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External jugular vein cannulation and its use for cvp monitoring
The Joumai of Emergency Medune,
Prlnted in the USA
Vol 6, pp 133-l 35, 1966
EXTERNAL JUGULAR VEIN CANNULATION
CopyrIght cc‘1968 Pergamon Press plc
??
AND ITS USE FOR CVP MONITORING
Robert H. Dailey, MD Chief, Emergency Medicine, Hlghland General Hospital; ClInIcal Professor of Mediclne, Unwersity of California, San Francisco Reprint address. Robert H. Dailey, MD, Chief, Emergency Medlclne, Highland General Hospital, 1411 East 31st Street, Oakland, CA 94602
17 Abstract-The techniques of external jugular vein (EJV) cannulation and central venous pressure (CVP) catheter placement using a J-tipped wire guide is described in detail. This technique has a high success rate with virtually no complications.
cannulation, recommends it enthusiastically, and describes the technique in detail here.
0 Keywords-external central venous access
About 90% of people have a single prominent EJV arising approximately at the angle of the jaw from smaller tributaries in the face and scalp; it then courses obliquely and superficially across the sternocleidomastoid muscle and terminates beneath the clavicle in the SCV. The EJV joins the SCV usually at an angle of about 90” and sometimes via a venous plexus instead of a single channel (Figure 1). Sometimes valves are present. All these anatomical factors cause problems in threading catheters into the central circulation. The vein is only loosely fixed in the subcutaneous tissues and is not easily distensible; thus venipuncture is often difficult.
ANATOMY
jugular vein; CVP monitoring;
INTRODUCTION
For the past three decades central venous pressure (CVP) measurements have proved useful in monitoring many unstable cardiovascular conditions. Although, originally, the basilic vein in the antecubital fossa was the most common venous access, the relatively low rate of success in threading catheters centrally led to wide usage of the deep veins at the root of the neck, namely, the internal jugular vein (IJV) and subclavian vein (SCV). However, although success rates are high, so too are complication rates.’ The most common complications are also the most serious, that is, carotid artery puncture and pneumothorax. Some complications are expected, since IJV and SCV punctures are blind procedures, but good technique and adherence to anatomical landmarks will reduce their incidence. So the search continues for a technique that is both reliable and safe. In 1974 Blitt et al described the technique of external jugular vein (EJV) cannulation with the use of a J-tipped wire guide.2 They had a success rate of 96% and no complications, in contrast to 50 to 70% rate prior to J-tipped wire guides.3,4 This author has had considerable success and no complications using EJV =zzz==
B
TECHNIQUE
In order to distend the vein, the patient must be supine, preferably in Trendelenburg’s position. Standing at the head of the guerney, the operator, regardless whether right- or left-handed, can easily access either EJV. To gain operating exposure, the head should be tilted contralaterally from the vein being cannulated. Venous distension may be achieved by several means: (1) a second operator may place a forefinger parallel and immediately superior to the clavicle, where the EJV dives beneath the clavicle; (2) a stethoscope may be positioned to occlude the vein5 (Figure 2); or, best, (3) the patient may be instructed in a Valsalva maneuver. This last measure is particu-
features practical, “how-to” articles of interest to all participating emergency physicians. This section is coordinated by George Sternbach, MD, Stanford University Medical Center.
Techniques and Procedures
RECEIVED:23 January 1987; ACCEPTED:8 October 1987 133
0736-4679188 $3.00 + .OO
134
Robert H. Dailey
External Jugular Vem
1st Rib Clawcle Subclawan Yin ‘p--r
Figure 1. Anatomy of EJV.
