Percutaneous cannulation of the internal jugular vein uses anatomic landmarks to guide venipuncture and a Seldinger technique to thread a central venous catheter through the internal jugular vein and into the superior vena cava. Three approaches (central, anterior, and posterior) are used; the central approach is described here.
An internal jugular central venous catheter (CVC) or a peripherally inserted central catheter (PICC) is usually preferred to a subclavian CVC (which has a higher risk of bleeding and pneumothorax) or a femoral CVC (which has a higher risk of infection).
Ultrasonographic guidance for placement of internal jugular lines increases the likelihood of successful cannulation and reduces the risk of complications. When ultrasonographic guidance and trained personnel are available, this method of placement is preferred.
(See also Vascular Access, Central Venous Catheterization, and How To Do Internal Jugular Vein Cannulation, Ultrasound-Guided.)
Indications for Internal Jugular Vein Cannulation
- Secure or long-term venous access that is not available using other sites
- Inability to obtain peripheral venous access or intraosseous infusion
- IV infusion of fluids and drugs for patients in cardiac arrest
- IV infusion of concentrated or irritating fluids
- IV infusion of high flows or large fluid volumes beyond what is possible using peripheral venous catheters
- Monitoring of central venous pressure (CVP)
- Hemodialysis or plasmapheresis
- Transvenous cardiac pacing (see video How to Insert a Transvenous Pacemaker) or pulmonary arterial monitoring (Swan-Ganz catheter)*
- Placement of inferior vena cava filter
Contraindications to Internal Jugular Vein Cannulation
- Internal jugular vein thrombosis
- Local infection at the insertion site
- Antibiotic-impregnated catheter in allergic patient
- Coagulopathy, including therapeutic anticoagulation*
- Local anatomic distortion, traumatic or congenital, or gross obesity
- Superior vena cava syndrome
- Severe cardiorespiratory insufficiency or increased intracranial or intraocular pressure (patients will be compromised by Trendelenburg [head down] positioning)
- History of prior catheterization of the intended central vein
- Uncooperative patient (should be sedated if necessary)
- Left bundle branch block (a guidewire or catheter in the right ventricle can induce complete heart block)
* Therapeutic anticoagulation (eg, for pulmonary embolism) increases the risk of bleeding with internal jugular vein cannulation, but this must be balanced against the increased risk of thrombosis (eg, stroke) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient. A femoral line may be preferred.
Complications of Internal Jugular Vein Cannulation
(See also Complications of central venous catheterization.)
- Arterial puncture
- Damage to the vein
- Air embolism
- Catheter misplacement*
- Arrhythmias or atrial perforation, typically caused by guidewire or catheter
- Nerve damage
* Rare complications due to catheter misplacement include arterial catheterization, hydrothorax, hydromediastinum, and damage to the tricuspid valve.
Guidewire or catheter embolism also rarely occurs.
To reduce the risk of venous thrombosis and catheter sepsis, CVCs should be removed as soon as they are no longer needed.
Equipment for Internal Jugular Vein Cannulation
Sterile procedure, barrier protection
- Antiseptic solution (eg, chlorhexidine-alcohol, chlorhexidine, povidone iodine, alcohol)
- Large sterile drapes, towels
- Sterile head caps, masks, gowns, gloves
- Face shields
Seldinger (catheter-over-guidewire) technique
- Cardiac monitor
- Local anesthetic (eg, 1% lidocaine without epinephrine, about 5 mL)
- Small anesthetic needle (eg, 25 to 27 gauge, about 1 inch [3 cm] long)
- Large anesthetic/finder* needle (22 gauge, about 1.5 inches [4 cm] long)
- Introducer needle (eg, thin-walled, 18 or 16 gauge, with internally beveled hub, about 2.5 inches [6 cm] long)
- 3- and 5-mL syringes (use slip-tip syringes for the finder and introducer needles)
- Guidewire, J-tipped
- Scalpel (#11 blade)
- Central venous catheter (adult: 8 French or larger, minimum length for internal jugular catheter is 15 cm for right side, 20 cm for left side)
- Sterile gauze (eg, 4 × 4 inch [10 × 10 cm] squares)
- Sterile saline for flushing catheter port or ports
- Nonabsorbable nylon or silk suture (eg, 3-0 or 4-0)
- Chlorhexidine patch, transparent occlusive dressing
* A finder needle is a thinner needle used for locating the vein before inserting the introducer needle. It is generally recommended for nonultrasound–guided internal jugular vein cannulation.
