the J-wire bend going in first.

  • The wire should advance with little resistance.
  • If any significant resistance is noted, remove the guidewire and ascertain if the needle is in the vein by checking for free-flowing blood with syringe aspiration.
• Once the guidewire is in place, carefully remove the needle, leaving the guidewire in the vein. Hold onto the wire at all times so it is not lost down the vein.
• Make a skin incision is made around the entry point. The incision should be relatively generous because, if the incision is too small, the skin will tent around the catheter and will eventually necrose, which can quickly lead to a catheter site infection.
• Carefully advance the semirigid dilator along the guidewire, and create a passage for the catheter in the soft tissue. Rotating the dilator back and forth allows for more gentle insertion and lower chance of tearing the vein.
• Thread the catheter over the guidewire to the level of the skin. Back the wire out so it just sticks out of the intravenous hub at the end of the catheter. Then hold the guidewire firmly while advancing the catheter over the wire into the internal jugular vein.
• Once the catheter is advanced to an appropriate depth, remove the guidewire.
• Reattach a syringe to the catheter, and verify that blood can be easily aspirated; this confirms that the catheter is indeed in the vein.
• Flush all lumens of the line with saline.
• Place sutures to hold the catheter in place. Most often, a wing device is placed over the catheter to allow it to be secured to the skin.
• Place antiseptic ointment over the entry point, and cover the site with an occlusive dressing.^[8]
• The final part of any internal jugular or subclavian vein central line procedure is obtaining a chest radiograph to confirm placement and to verify that no injury to the lung (ie, pneumothorax) has occurred.^[9]

  • Hold off on infusion of fluids until radiographic confirmation of appropriate placement is completed.
  • The tip of the line should be above the right atrium and below the level of the clavicle. If the tip is in the heart, it can whip back and forth as the heart contracts, and penetration of the heart wall can occur.

• Adequate local anesthesia in the area of cannulation is important to the success of this procedure. This is important for the patient's comfort and so the patient can hold still during the procedure.

  • A long 25-gauge needle can be used for the administration of the local anesthetic and to ascertain the position of the internal jugular vein. This can give the practitioner an idea of the depth and direction of the internal jugular vein without the trauma of searching for the vein with the larger introducer needle.
  • Take care to avoid injecting the local anesthetic into a vessel when hunting for the vein.
  • Placing the patient in the Trendelenburg position helps to dilate the internal jugular vein. The bigger the vein, the easier it is to cannulate. Once the guidewire is in place, the patient can be taken out of the Trendelenburg position, as it is often uncomfortable.
• Thorough cleansing of skin and complete draping of the patient and practitioner have been shown to decrease infections of a central line. These lines often must remain in place for a long period of time; therefore, performing the procedure in as sterile a manner as possible is important.
• As in any procedure to access a central vein, the angle of the introducer needle may need to be altered if the vein is not cannulated the first time. The large-bore introducer needle must be withdrawn out to the skin before adjusting the angle of insertion.
• Moving a beveled needle back and forth in an area with several large vessels can lacerate those vessels.
• The introducer needle should be advanced slowly to avoid going entirely through the vein. Ultrasonographic guidance can aid in the establishment of CV access.^[10] (For more information, see eMedicine article Bedside Ultrasonography, Central Line Placement.) However, a 2009 study reported that 64% of the residents participating penetrated the posterior wall of the internal jugular vein, even under ultrasonographic guidance.^[11]

• One of the more common, and feared, complications of internal jugular central line placement is injury to the lung resulting in pneumothorax or tension pneumothorax. This is particularly true if the cupula of the lung is above the clavicle, as it can be inadvertently punctured, causing a pneumothorax.

  • Any shortness of breath following or during the procedure needs to be immediately investigated with a chest radiograph.
  • Air embolism can occur if the catheter is allowed to be open to the air; to prevent air aspiration, the practitioner should keep his or her finger over the hub when the guidewire is removed or a syringe is attached or removed.
• A hematoma at the site of insertion can occur, particularly if the carotid artery is punctured.
• Loss or breakage of the guidewire has been described, and control of the guidewire must be maintained at all times. If any resistance is encountered during withdrawal of the wire through the needle, remove the needle and the wire as a single unit to avoid breakage of the wire against the bevel of the needle.
• Laceration of a vessel or nerve has been described with internal jugular vein central line placement.