Placement of jugular venous catheters

INTRODUCTION — Central venous catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [1-3]. The jugular veins are one of the most popular sites for central venous access due to accessibility and overall low complication rates. They are the preferred site for temporary hemodialysis access.

The initial selection of central venous access site and types of devices are reviewed separately. (See "Central venous access: Device and site selection in adults".)

Once a jugular access site has been selected as the best appropriate site, this topic guides the placement. Placement of central venous access devices at other sites are reviewed separately. (See "Placement of femoral venous catheters" and "Placement of subclavian venous catheters".)

Other considerations, catheter management, and complications of venous access are discussed elsewhere. (See "Central venous access in adults: General principles" and "Routine care and maintenance of intravenous devices" and "Central venous catheters: Overview of complications and prevention in adults".).

JUGULAR VEIN ANATOMY — The internal jugular vein is a continuation of the sigmoid sinus as it emerges from the jugular foramen at the skull base. The vein is contained within the carotid sheath traveling with the carotid artery and vagus nerve throughout its length (figure 1A-B). The internal jugular vein on the right is larger than the left in the majority of patients, with significant diameter discrepancy present in one-third of patients [4-6]. As the internal jugular vein descends into the chest, its diameter increases. In a study that measured the diameter of the vein on computed tomography of the neck, the vein was on average 8.7 mm in the upper neck, 10.8 mm in the middle neck, and 12.5 mm in the lower neck [4].

The internal jugular vein exits the skull posterior to the internal carotid artery but assumes a position anterolateral to the common carotid artery as it courses beneath the sternocleidomastoid muscle [7,8]. At the level of the cricoid cartilage, the internal jugular vein lies beneath the sternocleidomastoid muscle. More caudally, it is located between the two heads of the sternocleidomastoid muscle at the base of the neck. In this region, the vein is superficially located approximately 1 to 1.5 cm from the surface of the skin [8,9]. The internal jugular vein joins the subclavian vein to form the brachiocephalic (innominate) vein behind the medial clavicle [9].

The external jugular vein is a superficial vein of the neck amenable to visual identification. The vessel takes an oblique course across the sternocleidomastoid muscle (figure 2). It joins the subclavian vein anterior or just lateral to the anterior scalene muscle. External jugular veins are commonly greater than 10 mm in diameter; their diameter varies inversely with the diameter of the internal jugular vein [10].

GENERAL PREPARATION — General considerations for patient preparation including catheter and access site selection, monitoring and sedation, measures to control infection, and consent are discussed elsewhere. (See "Central venous access in adults: General principles", section on 'General preparation'.)

Equipment — Jugular venous catheters and other jugular devices are typically placed using a modified Seldinger technique in a series of defined steps and usually using a prefabricated kit that contains all required supplies (table 1)[11]. For nontunneled catheters, the steps for central venous catheterization are given in the table (table 2). For tunneled catheters and other devices, the steps are similar, except that a sheath is inserted into the target vessel, and the device (eg, pulmonary artery catheter, pacing wire, vena cava filter) is deployed through the sheath, which may then be removed in some situations.

Prior to the placement of jugular venous catheters, assemble the following equipment:

●Ultrasound machine (see "Basic principles of ultrasound-guided venous access", section on 'Ultrasound machine')

●Sterile ultrasound transducer gel

●Central line kit with intravenous catheter (confirm the required size and length)

●The catheter should be flushed with sterile saline prior to insertion

●Sterile drapes, gloves, gown, surgical mask, and cap

●Topical antiseptic (eg, chlorhexidine, povidone iodine)

●Local anesthetic (see "Clinical use of topical anesthetics in children" and "Subcutaneous infiltration of local anesthetics")

●Isotonic saline and/or heparin for flushing the catheter

●Transparent adhesive dressing, tape

●Intravenous tubing and connectors (eg, needleless Luer connector, three-way stopcock)

Proper functioning of any fluoroscopic equipment that will be used should be verified. Although fluoroscopy is rarely needed for jugular access, it may be useful when altered venous anatomy is encountered. When placing implanted catheters or devices (eg, pacemaker, defibrillator, pulmonary artery catheter, vena cava filter, extracorporeal life support cannula), fluoroscopy may be used to guide catheter positioning and/or device implantation following initial jugular access.

