Central Venous Access via Posterior Approach to Internal Jugular Vein Technique

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

Compared with the anterior approach, the posterior approach does not lend itself as easily to the use of ultrasonography (US) for guidance. However, US can allow visualization of the IJV and carotid artery and is often helpful regardless of the particular approach taken to the IJV. ^{[3, 4, 5, 6, 7, 8, 9, 10]}

In placing a central line in the IJV or the subclavian vein, the Trendelenburg position distends the veins in the patient's neck and thereby makes them easier to cannulate. Either side of the neck can be used, but the right IJV is most often used.

To begin the procedure, inspect the neck to identify landmarks, including the posterior edge of the sternocleidomastoid (see the image below) and the external jugular vein (EJV), and palpate the carotid artery to ascertain its position. Also, look for any skin infections or neck masses.

Place the patient in the Trendelenburg position, 10-15º, 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. ^{[11, 12]}

Preparation of puncture site

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 at the level just superior to where the EJV 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 that 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 IJV to determine how deep and at what angle to the skin the vein might lie. Even a long 25-gauge needle may not have sufficient length to reach the IJV. However, hunting for the vein with a smaller-gauge needle tends to be less traumatic than using the introducer needle would be.

Placement of 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 IJV. 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 laterally, toward the sternoclavicular joint as opposed to the notch, often allows the vein to be entered. ^{[13, 14]}

Once venous blood is free-flowing in the syringe, carefully remove the syringe so that the needle remains in the IJV.

Introduce the guide wire 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 guide wire and ascertain if the needle is in the vein by checking for free-flowing blood with syringe aspiration.

Once the guide wire is in place, carefully remove the needle, leaving the guide wire in the vein. Hold on to the wire at all times so that it is not lost down the vein.

Advancement of catheter

Make a skin incision is made around the entry point. This incision should be relatively generous because if it 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 guide wire, and create a passage for the catheter in the soft tissue. Rotating the dilator back and forth allows more gentle insertion and lowers the risk of tearing the vein.

Thread the catheter over the guide wire to the level of the skin. Back the wire out so that it just sticks out of the intravenous (IV) hub at the end of the catheter. Then hold the guide wire firmly while advancing the catheter over the wire into the IJV. Once the catheter is advanced to an appropriate depth, remove the guide wire.

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 lumina 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. ^[15]

Confirmation of catheter position

Finally, obtain a chest radiograph to confirm correct placement and to verify that no injury to the lung (eg, pneumothorax) has occurred. ^[16]  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.

Pearls

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 helps the patient 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 IJV. This can give the practitioner an idea of the depth and direction of the IJV without the trauma associated with 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 dilate the IJV. The bigger the vein, the easier it is to cannulate. Once the guide wire is in place, the patient can be taken out of the Trendelenburg position, which is often uncomfortable.

Thorough cleansing of the skin and complete draping of the patient and the practitioner have been shown to decrease infections of a central line. Because these lines often must remain in place for a long time, it is vital to perform the procedure in as sterile a manner as possible.

As in any procedure performed to gain access to a central vein, the angle of the introducer needle may have be altered if the vein is not cannulated the first time. The large-bore introducer needle must be withdrawn out to the skin before the angle of insertion is adjusted.

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 make sure that it does not go entirely through the vein. US guidance can aid in the establishment of central venous access. ^{[17, 18]}  (See Ultrasonography Assisted Central Line Placement.) However, one study reported that 64% of the residents participating penetrated the posterior wall of the IJV, even under US guidance. ^[19]  Various technical refinements have been proposed to reduce the incidence of this adverse consequence. ^{[20, 3, 21, 22, 9, 10]}

One of the more common, and feared, complications of central line placement in the IJV 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 warrants immediate investigation with chest radiography. 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 guide wire 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 guide wire has been described. Control of the wire 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 IJV central line placement.

Srinivasan et al studied the incidence of posterior-wall puncture, the number of attempts for successful cannulation, the incidence of inadvertent arterial punctures, and the occurrence of complications in 170 adults who required IJV central line placement, guided either by anatomic landmarks or by real-time US. ^[23] ​ The real-time US guidance significantly reduced but did not completely eliminate penetrations of the posterior venous wall, lowered the incidence of inadvertent arterial punctures, and reduced the number of attempts required for successful cannulation.