Internal Jugular Vein Approaches
Points of possible catheterization:
- ANTERIOR
- CENTRAL
- POSTERIOR
- SUPRACLAVICULAR
Traditional and safe approach is CENTRAL (pay attention to the direction of the needle):
The patient is placed in the
Trendelenburg position with his or
her head turned to the contralateral
side. The physician
stands above the patient on the
contralateral side of the bed, and a
large skin wheal is raised with local
anesthetic over the junction of the sternal and clavicular divisions
of the sternocleidomastoid muscle.
While the medially located carotid
artery (which courses under the sternal division) is palpated, a 11/2
inch, 22-gauge needle and syringe
are used to locate the internal jugular
vein which lies lateral to the carotid
artery, immediately beneath
the medial border of the clavicular
division. The needle should enter
the skin at a 30 to 45 angle directed laterally toward the midclavicle,
thereby avoiding possible puncture
of the carotid artery. On entering
the vein, the syringe is disengaged
but the needle is not removed; it
remains in the vein to serve as a
direct visual guide to the underlying
vein.
The large-bore needle (for
introduction of the catheter or
guide wire) can then be inserted
without trepidation 0.5 cm above
and parallel to the 22-gauge needle.
The smaller needle demonstrates
the exact location and depth of the
vein, and avoids complications (eg,
arterial puncture or pneumothorax)
of blind probing with a large-bore
needle. Use of the 22-gauge needle
with the patient in the Trendelenburg
position also renders the risk
of air embolus negligible.
POSTERIOR approach (pay attention to the direction of the needle):
Others points of insertion are more challenging due to possible artery catheterization and pneumothorax.
