Internal Jugular Vein Cannulation

Cannulation of the internal jugular vein may be the method of choice to measure the central venous pressure because of the lower incidence of complications. If hematomas form, they are visible and compressible, and the procedure provides a direct route to the right atrium when a balloon-tippped flow-directed catheter is inserted. The right internal jugular vein is usually chosen, since the right lung is lower than the left and this route does not endanger the thoracic duct. In penetrating wounds of the chest, the central venous catheter should be introduced on the same side as the penetrating injury. An alternative site may be indicated in suspected cervical spine injury.

Procedure

(Photo 1)

2) Place the patient in a supine, head down 15º Trendelemburg position. Turn the head 45º to the opposite side of the procedure (photo 2)

(Photo 2)

3) Prepare and drape the patient in the usual sterile manner ( fig.2 ). Identify the anatomical landmarks : the internal jugular vein lies lateral to the carotid artery; the sternocleidomastoid muscle overlies the internal jugular vein in the lower half of the neck ( photo 3 ).

(Photo 3)

4) Introduce 0.5 % to 1 % lidocaine ( Xylocaine ) at the apex of the triangle formed by the clavicle and clavicular and sternal heads of the sternocleidomastoid muscle. Make sure not to inject lidocaine directly into the intravascular space, as this could precipitate cardiac arrhytmias. In photo 4, aspiration done before injecting the lodocaine clearly showed that the needle was in the intravascular space, so that it has to be pulled out ( this illustrates a fundamental principle - always aspirate first before injecting anesthetic extravascular solutions ).

(Photo 4)

5) Attach a 5 to 10 ml syringe filled with sterile saline to the angiocath or cannulation needle being introduced. Insert the needle in the apex of the triangle formed by the clavicle and the clavicular and sternal heads of the sternocleidomastoid. The needle is advanced in a sagittal plane 30º posterior and caudad toward the ipsilateral nipple at a 50º angle with the frontal plane; advance and aspirate gently until there is free return of venous blood (photo 5 ). Remove the syringe carefully. Have the patient take and hold a deep breath, and, at the same time, cover the top of the needle with a gloved finger.

(Photo 5)

6) Then introduce the cannula into the needle ( photo 6 ). Insert the cannula through the needle into the internal jugular vein.

(Photo 6)

7) If a plastic angiocath is used, keep the tip of the catheter in the internal jugular vein and withdraw the needle.

8) Withdraw needle, aspirate to confirm blood flow, and flush with saline; attach to intravenous line.

9) Suture ( photo 7 ), apply sterile dressing with povidine-iodine ointment, and secure with tape. Obtain chest radiograph to rule out complications and to establish position of the catheter in the superior vena cava ( at he level of the seventh and eighth thoracic vertebrae ).

(Photo 7)

Note - As an alternative, in the posterior technique of internal jugular vein cannulation, aim the needle caudally and ventrally toward the suprasternal notch underneath the sternocleidomastoid at an angle that is 45º to the sagittal and horizontal planes and 15º forward in the frontal plane; aspiration is performed until there is free return of venous blood.

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