The Internal Jugular vein enters the neck at the jugular foramen and leaves the neck behind the head of the clavicle. At the jugular foramen it lies posterior to the internal carotid artery ( entering the skull at foramen ovale) and as it courses down the neck it lies lateral and then anterior to the carotid artery. At the lower third of the neck it is assumed to be antero-lateral to the artery and this is the level where puncture is usually performed.
The carotid artery is not the only vessel we need to be aware of the subclavian artery lies above the clavicle and first rib and gives origin to a several other vessels (thyroid, vertebral, dorsal scapular suprascapular arteries). Any of these could be injured when performing IJ cannulation. The dome of the pleura also may ascend above the first rib and pneumothorax is a possibility especially in short necked individuals or where the needle is passed too deep.
This illustration is adapted from Benumof and shows 12 described landmark approaches. Note that the needle passes medial to lateral for those in the mid to upper neck and lateral to medial for the low landmark approach. Ultrasound allows you to explore the neck and look at the size, patency and direction of the vein, and its position relative to arteries and pleura.
Figure 1. Anatomy of veins and arteries in the neck. Note arterial vessels deep to the vein.
There are three basic approaches to internal jugular cannulation:
I. Short axis view with out of plane needle technique. Easy to learn but with high risk of posterior vein wall puncture unless the needle tip is accurately imaged and followed by probe translocation.
II. Long axis view with in-plane needle technique. More difficult to master requiring careful probe rotation and risk of cannulating the artery, thinking it to be the vein.
III. Oblique view of vein and artery with in-plane needle imaging. May be the best option.
Step by step
1. Select probe & settings.
a. Small footprint Linear (L25) or curvilinear (C11) for long axis imaging
b. Linear high frequency probe (L25 or 38 –Sonosite) for short axis
Exam setting on Vascular or Vein
Use highest resolution setting ( Res ) 8-14Mhz
Select Depth –usually start at 3-4cm depth. Jugular vein is usually only 1-2cm deep.
Start with Autogain. Adjust Gain to provide good image using lowest gain.
Check Index mark and tap probe to confirm probe orientation. Alternately using the probe on the skin in short axis will quickly determine orientation, namely by making sure that when you move the probe to the right the image moves to right.
2. Position US machine
By ipsilateral chest. Ideally try to have your eye, needle, probe and monitor in your line of sight.
3. Position your sterile workspace
Your trolley workspace should be on the side of your needle holding hand. This means to your right if right handed and to your left if left-handed. This assists in passing things from trolley to needle without turning round.
4. Prepare sterile field
Chlorhexidine 2% in Alcohol 70% solution. Clean from centre of neck down to include the sternal notch, then below the clavicle then up to mastoid . Use large area drape.
5. Place US probe in sterile sheath.
You can pre gel probe and drop into the sheath or place sterile gel in sheath first. Stretch sheath over probe ensuring a thin layer of gel covers probe. Get rid of any bubbles which will degrade the US image. Use elastic bands to secure sheath over probe.
6. Position patient
Head should be rotated no more than 20 degrees to the contralateral side. Place the US probe at cricoid level holding the probe between thumb and index/middle fingers. Use the ulnar border of your hand as a support on the clavicle so very little pressure is placed on the probe. Excess probe pressure will collapse the vein.
7. Pre – Scan
Identify thyroid, carotid artery and jugular vein. The relationship of IJ to carotid artery is variable. This variability may be true or may be due to over-rotation of the head, and /or viewing the jugular with the probe held on the lateral side of the neck, i.e. operator dependent.
(Note: Keep probe as close to vertical as possible. Head rotation and probe position determine the relative position of vein and artery. Due to the convex shape of the neck it is often difficult to get the probe flat. Rotating the probe to parallel with medial 1/3 of clavicle helps. Try it yourself on a patient. ( Fig below from )
Figure 2. Probe position will affect relative position of vessels
Figure 3. Arteries in the lower neck
THEREFORE adjust probe position such that the vein is lateral to the carotid as in the image above.
Scan cranially then caudally to assess the course of jugular vein. Find a position where the vein is most lateral to the vein. This is the desired level for puncture and is usually in the mid neck level.
Scan down to the clavicle and look for arterial vessels below your intended puncture point and deep to the vein (thryocervical trunk and subclavian artery). Angulate probe back towards the head to scan into the root of the neck and identify the IJ / Subclavian vein junction / IJ valve and proximal SVC as it passes behing the sternum. This technique allows you to follow guidewires or catheters into the SVC.
Colour Flow Doppler may help identify vascular structures. Should you find a suspicious structure near the vein use Colour Doppler to confirm whether there is flow and whether it is arterial or venous. (Note: Angulate probe back and forth to be certain as flow perpendicular to the probe will not provide a Doppler signal.)
Ensure the vein is acceptable. The vein should be a good size, free from haematoma, stricture or scarring from previous line insertions. If the vein is small, place patient head down and check valsalva response if the patient is awake. The vein should increase in size during a Valsalva. In ventilated patients, a breath hold can be used to increase the cross sectional area during puncture of the vein but beware of apex of lung. Pressure on the liver may also expand the IJ vein
Veins of less than 5mm are difficult to cannulate. If the vein is scared, small or does not expand with these above maneuvers then please review whether the other side is a better option. It is likely that scar is involving the vein (whether or not you can see it ) and CVL insertion will be more difficult and injury is more likely.
8. Position yourself
Where you stand may have a bearing on the direction your needle takes through the Ultrasound image. Ideally the needle track should pass into the vein and at no stage be in danger of entering the carotid or Subclavian arteries. Starting relatively high (probe at cricoid,)the puncture site should prevent your 6cm needle from reaching the pleura–of course this will not be true in short neck individuals. A lateral to medial track is more likely if you stand to the right of the patient when performing a RIJ puncture – see below.
