Internal Jugular Access

Internal jugular vein access has been increasing in frequency despite concerns over infections rates. The internal jugular access site is preferred due to lower risk of insertion complications. The right side is the most frequently chosen as this provides the straightest and most direct path to the SVC. Various needle insertion approaches are used for internal jugular access including anterior, medial, posterior and low approaches in relation to the vein and the ultrasound probe. Positioning the patient in the Trendelenburg position enhances the filling of the jugular veins and reduces the risk of air emboli.

Step 1: After performing a pre-scan measure from insertion site to the third intercostal space, place the patient in the Trendelenburg position. Perform hand hygiene and establish sterile field. Prep insertion site using Chlorhexidine; allow site to dry. Then, drape patient using maximal sterile barrier precautions.

Step 2: Using ultrasound, scan neck to locate selected vein and isolate the carotid artery. Administer lidocaine. Access the internal jugular vein with the introducer needle. For safety, the introducer needle should have a syringe attached to the needle hub to prevent entry of air. During access, be aware of the position of the artery and angle of insertion to avoid lung penetration. The needle angle is positioned so that the tip of the needle is easily visualized with the ultrasound probe. Throughout insertion, follow the tip of needle from penetration of skin to access. Do not lose track of the tip. The imaging should show the needle tip creating a dimple as it touches the vein; as the needle penetrates the vessel, the image shows the vein bouncing back.

Step 3: Observe flashback of blood in the syringe or aspirate syringe to confirm placement of needle into vein.

Step 4: If using a Raulerson syringe, insert wire through the opening in the distal part of plunger. Otherwise, time the removal of syringe with patient expiration and insertion of wire through needle hub. Gently insert wire into vein approximately 10 to 20 centimeters or half the length of the wire feeling for wire advancement through vein.

Maintain control of the wire at all times, and respect the angle of the wire. Do not pull back against bevel of needle at any time, as this could cause kinking, shearing and/or breaking of the wire leading to wire embolism. While stabilizing the wire in the vessel, remove the needle.