Download Cannulation of the Internal Jugular Vein

Cannulation of the Internal Jugular Vein
Robert Cambria, MD
he use of indwelling venous catheters has become
T commonplace in the management of various medical
conditions. Facilitated by Seldinger's 1 description of catheter exchange over a guidewire for access to the intravascular space and by advances in catheter technology, therapeutic alternatives, and the management of critically ill
patients, access to the central venous system is practiced
by a growing number of medical specialists. Indications
for these types of procedures include administration of
antibiotic or chemotherapeutic agents, invasive hemodynamic monitoring, total parenteral nutrition, hemodialysis, plasmapheresis, and insertion of caval filtering devices or transjugular intrahepatic portosystemic shunts.
Before making any attempt to access the central veins,
the clinician needs to be familiar with the patient's medical history, physical findings, and imaging studies. A
history of bleeding disorders or coagulopathy should be
obtained, and coagulation studies and platelet count
should be within normal limits. Because many of these
patients have chronic illness, a careful history of previous
central lines or upper extremity swelling must be obtained. If there is a preexisting history of central access or
of possible subclavian vein thrombosis, then a duplex
ultrasound scan of the jugular and subclavian veins
should be obtained. Preprocedural duplex examination
revealed significant abnormalities in 35% of patients
scheduled for dialysis access catheters, and more than
50% of these abnormalities occurred in patients who had
been on dialysis for less than one year. 2 Finally, if there is
a history of chest pathology, a preprocedural chest x-ray
may be helpful in interpreting the x-ray following line
placement.
From the Division of Vasuiar Surgery, Medical College of Wisconsin, Milwaukee, WI.
Address reprint requests to Robert Cambria, MD, Medical College ofWisconsin,
Division of Vascular Surgery, 9200 West Wisconsin Ave, Milwaukee, Wl 53226.
Copyright9 2001 by W.B. SaundersCompany
1524-153X/01/0304-0002535.00/0
doi:10.1053/otgn.2001.27733
Operative Techniques in General Surgery,Vol 3, No 4 (December),2001: pp 217-225
2 17
218
RobertCambria
SURGICAL TECHNIQUE
Percutaneous Access to the Internal
Jugular Vein
Performance of any percutaneous procedure demands
strict attention to the regional surface anatomy and
technical detail. Occasionally, the use of adjunctive
imaging, such as ultrasound, for guidance can be helpful. In selected patients, ultrasound guidance may increase the rate of successful cannulation of the desired
vein and decrease the incidence of injury to adjacent
structures .3
J
Clavicle"
Clavicular head of
sternocleidomastoid
(SCM) muscle
iS.
Sternal head of SCM
Manubrium of sternum
1 The SCM muscle and the distinction of its sternal and clavicular heads are
of primary importance in the surface anatomy for internal jugular access.
219
Cannulation of the Internal Jugular Vein
External
Supraclavic
Sternocleidornas
ial jugular v.
B
1 With the head turned to the opposite side, the internal jugular vein runs in a straight
line from the pinna of the ear to the sternoclavicular joint, beneath the sternocleidomastoid
muscle. The vein is located lateral to the common carotid artery in the base of the neck (B).
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Robert Cambria
Protection of
carotid a. with medial
retraction of it and
sternal head of SCM
by fingertips
Point of insertion into
jugular v. between heads
of SCM
<:
j'/
Needle directed toward
ipsilateral nipple
]:
/
2
Needle inserted at angle 35 ~ - 45 ~
from horizontal plane
into jugular v. between
heads of SCM
Medial head SCM (sternal)
3
See legend on opposite page.
Cannulation of the Internal Jugular Vein
2 and 3 The patient is placed supine with the bed in Trendelenburg position and the head turned 45
degrees to the contralateral side. There are two common approaches to the internal jugular vein: the anterior
approach (sometimes referred to as the central approach) and the posterior approach. For both approaches,
the neck is prepped and draped following standard aseptic technique, with the angle of the mandible and
jugular notch to be included in the operative field. Once the insertion site is selected as described below, local
anesthetic is administered into the skin and subcutaneous area, withdrawing frequently to prevent inadvertent administration into the vascular space. For the anterior approach, the insertion site is located at the apex
of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle. The carotid pulse
is palpated, and gentle traction is applied medially to the carotid artery. After the local anesthetic is
administered, a 22-gauge finder needle on a syringe is inserted at the apex of the triangle with the bevel facing
upward. The needle is advanced toward the ipsilateral nipple at a 45-degree angle to the skin for up to 3 cm,
while gently aspirating. If no venous blood returns, then the needle should be slowly withdrawn while still
aspirating. If still unsuccessful, then the needle should be directed 1-3 cm more laterally and a second pass
made following the same procedure. If no venous blood returns, then a final pass directing the needle 1 cm
medial to the ipsilateral nipple may be attempted, with care taken to maintain medial traction on the carotid
artery to avoid inadvertent arterial puncture. If after three passes there is no venous blood return, then
consideration should be given to using the posterior approach or a different access site. If at any point arterial
blood or air is withdrawn into the syringe, then the procedure should be terminated and the complication
managed as detailed below. Once venous return has been obtained with the finder needle, the angle of
entry and direction should be committed to memory. The needle may then be removed, or the syringe
detached and the needle left in place. An 18-gauge needle attached to a syringe is then inserted following
the direction of the finder needle. After venous return is obtained, the syringe is removed and the hub
of the needle occluded with a finger to prevent air embolism. A guidewire is inserted and advanced
through the 18-gauge needle; it should pass with minimal resistance. If the wire does not pass easily,
then it should be immediately withdrawn and the needle position verified by aspiration and free return
of venous blood. The distance to the right atrium has been measured at less than 16 cm from the
right side and less than 19 cm from the left, 4 and the guidewire should not be inserted beyond
this distance to prevent atrial perforation or arrhythmia associated with irritation of the endocardium.
