The internal jugular vein (IJV) is the route most commonly chosen for insertion of a pulmonary artery catheter. Various insertion techniques including anterior, medial, posterior and low approaches have been described. The right side is most frequently chosen because it is most convenient for right-handed practitioners and, once cannulated, it offers the most direct route to the superior vena cava and thence to the right atrium, ventricle and pulmonary artery (Figure 1, Figure 2). It has also recently been demonstrated that the left IJV is significantly smaller than the right in about one third of the population ¹. Internal jugular cannulation is relatively contraindicated in patients who have undergone previous carotid surgery, have documented carotid disease, or superior vena caval obstruction.

At the level of the thyroid cartilage the internal jugular vein lies immediately deep to the body of the sternomastoid muscle somewhat posterior and lateral to the carotid artery. As it passes towards the thorax, it emerges from behind body of the muscle and comes to lie at the apex of the triangle between the sternal and clavicular insertions of the muscle (Figure 3).

The anterior approach to cannulation is performed as follows (Figure 4):

The neck is slightly extended by placing a rolled up sheet (or a litre bag of IV fluid) transversely under the shoulders and the head is turned slightly (~ 20 degrees) to the left. Extreme rotation of the head and / or extension of the neck should be avoided as these manoeuvres tend to collapse the internal jugular vein ^2,3. Unless the central venous pressure is already high, (or there is some other contraindication to placing the patient head down), the patient is placed in the Trendelenberg position.

After appropriate skin preparation and draping, the position of the carotid artery is identified by gentle palpation with the index and middle fingers of the left hand. If the carotid pulsation cannot be felt, the technique should probably not be used unless ultrasonic guidance is available. However, it should also be understood that carotid palpation itself may significantly reduce the diameter of the IJV ^2,3.

The skin and subcutaneous tissue at a point midway between the hyoid and thyroid cartilages, just lateral to the carotid pulse, is infiltrated with local anaesthetic. A 23g needle is introduced at the infiltration site an angle of 30 degrees to the skin in the sagittal plane. The needle is inserted at the medial border of the sternomastoid muscle, and passed towards the ipsilateral nipple. In most patients the internal jugular vein should be encountered within 2 to 4 cm. Constant, gentle negative pressure should be applied to the syringe of the exploring needle so that a flash of blood will be observed on entry into the vein. Moreso than the subclavian vein, the jugular vein is easily compressed, as a result, a blood flashback is quite frequently not encountered until the needle is being withdrawn (Figure 5).

After the internal jugular vein has been located, the syringe should be removed from the 23g needle, the needle left 'in situ', and the larger 18g, short-bevel needle which is used for introducing the Seldinger wire placed immediately adjacent to the locating needle. Again, the technique of continuous aspiration should be employed during location of the vein as it is passed along the track of the 23g needle.

The practise of priming the aspirating syringe with saline (as recommended in some resuscitation protocols ¹² ) is unwarranted and makes the differentiation of venous and arterial blood more difficult ¹³.

Once this cannulation has been accomplished and the intravenous position of the needle has been confirmed (Figure 6), the Seldinger ⁴ wire is passed through the 18g needle into the vein and threaded to a distance of not more than 18 cms.

Andrews et al ⁵, have recently measured the distance from skin puncture site to atrio-caval junction in 100 patients undergoing central venous cannulation by various routes. These distances were:

The pulmonary artery catheter introducer is now passed into the vein over the wire (Figure 7) (Video V2) and the catheter inserted (See catheter flotation).

The anterior approach is a 'higher' approach than the 'medial' and 'low' approaches to the vein and as such, carries a lower risk of pneumothorax. The 'low' approach to the IJV is particularly suitable for use in neonates and infants.

Doppler guided approaches to the IJV have been described which are reported to reduce both the number of needle passes required to locate the vein and the incidence of inadvertent carotid puncture ^{6, 7 , 8} . Such techniques may be particularly appropriate for use in children where the incidence of carotid puncture is particularly high ^{9, 10} (Figure 8).

However, at least two systematic reviews ^{14, 15} have now concluded that ultrasonic guidance during central venous cannulation also significantly increases the likelihood of successful cannulation and significantly reduces the incidence of complications in adults. Data from the meta-analysis by Randolph et al are shown in Figure 9 and in their analysis the impact of the use of ultrasonic guidance was clearly demonstrated in all the studies which they examined. Thus is seems likely that the use of ultrasound will become the 'Standard of Care' expected by the community in the near future.

A technique of Doppler guided internal jugular cannulation using a transoesophageal probe has also been recently described ¹¹.

In summary, internal jugular venepuncture is not without risk and readers are advised to at least perform an ultrasonic assessment of the target vessel before venepuncture is attempted. The complications of the procedure are outlined in the section entitled ('Complications of Internal Jugular Venepuncture').

1. Lobato EB, Sulek CA Moody RL et al Cross-sectional area of the right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999 Apr;13(2):136-138

2. Armstrong PJ, Sutherland R, Scott DH The effect of position and different manoeuvres on internal jugular vein diameter size. Acta Anaesthesiol Scand, 38:229-31, 1994 Apr

3. Bazaral M, Harlan S Ultrasonographic anatomy of the internal jugular vein relevant to percutaneous cannulation. Crit Care Med, 9:307-10, 1981 Apr

4. Seldinger SI Catheter replacement of the needle in percutaneous arteriography. Acta Radiol 39:368, 1953

5. Andrews RT, Bova DA, Venbrux AC How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Crit Care Med 2000 Jan;28(1):138-42

6. Gratz I; Afshar M; Kidwell P; Weiman DS; Shariff HM Doppler-guided cannulation of the internal jugular vein: a prospective, randomized trial. J Clin Monit, 10(3):185-8 1994 May

7. Gilbert TB; Seneff MG; Becker RB Facilitation of internal jugular venous cannulation using an audio-guided Doppler ultrasound vascular access device: results from a prospective, dual-center, randomized, crossover clinical study. Crit Care Med, 23:60-5, 1995

8. Caridi JG, Hawkins IF Jr, Wiechmann BN, Pevarski DJ, Tonkin JC Sonographic guidance when using the right internal jugular vein for central vein access. Am J Roentgenol 1998 Nov;171(5):1259-63

9. Hayashi Y, Uchida O, Takaki O, et al: Internal jugular vein catheterization in infants undergoing cardiovascular surgery: An analysis of the factors influencing successful catheterization. Anesth Analg 74:688-693, 1992

10. Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM, Ruttimann UE Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999 Jul;91(1):71-7

11. Sha K, Simokawa M Kawaguchi M et al Use of transesophageal Echocardiography Probe Imaging to Guide Internal Jugular Vein Cannulation. Anesth Analg 1998; 87 1032-3

12. Cummins RO. Advanced Cardiac Life Support. 6-9 American Heart Association. 1997

13. Ho AM, Chung DC, Tay BA, Yu LM, Yeo P Diluted venous blood appears arterial: implications for central venous cannulation. Anesth Analg 2000 Dec;91(6):1356-7

14. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med. 1996 Dec;24(12):2053-8.

15. Keenan SP.Use of ultrasound to place central lines. J Crit Care. 2002 Jun;17(2):126-37.

Last edited on: 5/04/2003