Placement of jugular venous catheters
- Mark P Androes, MD
Mark P Androes, MD
- Assistant Professor of Surgery
- University of South Carolina School of Medicine
- Alan C Heffner, MD
Alan C Heffner, MD
- Director of Critical Care
- Director of ECMO Services
- Pulmonary and Critical Care Consultants
- Department of Internal Medicine
- Department of Emergency Medicine
- Carolinas Medical Center
- Associate Clinical Professor
- University of North Carolina School of Medicine
- Section Editors
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [1-3]. The jugular veins are one of the most popular sites for central venous access due to accessibility and overall low complication rates, and are the preferred site for temporary hemodialysis.
Jugular venous cannulation and catheter placement will be reviewed here. General considerations for venous access and issues related to other access sites are discussed elsewhere. (See "Overview of central venous access" and "Complications of central venous catheters and their prevention" and "Placement of femoral venous catheters" and "Placement of subclavian venous catheters".)
The jugular veins (internal, external) are reliable access sites for temporary and permanent (table 1) (eg, tunneled central catheters and subcutaneous ports) venous cannulation to support hemodynamic monitoring, fluid and medication administration, and parenteral nutrition. Jugular venous access can also be used for the placement of inferior vena cava filters and other venous devices. (See "Placement of vena cava filters and their complications".)
Internal jugular venous access (especially right-sided) is associated with a low rate of catheter malposition , and is commonly used in situations that require reliable tip positioning for immediate use, such as drug administration or transvenous pacing. Similarly, the direct route from the right internal jugular vein to the superior vena cava facilitates hemodialysis access and pulmonary artery catheter placement. (See "Central catheters for acute and chronic hemodialysis access" and "Pulmonary artery catheters: Insertion technique in adults".)
Contraindications — Relative contraindications to jugular venous catheterization, in general, include coagulopathy, prior access, the presence of another device at the site, and altered local anatomy. (See "Overview of central venous access", section on 'Contraindications'.)
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123.
- Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986; 146:259.
- Baskin JL, Pui CH, Reiss U, et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet 2009; 374:159.
- McGee WT, Moriarty KP. Accurate placement of central venous catheters using a 16-cm catheter. J Intensive Care Med 1996; 11:19.
- Khatri VP, Wagner-Sevy S, Espinosa MH, Fisher JB. The internal jugular vein maintains its regional anatomy and patency after carotid endarterectomy: a prospective study. Ann Surg 2001; 233:282.
- Digby S. Fatal respiratory obstruction following insertion of a central venous line. Anaesthesia 1994; 49:1013.
- Wu PJ, Chau SW, Lu IC, et al. Delayed airway obstruction after internal jugular venous catheterization in a patient with anticoagulant therapy. Case Rep Anesthesiol 2011; 2011:359867.
- Lobato EB, Florete OG Jr, Paige GB, Morey TE. Cross-sectional area and intravascular pressure of the right internal jugular vein during anesthesia: effects of Trendelenburg position, positive intrathoracic pressure, and hepatic compression. J Clin Anesth 1998; 10:1.
- Botha R, van Schoor AN, Boon JM, et al. Anatomical considerations of the anterior approach for central venous catheter placement. Clin Anat 2006; 19:101.
- Turba UC, Uflacker R, Hannegan C, Selby JB. Anatomic relationship of the internal jugular vein and the common carotid artery applied to percutaneous transjugular procedures. Cardiovasc Intervent Radiol 2005; 28:303.
- Denys BG, Uretsky BF. Anatomical variations of internal jugular vein location: impact on central venous access. Crit Care Med 1991; 19:1516.
- The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. Clin Anat 1999; 12:43.
- Stickle BR, McFarlane H. Prediction of a small internal jugular vein by external jugular vein diameter. Anaesthesia 1997; 52:220.
- Cho SK, Shin SW, Do YS, et al. Use of the right external jugular vein as the preferred access site when the right internal jugular vein is not usable. J Vasc Interv Radiol 2006; 17:823.
- Blitt CD, Wright WA, Petty WC, Webster TA. Central venous catheterization via the external jugular vein. A technique employing the J-WIRE. JAMA 1974; 229:817.
- Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth 2000; 12:142.
- Muralidhar K. Left internal versus right internal jugular vein access to central venous circulation using the Seldinger technique. J Cardiothorac Vasc Anesth 1995; 9:115.
