Makindo Medical Notes

Related Subjects: Atropine |Acute Anaphylaxis |Basic Life Support |Advanced Life Support |Adrenaline/Epinephrine |Acute Hypotension |Cardiogenic shock |Distributive Shock |Hypovolaemic or Haemorrhagic Shock |Obstructive Shock |Septic Shock and Sepsis |Shock (General Assessment) |Toxic Shock Syndrome

Introduction: Internal Jugular Vein Cannulation

• Ensure formalized training is completed before attempting. Carefully assess the necessity; central lines have significant risks, and alternatives should be considered first, especially in emergency cases (e.g., severe GI bleed requiring surgical intervention).
• Document the justification for insertion, as central cannulation carries risks. Poor outcome predictors include emergency placement, obesity, coagulopathy, intubation, and hypotension. Contact a senior colleague if needed.

Indications

• IV access
• Infusion of irritant substances
• CVP monitoring
• Advanced haemodynamic monitoring (e.g., PICCO, PA catheter)
• Central venous oxygenation monitoring
• Cardiac pacing
• Extracorporeal therapies (ECMO, CRRT)
• Other: IVC filter placement, venous stenting, catheter-guided thrombolysis

Contraindications

• Lack of consent (special form required if patient lacks capacity)
• Inexperienced, unsupervised operator
• Obstructed vein (e.g., clot), distorted local anatomy, or severe coagulopathy
• Raised ICP, high FiO₂ respiratory failure (increased risk of PTX)
• Contaminated or traumatised site, recent clavicle fracture, or large neck mass
• Patient factors: uncooperative, cannot lie flat, agitated or coughing

Equipment and Ultrasound Guidance

• Ensure all equipment is available, including an ultrasound (USS) probe to differentiate the carotid artery from the jugular vein:
• Artery is circular, smaller, pulsatile, non-compressible, and shows pulsatile flow on Doppler.
• Vein is elliptical, larger, compressible, dilates with Valsalva.

Anatomy and Technique

• The internal jugular vein runs from the jugular foramen to the sternoclavicular joint and lies within the carotid sheath alongside the carotid artery and vagus nerve.
• Position patient supine with a 15° head-down tilt to distend neck veins and minimize air embolism risk. Turn head away from cannulation site, clean, and drape.
• Use either ultrasound guidance or the Seldinger landmark technique. If awake, apply local anaesthetic. Insert needle into the triangle formed by the sternocleidomastoid and clavicle, aiming towards the ipsilateral nipple.

Seldinger Technique and Catheter Positioning

• Upon blood aspiration, proceed with the Seldinger technique for catheter placement. Ensure the catheter tip rests in the superior vena cava above the pericardial reflection.
• Confirm positioning with a chest X-ray and check for pneumothorax.

Complications

• Pneumothorax/haemothorax: Use a high approach to reduce risk.
• Air embolism: Position head-down.
• Arrhythmias: Avoid advancing the guidewire too far; monitor cardiac rhythm.
• Carotid artery puncture/cannulation: Use ultrasound, palpate artery carefully, and position needle laterally.
• Chylothorax: Avoid left side and use a high approach.
• Infection: Follow protocols for catheter-related sepsis.

Additional Anatomy and Technique Images

References

• Also see the NEJM paper here