INTERNAL AND EXTERNAL JUGULAR VEINS
(continued)

The internal jugular approach allows for ultrasound guidance or landmark approach. Insertion-related complication rates are reduced when ultrasound guidance is used. Disadvantages of the internal jugular approach include inadvertent arterial puncture, increased risk of infection, discomfort due to location, and difficulty maintaining dressing at site. This site is compressible for patients with coagulation disorders and is associated with an overall lower risk of pneumothorax. However, it has a higher infection rate than the subclavian approach. The internal jugular is the preferred site for patients requiring temporary hemodialysis access and should not be the first site of choice in patients with tracheostomies or neck stabilization devices.

Landmarks include:
 · Angle of the mandible
 · Two heads of sternocleidomastoid muscle
 · Clavicle
 · External jugular vein
 · Trachea

Adjacent anatomy includes:
 · Carotid artery
 · Phrenic and vagus nerves
 · Pulmonary apex
 · Thoracic duct (left side approach)

The external jugular lies outside the SCM. It is visible from the surface making it easy to locate. Use of the external jugular vein is considered an advanced skill, due to the close proximity to the carotid artery. Use of the external jugular vein for CVC is relatively uncommon, and is limited primarily by difficulty advancing the guidewire into the SVC.

Disadvantages of the external jugular include inadvertent arterial puncture, increased risk of infection, discomfort due to location and difficulty maintaining an occlusive dressing at insertion site. Like the internal jugular site, the external jugular would not be the first site of choice in patients with tracheostomies or neck stabilization devices.

Adjacent anatomy includes:
 · Carotid artery
 · Phrenic and vagus nerves
 · Pulmonary apex
 · Thoracic duct (left side approach)