After the wire has been inserted, the needle is removed, with control of the wire maintained at all times.
Once wire access has been obtained, temporary catheters can be inserted directly over the wire, or
sheaths can be advanced with dilators into the central venous system to permit placement of a more
permanent device or insertion of other catheters such as a pulmonary artery catheter. Digital control of
the wire must be maintained at all times to prevent loss into the intravascular space. Once the sheath or
catheter has been positioned, the wire is withdrawn, and the device is secured to the skin with silk
sutures. A sterile dressing is applied, and a chest x-ray should be obtained immediately to confirm
appropriate placement and to assess for complications.
221
222
Robert Cambria
ior
~ward
4
Sternal notch
Needle
lateral
directe
4 and 5 For the posterior approach, the insertion site is located at the lateral border of the
sternocleidomastoid muscle 1 cm above the external jugular vein. After a local anesthetic has been
administered, a 22-gauge finder needle attached to a syringe is inserted with the bevel of the needle
oriented laterally. The needle is advanced anteriorly along the undersurface of the muscle and toward
the jugular notch of the sternum while aspirating. The jugular vein should be encountered within 5 - 6
cm with this approach. If it is not then the needle should be redirected more laterally, toward the
ipsilateral sternoclavicular joint. Once blood return is obtained with the finder needle, the procedure
continues as detailed for the anterior approach. Some data suggest that the posterior approach carries
a higher success rate and a lower complication rate, s but this is largely dependent on individual operator
experience and comfort.
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Cannulation of the Internal Jugular Vein
Operative Exposure of the Jugular Vein
Clavicular head and
origin of lateral SCM
6 Access to the internal jugular vein has become a percutaneous procedure in the vast majority of
patients. Miniaturization of implantable devices and advances in catheter and sheath technology have
made it possible to deliver even relatively large devices percutaneously. However, there remain several
indications for operative exposure and insertion of devices under direct vision. In patients with
coagulopathy or thrombocytopenia, open insertion of central lines may be preferable because of the
increased risk of bleeding with percutaneous access. In patients whose anatomy is obscured by body
habitus or regional disease, direct exposure of the venous access site minimizes the risk of technical
misadventure. Although the internal jugular vein may not be the first choice for all patients who require
direct exposure, it remains a viable and reliable option in some. The internal jugular vein lies laterally
in the carotid sheath, beneath the sternocteidomastoid muscle. The vein can be exposed using an
incision along the anterior border of this muscle in the midportion of the neck. Alternatively, the vein
can be exposed at the root of the neck, between the heads of the sternocleidomastoid muscle, using a
transverse supraclavicular incision. For both approaches, the patient is positioned supine with the head
turned away from the side of the procedure. Using the incision anterior to the sternocleidomastoid
muscle, the skin and subcutaneous tissues are divided. The platysma is incised, exposing the investing
layer of the deep cervical fascia. The fascia is divided and the sternocleidomastoid muscle is reflected
laterally, exposing the carotid sheath. The internal jugular vein can be isolated, taking care to preserve
the vagus nerve, which also runs in the carotid sheath between the vein and the carotid artery.
Tributaries of the jugular vein can be ligated with impunity, and if necessary, the jugular vein may be
ligated when the contralateral vein is known to be patent.
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Robert Cambria
SCM
~dially
ular v.
J
Laterat head of SCM
partially divided
7 The supraclavicular incision should be placed 1-2 cm above the
clavicle, beginning at the clavicular head and extending 5-7 cm laterally.
The platysma is divided, and the sternal head of the sternocleidomastoid
muscle is retracted medially. The clavicular head of the muscle can be
retracted laterally or, if necessary, partially transected along its medial
border. The carotid sheath with the internal jugular vein lies immediately
beneath the muscle and can be isolated at this level. The vagus nerve and
sympathetic chain course along the posteriolateral aspect of the carotid
sheath and should be carefully avoided. If approaching from the left, the
thoracic duct may also be visualized near its entry into the subclavian vein
and should be preserved.