Figure 2. Stethoscope
Figure 3. Initial needle positioning for EJV puncture.
method of EJV distention. Figure 4. Needle puncture of EJV.
larly effective and can easily be demonstrated to the patient by the operator. It does depend, however, on the patient being alert and cooperative. A common problem with venipuncture is penetration of both walls of the vein, leading to unsuccessful cannulation and hematoma formation. This can be avoided by entering the vein from the side instead of from on top. The following specific steps are recommended: (1) Have the patient successfully practice a Valsalva maneuver; (2) with the needle and syringe
held parallel to the vein, puncture the skin in a quick, definitive manner, entering the subcutaneous tissue just next to the vein (Figure 3); (3) have the patient perform the Valsalva maneuver (or use other means of distention); (4) with the vein distended, change the angle of attack of the needle to about 45”, and bowing the vein laterally (Figure 4), enter it with a slight “pop”; (5) again adjusting the needle to be parallel to the lumen of the vein, advance it a few millimeters
Jugular Vein Cannulatlon
135
within the lumen; (6) withdraw a few milliliters of blood to assure intraluminal placement; (7) allow the patient to assume normal breathing; (8) thread the Jtipped wire just past the needle tip into the lumen of the vein; (9) have the patient do the Valsalva maneuver once again; (10) pass the wire centrally; and, finally, (11) thread the catheter over the wire to its proper position in the proximal SCV. Several “tricks” will increase success rates. First, the more distended the vein, the more easily the vein is punctured and the better the wire will thread centrally, so a good Valsalva maneuver is often critical. Second, the J-tip should have no greater than a 3-mm radius: large Js negotiate turns less successfully than small ones.h Third, introducing a wire through a catheter (instead of through a needle) may enhance success2 (a 16-gauge catheter is compatible with the standard 0.35in diameter wire). Fourth, when using a needle to introduce the wire, if the wire will not pass at the level of the clavicle or repeatedly finds its way into a tributary vein, it should. be withdrawn through the needle and twisted 180” before rethreading; sometimes this m.aneuver provides successful tip redirection. Fifth, exaggeration of head tilt, combined with marked traction on the skin of the neck, will produce a less acute angle between the SCV and EJV, thus facilitating passage. Sixth, if wire passage is unsuccessful, and the purpose is placement of a pulmonary
artery catheter, it has been noted that the sheath can still be placed in the EJV, and then the catheter successfully passed centrally by virtue of the curved tip and flow-directed balloon of the pulmonary artery catheter.j
DISCUSSION
In patients who have an identifiable EJV, successful placements of CVP catheters with J-tipped wire guides occur in 75 to 100% of cases.3 The superiority of the J over the straight tip has been unequivocally demonstrated.’ Success is higher in adults than children,8xyalthough in children, patient size has not been a determining factor in success rate.’ Complications in placement, other than small subcutaneous hematomas, have not been described; this is not surprising since the EJV is visible and superficial. However, if the catheters are not placed under sterile conditions, thrombosis and infection can be logically expected to occur as often as with the use of other veins. Finally, even when a catheter cannot be advanced into the central circulation, if the tip is near the EJV/ SCV junction, venous pressure readings will approximate those in the superior vena cava (when the patient is supine with the head in a neutral position).”
REFERENCES 1. Sznajder JI, Zveivil FR, Bitterman H, et al: Central vein catheterization: Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986; 146(2):259. 2. Blitt CD, Wright WA, Petty WC, et al: Central venous catheterization via the external jugular vein. JAMA 1974; 229:817818. 3. Riddell GS, Latto IP, Ng WS: External jugular vein access to the central venous system-A trial of two types of catheter. Br JAnaesth 1982; 54:535-537. 4. Deitel M, Maclntyre JA: Radiographic confirmation of site of CVP catheters. Can J Surg 1971; 14:42-48. 5. Scheller MS, Saidman LJ: An aid to identifying the external jugular vein (Letter to the Editor). Anesthesiology 1982; 571546-547. 6. Nordstrom L, Fletcher R: Comparison of two different J-wires
for central venous cannulation via the external jugular vein. Anesth Analg 1983; 62:365. 7. Blitt CD, Carlson GL, Wright WA, et al: J-wire v’ersus straight wire for central venous system cannulation via the external jugular vein. Anesth Aria/g 1982; 61:536-537. 8. Jobes DR, Schwartz AJ, Greenhow DE, et al: Safer jugular vein cannulation: Recognition of atrial puncture and preferential use of the external jugular route. Anesfhesiology 1983; 59:353-355. 9. Humphrey MJ, Blitt CD: Central venous access in children via the external jugular vein. Anesthesiology 1982; 57:50-5 I. IIO. Briscoe CE: A comparison of jugular and central venous pressure measurements during anaesthesia. Br J Anaesth 1973; 45:173-177.
