Preprocedural Planning

In patients who need long-term venous access (eg, patients with a small-bowel transplant), imaging of the neck veins may be necessary before the procedure.

Doppler ultrasonography (US), magnetic resonance (MR) venography, or both can be used to establish venous patency and anatomy, thus improving planning and anticipation of potential problems with access.^[3]

Particularly in patients with multiple medical problems, a complete blood count, clotting profile, and relevant renal and liver function tests should be included in the preprocedural workup. Depending on the platelet count, platelet transfusion may be needed.

Equipment

Materials required for the procedure include the following:

Central venous catheter tray (line kit; see the images below)
Sterile gloves
Antiseptic solution with skin swab
Sterile drapes or towels
Sterile gown
Sterile saline flush, approximately 30 mL
Lidocaine 1%
Gauze
Dressing
Scalpel, No. 11
Vascular forceps (DeBakey)
Needle driver
Polypropylene suture 4-0
Steri-Strips
Mepore adhesive tape

Double-lumen tunneled line.

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Hemocatheter.

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Anesthesia

A local anesthetic agent is used before the catheter is tunneled. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Positioning

Trendelenburg positioning with the head turned to the side opposite the central venous line insertion is optimal (see the image below); the internal jugular vein (IJV) distends in this position, providing a maximal cross-sectional area for access.^[4]The ipsilateral arm should be extended minimally at the axilla. In adults, neutral positioning of the neck has been shown to be equally safe.^[5]

Correct positioning of patient, with head down and turned to opposite side with roll under neck.

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A 10-15º head-down (Trendelenburg) position distends the IJV and also elimimates the risk of air embolism. This dual advantage also facilitates successful venipuncture on the first attempt.^[6]

Technique

Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug. 40 (8):2479-85. [QxMD MEDLINE Link].
Breschan C, Platzer M, Jost R, Stettner H, Likar R. Size of internal jugular vs subclavian vein in small infants: an observational, anatomical evaluation with ultrasound. Br J Anaesth. 2010 Aug. 105 (2):179-84. [QxMD MEDLINE Link].
Rodrigues AF, van Mourik ID, Sharif K, Barron DJ, de Giovanni JV, Bennett J, et al. Management of end-stage central venous access in children referred for possible small bowel transplantation. J Pediatr Gastroenterol Nutr. 2006 Apr. 42 (4):427-33. [QxMD MEDLINE Link].
Suarez T, Baerwald JP, Kraus C. Central venous access: the effects of approach, position, and head rotation on internal jugular vein cross-sectional area. Anesth Analg. 2002 Dec. 95 (6):1519-24, table of contents. [QxMD MEDLINE Link].
Lamperti M, Subert M, Cortellazzi P, Vailati D, Borrelli P, Montomoli C, et al. Is a neutral head position safer than 45-degree neck rotation during ultrasound-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial. Anesth Analg. 2012 Apr. 114 (4):777-84. [QxMD MEDLINE Link].
Jamshidi R. Central venous catheters: Indications, techniques, and complications. Semin Pediatr Surg. 2019 Feb. 28 (1):26-32. [QxMD MEDLINE Link].
Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010 Jan 7. 362 (1):18-26. [QxMD MEDLINE Link].
Augoustides JG, Cheung AT. Pro: ultrasound should be the standard of care for central catheter insertion. J Cardiothorac Vasc Anesth. 2009 Oct. 23 (5):720-4. [QxMD MEDLINE Link].
Aurshina A, Hingorani A, Hingorani A, Marks N, Ascher E. Routine use of ultrasound to avert mechanical complications during placement of tunneled dialysis catheters for hemodialysis. J Vasc Surg Venous Lymphat Disord. 2019 Jul. 7 (4):543-546. [QxMD MEDLINE Link].
Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, et al. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019 Sep 6. 14:E1-E22. [QxMD MEDLINE Link].
Soundappan SSV, Lam L, Cass DT, Karpelowsky J. Open Versus Ultrasound Guided Tunneled Central Venous Access in children: A Randomized Controlled Study. J Surg Res. 2021 Apr. 260:284-292. [QxMD MEDLINE Link].
Arul GS, Livingstone H, Bromley P, Bennett J. Ultrasound-guided percutaneous insertion of 2.7 Fr tunnelled Broviac lines in neonates and small infants. Pediatr Surg Int. 2010 Aug. 26 (8):815-8. [QxMD MEDLINE Link].
Goldstein SD, Pryor H, Salazar JH, Dalesio N, Stewart FD, Abdullah F, et al. Ultrasound-Guided Percutaneous Central Venous Access in Low Birth Weight Infants: Feasibility in the Smallest of Patients. J Laparoendosc Adv Surg Tech A. 2015 Sep. 25 (9):767-9. [QxMD MEDLINE Link].
Galloway S, Bodenham A. Long-term central venous access. Br J Anaesth. 2004 May. 92 (5):722-34. [QxMD MEDLINE Link].
Bishop L, Dougherty L, Bodenham A, Mansi J, Crowe P, Kibbler C, et al. Guidelines on the insertion and management of central venous access devices in adults. Int J Lab Hematol. 2007 Aug. 29 (4):261-78. [QxMD MEDLINE Link].
Premuzic V, Perkov D, Smiljanic R, Brunetta Gavranic B, Jelakovic B. The Different Impacts on the Long-Term Survival of Tunneled Internal Jugular Hemodialysis Catheters Based on Tip Position and Laterality. Blood Purif. 2017. 43 (4):315-320. [QxMD MEDLINE Link].
Funaki B. Central venous access: a primer for the diagnostic radiologist. AJR Am J Roentgenol. 2002 Aug. 179 (2):309-18. [QxMD MEDLINE Link].
Silberzweig JE, Mitty HA. Central venous access: low internal jugular vein approach using imaging guidance. AJR Am J Roentgenol. 1998 Jun. 170 (6):1617-20. [QxMD MEDLINE Link].
Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med. 2010 Apr 22. 362 (16):e57. [QxMD MEDLINE Link].
Murphy PC, Arnold P. Ultrasound-assisted vascular access in children. Contin Educ Anaesth Crit Care Pain. 2011 Apr. 11 (2):44-9. [Full Text].
Tsai HC, Huang LM, Chang LY, Lee PI, Chen JM, Shao PL, et al. Central venous catheter-associated bloodstream infections in pediatric hematology-oncology patients and effectiveness of antimicrobial lock therapy. J Microbiol Immunol Infect. 2015 Dec. 48 (6):639-46. [QxMD MEDLINE Link].
Kara TT, Özdemir H, Erat T, Yahşi A, Aysev AD, Taçyıldız N, et al. Is antibiotic lock therapy effective for the implantable longterm catheter-related bloodstream infections in children?. Turk J Pediatr. 2019. 61 (6):895-904. [QxMD MEDLINE Link].
Premuzic V, Mihaljevic D, Pasini M, Mesar I, Luetic T, Antabak A. Durability of tunneled catheters in children is associated with catheter tip depth: A single-center report. Ther Apher Dial. 2021 Aug. 25 (4):490-496. [QxMD MEDLINE Link].
Li XY, Ye JB, Zhang LG, Jia YZ, Zhou RM, Pai P. Misplacement of Tunneled Hemodialysis Catheter into Azygos Vein: Left or Right Jugular Insertion Has Similar Susceptibility. Blood Purif. 2019. 48 (1):1-9. [QxMD MEDLINE Link].