9. Select Puncture site
To eliminate risk of arterial puncture (carotid, subclavian, vertebral arteries) and other structures e.g pleura. You should now know where these structures are.
10. Needle passage and Probe movement to track needle tip.
The supplied 18g needle or 20g needle with cannula. There is much to commend using the latter as you will need to remove the needle to insert the guidewire thus eliminating the problems associated with the Raulerson syringe. (no pulsatility or colour features of arterial blood). Cases of inadvertent needle movement after confirmation of puncture with US and pressure monitoring have been associated with arterial cannulation and posterior vein wall puncture so my preference is to use the cannula.
Short Axis cannulation
Centre the vein in the monitor screen.
Rotate the probe so it lies perpendicular to a line joining needle entry point and the ipsilateral nipple. (see image below)
Note the depth of the anterior vein wall (D) from the depth scale on right side of the monitor.
The needle entry point is at distance D cranial to the probe.
Direct the needle at 45 degress in a line through the target vein and directed laterally towards the ipsilateral nipple. (To reduce the risk of carotid artery puncture).
The needle tip will become visible as it depresses the anterior vein wall. Follow the needle tip by moving the probe caudally as it advances observing its progression into the vein. A common error is to continue passing the needle without moving the probe, expecting to see the needle appear inside the vein. In one study the posterior vein wall was penetrated in 64% of cannulations, as the needle tip was not imaged correctly.
Aspirate to confirm intravenous placement. IF using the supplied 20g cannula advance this into the vein. This is probably safer than the 19g needle in the Arrow kit.
Figure 4. Short axis out-of-plane approach. Note needle passing towards the ipsilateral nipple
Using this approach you can observe the needle as it passes into the vein. Needle visibility is best at insertion angles less than 45 degrees to skin. Smaller necks do not allow large probes so use the L25 or C11 probes.
Using similar principles to the description above, once you have performed your scan of the neck rotate the probe (takes practice) keeping the vein in view. Having done this angulate the probe medially to confirm the artery and then angulate back onto vein. Note difference in the wall characteristics of the two. Once you have confirmed the target vein do not look away. If you do your probe can move and you may then target the wrong vessel.
The attractiveness of this technique is totally negated if you fail to focus on the vessel you are cannulating. ALWAYS ensure you can recognize the vein (thin walled, a, c and v wave pulsation, and position with respect to the artery. Change of calibre with probe pressure does not confer certainty that the vessel is a vein since the artery may roll from under the probe giving the appearance of compression.
Rotating the probe from the short axis view by 45 degrees results in an oblique view of the internal jugular vein and carotid artery. This increases the cross sectional area of the vein and enables in-plane visualisation of the needle. The needle direction is less likely to result in penetration of the opposing wall. These methods therefore appear to combine the advantages of both in-plane needle imaging whilst also confirming the target vessel and artery. Both a medial oblique and lateral oblique method have been described.
10. Confirm you are in the vein
i. By Ultrasound confirm needle tip position
ii. Disconnect syringe and check flow is not arterial. Measure pressure with transduction probe if any uncertainty.
iii. The Raulerson syringe enables the wire to be passed into the vein through the syringe barrel, but does not allow you to see arterial pressure. The green transduction probe enables you to connect to your monitoring to check intravascular pressure.
11. Pass guide-wire
The guide-wire should pass easily into the vein. The J tip should point medially to reduce the risk of subclavian placement. A blue mark on the wire denotes how much wire to pass into the vein. Insert the wire no more than 15cm. Arrhythmia indicates you are in the heart and thus risk perforation of a heart chamber.
IT IS NOT THE DESIRED END-POINT. If there is any difficulty in passing the wire STOP and reimage to confirm the wire has not exited the vein.
12. Check guidewire position.
Scan the wire in its course in the neck ensuring the posterior vein wall is not punctured and the wire is entering the SVC at the root of the neck.
Published data suggests that if you do not follow the wire down the IJ vein with US for some distance( to make sure it has not gone out the back wall of the vein and into an artery), or if you do not transduce the catheter or needle( and get a good CVP waveform) that you will miss 20% of all arterial punctures.
Figure 5. Pressure monitoring options
13. Dilate the tract to the vein – You only need to pass 4-5cm of dilator.
14. Pass the catheter into the vein and remove guidewire
15. Suture in place, check aspiration of all lumens and apply occlusive dressing
Malposition 2% - Distance to RA 16.4cm mean. Lines placed at 13-14cm unlikely to be within the pericardial reflection.
Arterial puncture 0.5% May lead to CVA, AV fistula, Airway obstruction
Pneumothorax 0.1% Significant PTX is detectable by Ultrasound intra-operatively
Cardiac tamponade High mortality
Vessel perforation – increased risk with stiff large bore and multilumen catheters. Lines placed from left side must lie vertically in SVC or be withdrawn back to L brachiocephalic vein
Catheter related infection. Ensure all lines are inserted with full CLAB precautions
Air embolism Head down position during catheter insertion and removal to ensure venous pressue exceeds atmospheric pressure.
New ultrasound machines are coming to market which use magnetic tracking systems to overlay on the screen the position of the needle tip and the direction of the needle. This means we can direct a needle to a point on the screen even if it is not is view on the monitor. This technology is not infallible as extraneous magnetic signals may interfer with the positioning information, and the needle may still injure unseen structures. Nevertheless this technology will certainly reduce the learning curve associated with ultrasound needle guidance.
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