Prlnted in the USA
Vol 6, pp 133-l 35, 1966
EXTERNAL JUGULAR VEIN CANNULATION
CopyrIght cc‘1968 Pergamon Press plc
??
AND ITS USE FOR CVP MONITORING
Robert H. Dailey, MD Chief, Emergency Medicine, Hlghland General Hospital; ClInIcal Professor of Mediclne, Unwersity of California, San Francisco Reprint address. Robert H. Dailey, MD, Chief, Emergency Medlclne, Highland General Hospital, 1411 East 31st Street, Oakland, CA 94602
17 Abstract-The techniques of external jugular vein (EJV) cannulation and central venous pressure (CVP) catheter placement using a J-tipped wire guide is described in detail. This technique has a high success rate with virtually no complications.
cannulation, recommends it enthusiastically, and describes the technique in detail here.
0 Keywords-external central venous access
About 90% of people have a single prominent EJV arising approximately at the angle of the jaw from smaller tributaries in the face and scalp; it then courses obliquely and superficially across the sternocleidomastoid muscle and terminates beneath the clavicle in the SCV. The EJV joins the SCV usually at an angle of about 90” and sometimes via a venous plexus instead of a single channel (Figure 1). Sometimes valves are present. All these anatomical factors cause problems in threading catheters into the central circulation. The vein is only loosely fixed in the subcutaneous tissues and is not easily distensible; thus venipuncture is often difficult.
ANATOMY
jugular vein; CVP monitoring;
INTRODUCTION
For the past three decades central venous pressure (CVP) measurements have proved useful in monitoring many unstable cardiovascular conditions. Although, originally, the basilic vein in the antecubital fossa was the most common venous access, the relatively low rate of success in threading catheters centrally led to wide usage of the deep veins at the root of the neck, namely, the internal jugular vein (IJV) and subclavian vein (SCV). However, although success rates are high, so too are complication rates.’ The most common complications are also the most serious, that is, carotid artery puncture and pneumothorax. Some complications are expected, since IJV and SCV punctures are blind procedures, but good technique and adherence to anatomical landmarks will reduce their incidence. So the search continues for a technique that is both reliable and safe. In 1974 Blitt et al described the technique of external jugular vein (EJV) cannulation with the use of a J-tipped wire guide.2 They had a success rate of 96% and no complications, in contrast to 50 to 70% rate prior to J-tipped wire guides.3,4 This author has had considerable success and no complications using EJV =zzz==
B
TECHNIQUE
In order to distend the vein, the patient must be supine, preferably in Trendelenburg’s position. Standing at the head of the guerney, the operator, regardless whether right- or left-handed, can easily access either EJV. To gain operating exposure, the head should be tilted contralaterally from the vein being cannulated. Venous distension may be achieved by several means: (1) a second operator may place a forefinger parallel and immediately superior to the clavicle, where the EJV dives beneath the clavicle; (2) a stethoscope may be positioned to occlude the vein5 (Figure 2); or, best, (3) the patient may be instructed in a Valsalva maneuver. This last measure is particu-
features practical, “how-to” articles of interest to all participating emergency physicians. This section is coordinated by George Sternbach, MD, Stanford University Medical Center.
Techniques and Procedures
RECEIVED:23 January 1987; ACCEPTED:8 October 1987 133
0736-4679188 $3.00 + .OO
134
Robert H. Dailey
External Jugular Vem
1st Rib Clawcle Subclawan Yin ‘p--r
Figure 1. Anatomy of EJV.
Figure 2. Stethoscope
Figure 3. Initial needle positioning for EJV puncture.
method of EJV distention. Figure 4. Needle puncture of EJV.