- Oner B, Karam AR, Surapaneni P, Phillips DA. Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience. J Intensive Care Med 2012; 27:370.
- SELDINGER SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953; 39:368.
- Mallory DL, Shawker T, Evans RG, et al. Effects of clinical maneuvers on sonographically determined internal jugular vein size during venous cannulation. Crit Care Med 1990; 18:1269.
- Beddy P, Geoghegan T, Ramesh N, et al. Valsalva and gravitational variability of the internal jugular vein and common femoral vein: ultrasound assessment. Eur J Radiol 2006; 58:307.
- Parry G. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Can J Anaesth 2004; 51:379.
- Armstrong PJ, Sutherland R, Scott DH. The effect of position and different manoeuvres on internal jugular vein diameter size. Acta Anaesthesiol Scand 1994; 38:229.
- Ely EW, Hite RD, Baker AM, et al. Venous air embolism from central venous catheterization: a need for increased physician awareness. Crit Care Med 1999; 27:2113.
- Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007; 106:164.
- Troianos CA, Kuwik RJ, Pasqual JR, et al. Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography. Anesthesiology 1996; 85:43.
- Wang R, Snoey ER, Clements RC, et al. Effect of head rotation on vascular anatomy of the neck: an ultrasound study. J Emerg Med 2006; 31:283.
- Sulek CA, Gravenstein N, Blackshear RH, Weiss L. Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996; 82:125.
- Lieberman JA, Williams KA, Rosenberg AL. Optimal head rotation for internal jugular vein cannulation when relying on external landmarks. Anesth Analg 2004; 99:982.
- Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg 2008; 48:918.
- Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002; 28:1.
- Boyd R, Saxe A, Phillips E. Effect of patient position upon success in placing central venous catheters. Am J Surg 1996; 172:380.
- Lim T, Ryu HG, Jung CW, et al. Effect of the bevel direction of puncture needle on success rate and complications during internal jugular vein catheterization. Crit Care Med 2012; 40:491.
- Mangar D, Turnage WS, Mohamed SA. Is the internal jugular vein cannulated during insertion or withdrawal of the needle during central venous cannulation? Anesth Analg 1993; 76:1375.
- Albuquerque Júnior FC, Vasconcelos PR. Technical aspects of central venous catheterization. Curr Opin Clin Nutr Metab Care 1998; 1:297.
- Tripathi M, Pandey M. Anchoring of the internal jugular vein with a pilot needle to facilitate its puncture with a wide bore needle: a randomised, prospective, clinical study. Anaesthesia 2006; 61:15.
- Defalque RJ. Percutaneous catheterization of the internal jugular vein. Anesth Analg 1974; 53:116.
- Ho AM, Ricci CJ, Ng CS, et al. The medial-transverse approach for internal jugular vein cannulation: an example of lateral thinking. J Emerg Med 2012; 42:174.
- Nguyen BV, Prat G, Vincent JL, et al. Determination of the learning curve for ultrasound-guided jugular central venous catheter placement. Intensive Care Med 2014; 40:66.
- Ezaru CS, Mangione MP, Oravitz TM, et al. Eliminating arterial injury during central venous catheterization using manometry. Anesth Analg 2009; 109:130.
- 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; 28:138.
- Kim WY, Lee CW, Sohn CH, et al. Optimal insertion depth of central venous catheters--is a formula required? A prospective cohort study. Injury 2012; 43:38.
- Stuart RK, Shikora SA, Akerman P, et al. Incidence of arrhythmia with central venous catheter insertion and exchange. JPEN J Parenter Enteral Nutr 1990; 14:152.
- Propp DA, Cline D, Hennenfent BR. Catheter embolism. J Emerg Med 1988; 6:17.
- Robinson JF, Robinson WA, Cohn A, et al. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995; 155:1225.
- Czepizak CA, O'Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest 1995; 107:1662.
- Peres PW. Positioning central venous catheters--a prospective survey. Anaesth Intensive Care 1990; 18:536.
- Booth SA, Norton B, Mulvey DA. Central venous catheterization and fatal cardiac tamponade. Br J Anaesth 2001; 87:298.
- Collier PE, Blocker SH, Graff DM, Doyle P. Cardiac tamponade from central venous catheters. Am J Surg 1998; 176:212.