225
Cannulation of the Internal Jugular Vein
Complications
The complications associated with percutaneous access
to the internal jugular vein fall into two broad areas:
injury to adjacent structures during insertion and devicerelated complications. The most common complication
of percutaneous internal jugular access is inadvertent
puncture of arterial structures, usually the carotid artery,
which has been reported in 2%-10% of attempts. If the
procedure outlined above is followed and the carotid artery is punctured with a 22-gauge finder needle, then
immediate withdrawal of the needle followed by digital
compression is usually successful in managing this problem. If the carotid puncture is unrecognized and the artery is instrumented with a dilator or sheath, or if manual
compression following needle puncture of the artery is
unsuccessful and progressive hematoma develops, then
surgical repair of the arterial injury is required. Late presentation of an arterial injury as a pseudoaneurysm or
arteriovenous fistula has been described but occurs infrequently.
Pneumothorax is a well-described complication of central venous access and can occur from any approach.
Although most reports quote the incidence of pneumothorax following central line placement as 1% or less,
some investigators have found an incidence as high as
2.5% following internal jugular access.6 The development
of tension pneumothorax is even rarer, but necessitates
immediate decompression to avoid hemodynamic compromise. Small collections of air in the thorax can be
monitored or aspirated, but most patients with a significant pneumothorax require tube thoracostomy.
Air embolism is an extremely rare but potentially lethal
complication of central venous access. When recognized,
any air that can be withdrawn from the catheter should be
evacuated. If cardiopulmonary collapse ensues, then standard advanced cardiac life support measures should be
initiated and consideration given to thoracotomy. Patients with lesser degrees of respiratory failure should be
placed in the left lateral decubitus position with the head
down to trap air in the right atrium. Air will eventually be
dissolved in the blood, and chest x-ray can be used to
monitor the air collection.
Thrombosis of the central veins is the most common
device-related complication, occurring in 4%-10% of patients. The incidence may be higher in selected populations (e.g., patients with malignancies known to be associated with hypercoagulable states), and some authors
have suggested that small thrombi are associated with
central lines in up to 50% of patients even when prophylactic anticoagulation is given. 7 Classic management of
symptomatic central venous thrombosis involves removing the offending catheter and administering systemic
anticoagulation. However, in selected patients with limited access options, preservation of the catheter may be
possible with systemic anticoagulation or catheter-di-
rected thrombolytic therapy to recanalize the central
vein. s Prophylactic anticoagulation to prevent venous
thrombosis in patients with central lines has been proven
effective, but remains controversial. Thrombosis of the
catheter itself can be treated by infusing thrombolytic
agents directly into the occluded catheter. Although
urokinase is not currently available in the United States,
tissue plasminogen activator has been used successfully
for this purpose. 9
Infectious complications of central lines remain problematic, occurring in 10%-30% of catheters. Strict adherence to aseptic technique during catheter placement and
subsequent handling is the best means of prevention. The
diagnosis of line infection can be difficult and usually
relies on an increase in colony-forming units of cultures
drawn through the catheter as compared to simultaneously drawn peripheral blood cultures. Suspicion of
infection in temporary catheters can be managed by
changing the line over a guidewire and culturing the tip.
Attempts to sterilize infected permanent catheters or
ports with systemic antibiotics can be successful, 1~ but
failure to control the infection within 72 hours, recurrent
line infection, or infection of the subcutaneous tunnel
necessitate removal of the catheter. In general, muhilumen and external catheters are more susceptible to both
thrombotic and infectious complications than totally implantable ports.
REFERENCES
1. Seldinger SL: Catheter replacement of the needle in percutaneous
arteriography. Acta Radiol 39:368, 1953
2. Forauer AR, Glockner JF: Importance of US findings in access
planning during jugular vein hemodialysis catheter placements. J
Vasc Interv Radiol 11:233-238, 2000
3. Fry WR, Clagett GC, O'Rourke PT: Ultrasound guided central
venous access. Arch Surg 134:738-740, 1999
4. Andrews RT, Bova DA, Venbrux AC: How much guidewire is too
much? Direct measurement of the distance from subclavian and
internal jugular vein access sites to the superior vena cava-atrial
junction during central venous catheter placement. Crit Care Med
28:138-142, 2000
5. Chudhari LS, Karmarkar US, Dixit RT, et al: Comparison of two
different approaches for internal jugular vein cannulation in surgical patients. J Postgrad Med 44:57-62, 1998
6. Miller JA, Singireddy S, Maldjian P, et al: A reevaluation of the
radiographically detectable complications of percutaneous venous access lines inserted by four subcutaneous approaches. Am
Surg 65:125-130, 1999
7. Wu X, Studer W, Skarvan K, et al: High incidence of intravenous
thrombi after short-term central venous catheterization of the
internal jugular vein. J Clin Anesth 11:482-485, 1999
8. Haire WD, Lieberman RP, Lurid GB, et al: Obstructed central
venous catheters: Restoring function with a 12 hour infusion of
low dose urokinase. Cancer 66:2279-2285, 1990
9. Daeihagh P,JordanJ, ChenJ, et al: Efficacy of tissue plasminogen
activator administration on patency of hemodialysis access catheters. AmJ Kidney Dis 36:75-79, 2000
10. Johnson L, Brown AE: Infections related to central venous access
devices in patients with cancer. Infect Med 11:502-504, 1994