Equipment

The equipment needed for central venous cannulation via the external jugular vein (EJV) is widely available as a prepackaged kit (see the image below).

Central venous access kit.

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The basic materials include the following:

Povidone-iodine or chlorhexidine solutions to swab and prepare the venipuncture site
Sterile drapes and towels
Sterile gloves
Gown, mask, and cap
Lidocaine 1%
27-gauge needle with 2- to 5-mL syringe for injecting local anesthetic
20- to 22-gauge needle with 10-mL syringe to access the EJV
16-gauge Angiocath (BD, Franklin Lakes, NJ) to cannulate the EJV
Flexible guide wire with a maximum diameter of 0.35 mm and with a J tip 3 mm or less in radius
No. 11 scalpel
Dilator device for the skin and soft tissue overlying the vein
Single-lumen or multilumen catheter
Silk or nylon sutures
Needle holder
Suture scissors
Dressings (plastic tape, antibiotic patch, gauze pads)

Anesthesia

Because this is initially peripheral venous access, local anesthesia by infiltration is generally unnecessary and is not recommended, because it can obscure the surface anatomy and thereby render the venipuncture more difficult. If time permits, a topical anesthetic can be applied before the skin is punctured. However, local anesthetic should be used before the incision is made and the dilator employed.

Sedation or analgesia may be necessary for certain patients, such as those with procedural anxiety or differing levels of pain tolerance. Of note, 10-20 mg of preservative-free lidocaine can be slowly infused to diminish any discomfort associated with passing the guide wire and catheter.

Positioning

The patient should be positioned so as to optimize venous distention and thus allow easier cannulation.^[9] He or she should lie supine, with 10-30° of Trendelenburg and with the head tilted contralaterally from the vein being cannulated. The operator should stand at the head of the bed.

Monitoring & Follow-up

A cardiac monitor should be used to observe for cardiac dysrhythmia that could arise if the guide wire or catheter enters the right atrium.

Technique

Wang P, Wang Y, Qiao Y, Zhou S, Liang X, Liu Z. A Retrospective Study of Preferable Alternative Route to Right Internal Jugular Vein for Placing Tunneled Dialysis Catheters: Right External Jugular Vein versus Left Internal Jugular Vein. PLoS One. 2016 Jan 11. 11 (1):e0146411. [QxMD MEDLINE Link]. [Full Text].
Liou FK, Kim PY, Yap SP, Khan A, Taylor S, Pillai R, et al. Alternate Cervical Venous Access Sites for Implantable Port Catheters: Experience at a Single Quaternary Care Institution. Cardiovasc Intervent Radiol. 2023 Jan. 46 (1):43-48. [QxMD MEDLINE Link]. [Full Text].
Zeng X, Zeng X, Zeng Q, Wu Y, Zhang S, Zhu X, et al. The external jugular vein is a feasible and safe alternative access for retrieval of inferior vena cava filter. J Vasc Access. 2022 Feb 15. 11297298211064467. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Uvelin A, Kolak R, Putnik D. External jugular cannulation is irreplaceable in many situations. Resuscitation. 2010 Jun. 81 (6):773; author reply 774. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Paraskevas G, Natsis K, Ioannidis O, Kitsoulis P, Anastasopoulos N, Spyridakis I. Multiple variations of the superficial jugular veins: case report and clinical relevance. Acta Medica (Hradec Kralove). 2014. 57 (1):34-7. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Dailey RH. External jugular vein cannulation and its use for CVP monitoring. J Emerg Med. 1988 Mar-Apr. 6 (2):133-5. [QxMD MEDLINE Link].
Segura-Vasi AM, Suelto MD, Boudreaux AM. External jugular vein cannulation for central venous access. Anesth Analg. 1999 Mar. 88 (3):692-3. [QxMD MEDLINE Link].
Cruzeiro PC, Camargos PA, Tatsuo ES, Piçarro C, Campos BA, Paixão RM, et al. Percutaneous central venous catheterization through the external jugular vein in children: is inserting the guide wire into the superior vena cava essential for successful catheterization?. J Pediatr Surg. 2012 Sep. 47 (9):1742-7. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Magoon R, Malhotra SK, Saini V, Sharma R, Kaur J. Randomised controlled trial of central venous catheterisation through external jugular vein: A comparison of success with or without body manoeuvres. Indian J Anaesth. 2017 Dec. 61 (12):985-989. [QxMD MEDLINE Link]. [Full Text].
Kagawa T, Ueyama S, Kobayashi T, Okabayashi H, Kuroda S, Fujiwara T. A novel "shrug technique" for totally implantable venous access devices via the external jugular vein: A consecutive series of 254 patients. J Surg Oncol. 2017 Mar. 115 (3):291-295. [QxMD MEDLINE Link].
Kosaka M, Oyama Y, Uchino T, Ogihara Y, Koga H, Shingu C, et al. Ultrasound-guided central venous tip confirmation via right external jugular vein using a right supraclavicular fossa view. J Vasc Access. 2019 Jan. 20 (1):19-23. [QxMD MEDLINE Link].
Luo S, Xue Y, Tang S, Hou S, Pei M. Application of ultrasound-guided external jugular vein puncture in intensive care unit (ICU) patients with severe sepsis: a randomised trial. Ann Palliat Med. 2021 Jan. 10 (1):530-537. [QxMD MEDLINE Link]. [Full Text].
Karaaslan D, Altinisik U, Peker TT, Nayir E, Ozmen S. External jugular vein catheterization using 'intra-atrial electrocardiogram'. Yonsei Med J. 2009 Apr 30. 50 (2):222-6. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Jaroch M, Steiger E. Rapid identification of the external jugular vein. Cleve Clin J Med. 1990 Jan-Feb. 57 (1):95-6. [QxMD MEDLINE Link].
Ahn S, Lee JH, Park C, Hong YW, Chun DH. Malposition of central venous catheter in the jugular venous arch via external jugular vein -a case report. Korean J Anesthesiol. 2015 Apr. 68 (2):175-8. [QxMD MEDLINE Link]. [Full Text].
Mohanty CR, Ahmad SR, Jain M, Sriramka B. Air embolism through open hub of external jugular vein intravenous cannula. Turk J Emerg Med. 2019 Jul. 19 (3):117-119. [QxMD MEDLINE Link]. [Full Text].
Tecklenburg FW, Cochran JB, Webb SA, Habib DM, Losek JD. Central venous access via external jugular vein in children. Pediatr Emerg Care. 2010 Aug. 26 (8):554-7. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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].
Ju JW, Hwang Y, Lee HJ. Retrospective analysis of the feasibility and safety of external jugular vein cannulation in surgical patients. Anesth Pain Med (Seoul). 2023 Jan. 18 (1):84-91. [QxMD MEDLINE Link]. [Full Text].