larly effective and can easily be demonstrated to the patient by the operator. It does depend, however, on the patient being alert and cooperative. A common problem with venipuncture is penetration of both walls of the vein, leading to unsuccessful cannulation and hematoma formation. This can be avoided by entering the vein from the side instead of from on top. The following specific steps are recommended: (1) Have the patient successfully practice a Valsalva maneuver; (2) with the needle and syringe
held parallel to the vein, puncture the skin in a quick, definitive manner, entering the subcutaneous tissue just next to the vein (Figure 3); (3) have the patient perform the Valsalva maneuver (or use other means of distention); (4) with the vein distended, change the angle of attack of the needle to about 45”, and bowing the vein laterally (Figure 4), enter it with a slight “pop”; (5) again adjusting the needle to be parallel to the lumen of the vein, advance it a few millimeters
Jugular Vein Cannulatlon
135
within the lumen; (6) withdraw a few milliliters of blood to assure intraluminal placement; (7) allow the patient to assume normal breathing; (8) thread the Jtipped wire just past the needle tip into the lumen of the vein; (9) have the patient do the Valsalva maneuver once again; (10) pass the wire centrally; and, finally, (11) thread the catheter over the wire to its proper position in the proximal SCV. Several “tricks” will increase success rates. First, the more distended the vein, the more easily the vein is punctured and the better the wire will thread centrally, so a good Valsalva maneuver is often critical. Second, the J-tip should have no greater than a 3-mm radius: large Js negotiate turns less successfully than small ones.h Third, introducing a wire through a catheter (instead of through a needle) may enhance success2 (a 16-gauge catheter is compatible with the standard 0.35in diameter wire). Fourth, when using a needle to introduce the wire, if the wire will not pass at the level of the clavicle or repeatedly finds its way into a tributary vein, it should. be withdrawn through the needle and twisted 180” before rethreading; sometimes this m.aneuver provides successful tip redirection. Fifth, exaggeration of head tilt, combined with marked traction on the skin of the neck, will produce a less acute angle between the SCV and EJV, thus facilitating passage. Sixth, if wire passage is unsuccessful, and the purpose is placement of a pulmonary
artery catheter, it has been noted that the sheath can still be placed in the EJV, and then the catheter successfully passed centrally by virtue of the curved tip and flow-directed balloon of the pulmonary artery catheter.j
DISCUSSION
In patients who have an identifiable EJV, successful placements of CVP catheters with J-tipped wire guides occur in 75 to 100% of cases.3 The superiority of the J over the straight tip has been unequivocally demonstrated.’ Success is higher in adults than children,8xyalthough in children, patient size has not been a determining factor in success rate.’ Complications in placement, other than small subcutaneous hematomas, have not been described; this is not surprising since the EJV is visible and superficial. However, if the catheters are not placed under sterile conditions, thrombosis and infection can be logically expected to occur as often as with the use of other veins. Finally, even when a catheter cannot be advanced into the central circulation, if the tip is near the EJV/ SCV junction, venous pressure readings will approximate those in the superior vena cava (when the patient is supine with the head in a neutral position).”
REFERENCES 1. Sznajder JI, Zveivil FR, Bitterman H, et al: Central vein catheterization: Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986; 146(2):259. 2. Blitt CD, Wright WA, Petty WC, et al: Central venous catheterization via the external jugular vein. JAMA 1974; 229:817818. 3. Riddell GS, Latto IP, Ng WS: External jugular vein access to the central venous system-A trial of two types of catheter. Br JAnaesth 1982; 54:535-537. 4. Deitel M, Maclntyre JA: Radiographic confirmation of site of CVP catheters. Can J Surg 1971; 14:42-48. 5. Scheller MS, Saidman LJ: An aid to identifying the external jugular vein (Letter to the Editor). Anesthesiology 1982; 571546-547. 6. Nordstrom L, Fletcher R: Comparison of two different J-wires
for central venous cannulation via the external jugular vein. Anesth Analg 1983; 62:365. 7. Blitt CD, Carlson GL, Wright WA, et al: J-wire v’ersus straight wire for central venous system cannulation via the external jugular vein. Anesth Aria/g 1982; 61:536-537. 8. Jobes DR, Schwartz AJ, Greenhow DE, et al: Safer jugular vein cannulation: Recognition of atrial puncture and preferential use of the external jugular route. Anesfhesiology 1983; 59:353-355. 9. Humphrey MJ, Blitt CD: Central venous access in children via the external jugular vein. Anesthesiology 1982; 57:50-5 I. IIO. Briscoe CE: A comparison of jugular and central venous pressure measurements during anaesthesia. Br J Anaesth 1973; 45:173-177.