Background
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 (IV) 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 for gauging whether a patient has been given an adequate amount of fluids.
Three central veins are typically used for venous access:
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Internal jugular vein (IJV)
The capacity to place a line in the IJV is an important skill; this 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 that it can be compressed, the IJV 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.
There are three traditional approaches to the IJV:
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Posterior
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Central
The central and posterior approaches are most commonly used and are less likely to result in puncture of the carotid artery. This article describes the posterior approach to cannulation of the IJV.
Indications
Indications for the posterior approach to the IJV are the same as for any of the indications for a central line. They include the following:
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Fluid resuscitation requiring a large-bore IV line for medical or trauma resuscitation
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Need for a multilumen IV line
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Lack of peripheral access
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Measurement of CVP
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Access via the superior vena cava (SVC) to the right ventricle for passage of a venous pacemaker
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Access to the pulmonary artery via the right ventricle for passage of a Swan-Ganz catheter
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Access to a large vein for temporary renal dialysis
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Access to a large vein for administration of hypertonic solutions (eg, for total parenteral nutrition [TPN])
Contraindications
No absolute contraindications exist for placement of a central line in the IJV via the posterior approach.
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 IJV 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 the IJV, unlike the subclavian vein, is compressible. The compressibility of the IJV allows it to be used for central line placement in a patient with a clotting disorder.
The ability to turn the head away from the side where the line is being placed, though not essential, is helpful with the posterior approach to the IJV. In patients with limited neck mobility (eg, trauma patients who do not have the cervical spine cleared), the posterior approach can be quite difficult. [2]
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.
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Diagram of external jugular vein going up over edge of sternocleidomastoid (main landmark for posterior approach).
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Point of insertion for introducer needle is along posterior edge of sternocleidomastoid at level just superior to where external jugular vein crosses muscle. This is typically one third of distance between mastoid and clavicle.
