Approach Considerations
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 to the side opposite that of the vein being cannulated. Position for maximal venous distention.
For vessel occlusion, the second operator may place a forefinger parallel and immediately superior to the clavicle, where the EJV dives into cervical fascia. A stethoscope may be positioned to occlude the vein. [9] 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. Employ full sterile technique by donning gown, mask, cap, and sterile gloves. Apply a sterile drape.
The EJV begins at the level of the mandible and 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 with the nondominant hand (thumb), applying traction to the skin distal to the chosen site of insertion to prevent the vein from rolling away from the 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). Once flashback is obtained, 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 with the 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.
Seldinger Technique
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 previously 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. [10] Anteriorly manipulate the shoulder, [12] or attempt the "shrug technique." [14] 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 the wire can be anesthetized at this time, if this has not already been done.
A nick made adjacent to the 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 the skin and soft tissue to allow easy passage of the catheter.
Remove the dilator, and thread the catheter over the wire until the 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-Tip 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.
-
External jugular venous anatomy.
-
Anatomy of major vessels in neck.
-
Surface anatomy of neck. Large arrows point to external jugular vein.
-
Central venous access kit.
-
Central venous access via external jugular vein.