Having an assistant or two is helpful.
- Cannulation attempts sometimes fail. Do not exceed 2 or 3 attempts (which increases the risk of complications), and use new equipment with each attempt (ie, do not re-use needles, catheters, or other equipment because they may have become blocked with tissue or blood).
- During cardiopulmonary arrest, or even low blood pressure and hypoxia, arterial blood may be dark and not pulsatile and may be mistaken for venous blood.
- If the internal jugular artery is errantly cannulated by either the tissue dilator or the CVC, leave the dilator or catheter in place and obtain surgical consultation for possible surgical removal.
Relevant Anatomy for Internal Jugular Vein Cannulation
- The anterior cervical triangle is bordered by the clavicle inferiorly and by the sternal and clavicular heads of the sternocleidomastoid muscle medially and laterally.
- The carotid artery is usually palpated near the lateral side of the sternal head of the sternocleidomastoid, and the internal jugular vein usually lies superficial and lateral (often minimally lateral) to the carotid artery. However, variant orientation of these vessels occurs regularly (in 9 to 19% of patients). The orientation of the carotid artery and internal jugular vein to each other also may change if the position of the patient’s head changes.
- Most commonly, the central approach to the internal jugular vein is used, which may decrease the chance of pleural or carotid arterial puncture. The introducer needle is inserted at about a 30 to 40° angle to the skin at the apex (superior angle) of the anterior cervical triangle, aiming toward the ipsilateral nipple.
- The right internal jugular vein is usually preferred over the left for cannulation because it has a larger diameter and affords a straighter path to the superior vena cava.
Positioning for Internal Jugular Vein Cannulation
- Raise the bed to a comfortable height for you (ie, so you may stand straight while doing the procedure).
- Place the patient supine and in Trendelenburg position (bed tilted head down 15 to 20°) to distend the internal jugular vein and prevent air embolism.
- Turn the patient's head only slightly (or not at all) to the contralateral side to expose the internal jugular vein but not cause overlap with the carotid artery.
- Stand at the head of the bed.
Step-by-Step Description of Procedure
- Do a preliminary inspection (nonsterile) to identify the anterior cervical triangle, palpate the carotid arterial pulse, and (optionally) mark the lateral border of the carotid.
- Attach the cardiac monitor to the patient and turn it on.
Prepare the equipment
- Place sterile equipment on sterilely covered equipment trays.
- Dress in sterile garb and use barrier protection.
- Draw the local anesthetic into a syringe.
- Attach a finder needle to a 5-mL syringe with 1 to 2 mL of sterile saline in it.
- Attach the introducer needle to a 5-mL syringe with 1 to 2 mL of sterile saline in it. Align the bevel of the needle with the volume markings on the syringe.
- Pre-flush all lines of the CVC with 3 to 5 mL of sterile saline and then close the ports with caps or syringes.
When flushing a central line, use a 10-mL syringe (or one of equal or greater diameter) and do not push too hard to avoid rupturing the line.
Prepare the sterile field
- Swab a broad area of skin with antiseptic solution, encompassing the side of the neck, clavicle, and anterior chest to below the ipsilateral nipple. Creating this broad sterile area permits immediately switching to subclavian vein cannulation should the jugular cannulation attempt fail.
- Allow the antiseptic solution to dry for at least 1 minute.
- Place sterile towels around the site, keeping the ipsilateral nipple exposed.
- Place large sterile drapes (eg, a full-body drape) to establish a large sterile field.
Establish the needle insertion path (internal jugular vein, central approach)
- Gently palpate the carotid arterial pulse using 3 fingers to appreciate the course of the artery. Palpate gently so as not to compress the adjacent internal jugular vein (a compressed venous lumen is difficult to cannulate).