Media Gallery

Insertion of central line into internal jugular vein (IJV). Procedure performed by James Lee, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).
Correct positioning of patient, with head down and turned to opposite side with roll under neck.
Correct exposure and draping of patient.
Seldinger technique for internal jugular vein (IJV) puncture.
Guide wire passage.
Dilator peeloff sheath threaded over guide wire.
Line tunneled in.
Line length being adjusted. Handle the line with vascular forceps only (no-touch technique).
Line insertion into peeloff sheath.
Radiograph showing final position of line in right atrium.
Line fixation with suture.
Mepore dressing.
Ultrasonogram of neck showing venous anatomy: (a) internal jugular vein; (b) common carotid artery. Image reproduced with permission from BMJ Publishing Group.
Ultrasound-guided internal jugular vein (IJV) puncture (arrow shows needle entering IJV). Image reproduced with permission from BMJ Publishing Group.
Double-lumen tunneled line.
Neck anatomy showing course of internal jugular vein (IJV). Image reproduced with permission from BMJ Publishing Group.
Hemocatheter.

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Author

Krishna Kumar Govindarajan, MBBS, MRCS, MS, MCh, DNB Additional Professor of Pediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, India

Krishna Kumar Govindarajan, MBBS, MRCS, MS, MCh, DNB is a member of the following medical societies: American College of Surgeons, Association of Colon and Rectal Surgeons of India, Association of Minimal Access Surgeons of India, Association of Surgeons of India, British Association of Paediatric Surgeons, Indian Association of Pediatric Surgeons, International College of Surgeons, National Academy of Medical Sciences (India)

Disclosure: Nothing to disclose.

Coauthor(s)

Peter N Bromley, MBBS Consulting Anesthetist, Birmingham Children's Hospital

Peter N Bromley, MBBS is a member of the following medical societies: Medical Protection Society, Royal College of Anaesthetists, Association of Anaesthetists of Great Britain and Ireland

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Integrated Vascular Surgery Residency and Fellowship, Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Additional Contributors

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Acknowledgements

The author would like to thank Alexander Davey, medical student on summer studentship, Department of Anatomy, Queen’s University, Belfast; and Christopher Boyd, consultant radiologist, Belfast City Hospital, for permission to reproduce images media files 13 (Ultrasound-guided internal jugular vein [IJV] puncture [arrow shows needle entering IJV]), 14 (Double-lumen tunneled line), and 15 (Neck anatomy showing the course of the internal jugular vein [IJV]).