Site Selection
|
INTERNAL JUGULAR |
|
|---|---|
|
ADVANTAGES |
DISADVANTAGES |
|
Compressible site |
Trendelenburg positioning (often not tolerated in respiratory distress) |
|
Lower risk of pneumothorax (compared to subclavian) |
Risk of neck hematoma with upper airway compromise |
|
Hemodynamic monitoring with CVP, CvO2, and PA catheter placement |
Potential cannulation of carotid (2-10%) |
|
Patient can be ambulatory |
|
|
Lower risk of deep vein thrombosis |
|
When to consider a different site:
- Respiratory distress with inability to tolerate Trendelenburg.
- Patient discomfort with positioning.
- Inability to access due to ongoing CPR.
- Prior condition that alter local anatomy: clavicle fracture, sternotomy, neck surgery, or neck irradiation.
Catheter length: RIJ: 15cm, LIJ: 20cm
Technique
Positioning:
- Supine & Trendelenburg (10°): reduces risk of air embolism and engorges vein.
- Patient head rotated about 30° to contralateral side. Over-rotation distorts anatomy.
- Operator standing at the patient's head and positioned facing the patient’s feet.
Locating access point:
NOTE: at UCSF, cannulation is done with ultrasound guidance with the exception of emergency situations.
- Landmarks: locate the triangle separating the medial (sternal) & lateral (clavicular) components of the sternocleidomastoid (SCM).
- In this space, use the ultrasound to locate the IJ superficial and lateral to the carotid artery (compressible, nonpulsatile, Doppler flow towards heart).
- RIJ generally preferred over LIJ due to larger vein, direct path to SVC, ease of access for a right-handed operator, and absence of a thoracic duct.
Entry:
- Ensure entry site is at the apex of the medial and lateral components of the SCM (about mid-neck 4-5cm above the SCM notch).
- Direct needle tip towards the ipsilateral nipple at a 30-45° angle to the skin.
- Use ultrasound guidance to confirm entry into IJ (decreases risk of PTX).
- See Principles of Vascular Access: Procedural Technique for remainder of procedural approach.