- The needle insertion path: Insert procedural needles (local anesthetic, finder, and introducer needles) into the apical area (superior angle) of the anterior cervical triangle, just lateral to the carotid pulse, at a 30 to 40° angle into the skin, aiming toward the ipsilateral nipple.
Maintain carotid artery palpation during needle insertions and keep the needle lateral to the artery to avoid impaling the artery.
Anesthetize the cannulation site
- Place a wheal of anesthetic at the needle entry site and then inject anesthetic into the skin and soft tissues along the anticipated needle insertion path. Maintain gentle negative pressure on the syringe plunger as you advance to identify intravascular placement and prevent an intravascular injection. If blood returns into the syringe, stop advancing, hold the syringe in place, and now regard this needle as a finder needle. Proceed to Assess the blood return below.
Insert the finder needle
- Insert the finder needle along the needle insertion path.
- Maintain gentle negative pressure on the syringe plunger as you advance the needle.
- Stop advancing when a flash of blood appears in the barrel of the syringe (you may feel the needle pop through the wall as it enters the lumen). Hold the syringe motionless in this spot. Even a slight movement may displace the needle tip from the vein.
If no flash of blood appears in the barrel after about 3 to 5 cm of insertion, withdraw the needle slowly. If the needle had initially passed completely through the vein, a flash of blood may now appear as you withdraw the needle tip back into the lumen. If a flash still does not appear, withdraw the needle almost to the skin surface, change direction (usually slightly medially), and try again to advance the needle into the vein. Do not change the direction of the needle while it is fully inserted.
Assess the blood return
- Continue to hold the syringe motionless.
- Securely grasp the needle hub and also hold it motionless.
- Remove the syringe from the needle hub and briefly let blood flow out to confirm that the blood is venous (ie, dark red and flowing but not pulsatile). Then immediately cover the hub with your thumb to stop the blood flow and prevent air embolism.
However, if the blood is bright red and pulsatile (arterial), terminate the procedure. Remove the needle and use 4 × 4 gauze squares for 10 minutes to hold external pressure on the area and to help prevent bleeding and hematoma.
Insert the introducer needle, using the finder needle as a guide
- Hold the introducer syringe with the needle bevel facing up.
- Use one of two insertion methods: Either remove the finder needle and immediately insert the introducer needle along the same path, or keep the finder needle in place and insert the introducer needle underneath and roughly parallel to it (at a slightly shallower angle to the skin).
- Stop advancing the introducer needle when a flash of blood appears in the barrel of the syringe. Hold the syringe motionless in this spot.
- If the finder needle has not been removed, remove it now.
- Assess blood flow from the introducer needle as described in Assess the blood return above.
Insert the guidewire
- Carefully rotate the introducer syringe such that the bevel of the needle now faces medially (ie, toward the heart and away from the subclavian vein).
- Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing medially (ie, in the same direction as the needle bevel).
- Advance the guidewire through the needle and into the vein. Do not force the wire; it should slide smoothly. Advance the wire 10 to 15 cm for a right-sided internal jugular insertion, 15 to 20 cm for a left-sided insertion, or until ectopic heartbeats occur (withdraw from this point until ectopy stops).
If you feel any resistance as you advance the guidewire, stop advancing it. Try to gently withdraw the wire slightly, rotate it slightly, and then readvance it, or try to gently withdraw the wire entirely, reestablish the needle tip within the vein (confirmed by venous blood return), and then reinsert the wire.
However, if you feel any resistance as you withdraw the wire, terminate the procedure and withdraw the needle and guidewire together as a unit (to prevent the needle tip from shearing through the guidewire within the patient). Then use 4 × 4 gauze squares for 10 minutes to hold external pressure on the area and to help prevent bleeding and hematoma.
Once the guidewire has been inserted, continue to hold it securely in place with one hand and maintain control of it throughout the remainder of the procedure.
Remove the introducer needle (after successful guidewire insertion)
- First, securely hold the guidewire distal to the needle and pull the needle from the skin.
- Then, securely hold the guidewire at the skin surface and slide the needle down the remaining length of the guidewire to remove the needle.