- Tocino IM, Watanabe A. Impending catheter perforation of superior vena cava: radiographic recognition. AJR Am J Roentgenol 1986; 146:487.
- Dailey RH. Late vascular perforations by CVP catheter tips. J Emerg Med 1988; 6:137.
- Duntley P, Siever J, Korwes ML, et al. Vascular erosion by central venous catheters. Clinical features and outcome. Chest 1992; 101:1633.
- Mukau L, Talamini MA, Sitzmann JV. Risk factors for central venous catheter-related vascular erosions. JPEN J Parenter Enteral Nutr 1991; 15:513.
- Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85:188.
- Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol 2003; 14:527.
- Stonelake PA, Bodenham AR. The carina as a radiological landmark for central venous catheter tip position. Br J Anaesth 2006; 96:335.
- Kowalski CM, Kaufman JA, Rivitz SM, et al. Migration of central venous catheters: implications for initial catheter tip positioning. J Vasc Interv Radiol 1997; 8:443.
- Chalkiadis GA, Goucke CR. Depth of central venous catheter insertion in adults: an audit and assessment of a technique to improve tip position. Anaesth Intensive Care 1998; 26:61.
- Gillman LM, Blaivas M, Lord J, et al. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Scand J Trauma Resusc Emerg Med 2010; 18:39.
- Gu X, Paulsen W, Tisnado J, He Y, Li Z, Nixon JV: Malposition of a central venous catheter in the right main pulmonary artery detected by transesophageal echocardiography. J Am Soc Echocardiogr 2009; 22:1420
- Sawchuk C, Fayad A. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Can J Anaesth 2001; 48:688.
- Lucey B, Varghese JC, Haslam P, Lee MJ. Routine chest radiographs after central line insertion: mandatory postprocedural evaluation or unnecessary waste of resources? Cardiovasc Intervent Radiol 1999; 22:381.
- Gebhard RE, Szmuk P, Pivalizza EG, et al. The accuracy of electrocardiogram-controlled central line placement. Anesth Analg 2007; 104:65.
- Abood GJ, Davis KA, Esposito TJ, et al. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients. J Trauma 2007; 63:50.
- Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triple-lumen catheter in the right internal jugular vein, using the anterior approach? Chest 2005; 127:220.
- Wirsing M, Schummer C, Neumann R, et al. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Chest 2008; 134:527.
- Francis KR, Picard DL, Fajardo MA, Pizzi WF. Avoiding complications and decreasing costs of central venous catheter placement utilizing electrocardiographic guidance. Surg Gynecol Obstet 1992; 175:208.
- Ammirati C, Maizel J, Slama M. Is chest X-ray still necessary after central venous catheter insertion? Crit Care Med 2010; 38:715.
- Gladwin MT, Slonim A, Landucci DL, et al. Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med 1999; 27:1819.
- Vezzani A, Brusasco C, Palermo S, et al. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: an alternative to chest radiography. Crit Care Med 2010; 38:533.
- Aslamy Z, Dewald CL, Heffner JE. MRI of central venous anatomy: implications for central venous catheter insertion. Chest 1998; 114:820.
- Schuster M, Nave H, Piepenbrock S, et al. The carina as a landmark in central venous catheter placement. Br J Anaesth 2000; 85:192.
- Albrecht K, Nave H, Breitmeier D, et al. Applied anatomy of the superior vena cava-the carina as a landmark to guide central venous catheter placement. Br J Anaesth 2004; 92:75.
- JUGULAR VEIN ANATOMY
- JUGULAR SITE SELECTION
- Static ultrasound guidance for vein localization
- GENERAL PREPARATION
- Skin preparation
- INTERNAL JUGULAR VEIN CANNULATION
- Needle access
- - General techniques
- Access with introducer needle
- Using a seeker needle
- Using an angiocatheter
- - Approaches to the internal jugular vein
- - Dynamic ultrasound-guided internal jugular access
- Venous confirmation
- CATHETER PLACEMENT
- Guidewire handling
- Tract dilation
- Positioning the catheter
- Catheter flushing and fixation
- CONFIRMATION OF JUGULAR CATHETER POSITION
- CATHETER MANAGEMENT
- SUMMARY AND RECOMMENDATIONS