Widen the insertion tract
- Extend the skin insertion site: Using the scalpel, make a small stab incision (about 4 mm) into the skin insertion site, avoiding contact with the guidewire, to enlarge the site and allow it to accommodate the larger diameters of the tissue dilator and the catheter.
- Advance the tissue dilator over the guidewire: First, grasp the guidewire at the skin and slide the dilator down the length of the wire to the skin. Then grasp the wire just distal to the dilator, hold the dilator near the skin surface, and use a corkscrew motion as needed to stepwise insert the entire length of the dilator. Maintain your grasp on the wire at all times during the insertion.
- Remove the dilator: First, securely hold the guidewire distal to the dilator and pull the dilator from the skin. When the guidewire is visible at the skin surface, completely remove the dilator by sliding it down the remaining length of the guidewire.
- Maintain your grasp on the guidewire at the skin surface.
Place the catheter
- Advance the catheter over the guidewire to the skin surface: Hold the guidewire fixed at the skin surface, thread the catheter tip over the distal end of the guidewire, and slide the catheter down to the skin surface. The distal end of the guidewire should now be protruding from the port hub.
- If the distal end of the guidewire is not protruding from the port hub, inch the guidewire outward from the skin surface while holding the catheter tip close to the skin surface until the guidewire protrudes.
- Continue to advance the catheter into the vein: Grasp and control the guidewire where it protrudes from the hub. Hold the catheter near its tip and insert the tip through the skin. Then, in increments of several centimeters and using a corkscrew motion as necessary, stepwise advance the internal jugular catheter. If ectopic heartbeats occur, slowly withdraw the catheter until ectopy stops.
- Maintain your grasp on both the guidewire and the catheter.
- Remove the guidewire: Withdraw the guidewire while holding the catheter securely in place at the skin surface.
- Flush each catheter port with saline: First, draw any air from the line and confirm venous blood flow into the hub. Then, using a 10-mL syringe (or one of equal or greater diameter) and nonexcessive force, push 20 mL of saline into the line to clear it.
Dress the site
- If the patient is awake or minimally sedated, use 1% lidocaine to numb the skin at the planned suture locations.
- Place a chlorhexidine-impregnated disk on the skin at the catheter insertion point.
- Suture the skin to the mounting clip on the catheter.
- To prevent pulling on the insertion site, suture the catheter at a second site so that a curved or looped segment of catheter lies between the two sites.
- Apply a sterile occlusive dressing. Transparent membrane dressings are commonly used.
Aftercare for Internal Jugular Vein Cannulation
- Do a chest x-ray to confirm that the tip of a jugular (or subclavian) CVC lies in the superior vena cava near its junction with the right atrium (the catheter can be advanced or retracted if not in the appropriate position) and to confirm that pneumothorax has not occurred.
Warnings and Common Errors
- The tip of a CVC must never lie in the right atrium because the atrium is thin-walled and easily perforated.
- Cardiac ectopy may be induced by a guidewire or catheter in the right atrium or ventricle.
- Never lose grasp of the guidewire.
- During cardiopulmonary arrest, or even low blood pressure and hypoxia, arterial blood may be dark and not pulsatile and may be mistaken for venous blood.
- To help prevent air embolism, CVCs should be inserted (and removed) with the vascular cannulation site positioned dependant to the heart.
Tips and Tricks for Internal Jugular Vein Cannulation
- A thin (finder, scout) needle often is used to first find the internal jugular vein (before inserting the larger introducer needle) so that less bleeding and hematoma result if the needle aberrantly impales the carotid artery. (Ultrasound guidance eliminates the need for a finder needle.)
- The orientation of the carotid artery and internal jugular vein to each other may change if the position of the patient’s head changes; thus, to avoid impaling the artery, you should gently palpate the carotid pulse during the needle insertions included in this procedure.
- The size of the internal jugular vein varies with respiration (maximum diameter in patients not intubated occurs just prior to inspiration [prior to expiration in intubated patients]) and is increased by the Trendelenburg position, the Valsalva maneuver, humming, and external abdominal compression. To increase your chance of successful internal jugular cannulation, advance the introducer at moments of increased jugular diameter.
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