Skin preparation — For jugular venous access, a wide skin preparation that includes the neck and chest above the nipple line allows the operator to attempt cannulation at an alternative ipsilateral target (eg, supraclavicular or infraclavicular subclavian approach) if the initial approach fails. If difficult access is anticipated, we prepare the neck and chest bilaterally.

Positioning — Patient positioning that maximizes the diameter of the jugular vein is associated with cannulation success [5,12,13]. This is accomplished primarily with Trendelenburg position, when tolerated, and proper neck positioning. The Trendelenburg position (head down) of 10 to 15 degrees significantly increases jugular diameter compared with flat positioning [5,8,12-15]. Placing the patient in the Trendelenburg position may also reduce the potential for venous air embolism [16,17].

Most patients can be safely positioned supine or in the Trendelenburg position [16,17]. However, critically ill and patients with obesity may develop respiratory compromise in the supine position and require close monitoring. Some patients may require anesthesia with a controlled airway for safe placement of central venous catheters and devices. (See "Anesthesia for the patient with obesity", section on 'Patient positioning'.)

The diameter of the compliant jugular vein varies with the respiratory cycle. Inspiration generates a negative intrathoracic pressure, which collapses the vein, while exhalation accentuates distention. To increase the vein diameter, cooperative patients can be asked to hum or perform a Valsalva maneuver. If the patient is not awake or is unable to cooperate, slight abdominal compression can increase venous dimension [8,13,15].

The position of the patient's head also influences jugular vein diameter and its relationship to the carotid artery. Vein diameter in the mid- and proximal neck is increased with slight head elevation while the use of a shoulder bolster or head rotation past 45 degrees both decrease vein diameter [14,15]. Some degree of overlap of the jugular vein and carotid artery is common [18]. The overlap progressively increases with lateral rotation of the head from a neutral position [19-21]. Limiting head rotation minimizes superimposition of the vessels and decreases the risk of arterial puncture [19,20,22,23]. Although a neutral head position provides the maximal distance between the artery and vein, some head rotation may be needed to adequately expose the anterior neck. These anatomic differences may influence the success of cannulation or incidence of complications for landmark-guided technique.

Ultrasound visualization of needle entry into the vein allows adjustments in real time. In a trial that randomly assigned 650 patients to a neutral (zero degrees) head position or turned (45 degrees) during ultrasound-guided cannulation of the internal jugular vein, technical success was 100 percent, and there was no significant difference in complications between groups [24].

JUGULAR SITE SELECTION — A jugular site is often favored over other sites. Factors that influence the choice between a jugular, subclavian, or femoral site are discussed separately. (See "Central venous access: Device and site selection in adults", section on 'Access site'.)

The internal jugular vein is more often chosen for the placement of central venous catheters; however, the external jugular vein is an excellent choice for rapid intravenous access, or as an alternative site following internal jugular vein occlusion [25,26]. External jugular venous access is performed in a manner that is like other superficial peripheral vein access, typically using an angiocatheter rather than a needle. (See "Peripheral venous access in adults".)

Right internal jugular vein cannulation is generally preferred over the left due to the larger diameter of the right-sided vein, its more direct path to the superior vena cava, the lower dome of the right pleura, absence of the thoracic duct, and the relative ease of access for a right-handed operator [6]. Right-sided access is also associated with a low rate of catheter malposition [4] and is commonly used in situations that require reliable catheter positioning for immediate use, such as drug administration or transvenous pacing. Two single-center randomized trials found that cannulation of the left jugular vein is more time consuming and associated with a higher incidence of complications [22,27]. However, a left-sided approach may be necessary for those with prior right-sided access, excessive scarring, vein thrombosis, or those with other indwelling central venous devices.

In the absence of another factor, consider targeting the vein ipsilateral to the compromised lung in patients with significant unilateral lung disease to minimize respiratory decompensation in the event of a procedure-related pneumothorax. Thankfully, the risk of pneumothorax is low when an ultrasound-guided technique is used to access the internal jugular vein [28]. (See 'Dynamic ultrasound-guided access' below.)

For patients with prior indwelling catheter placement in the subclavian or internal jugular veins, or a history of upper extremity deep venous thrombosis, consider ultrasound to assess venous patency prior to attempting jugular access. This assessment can be performed concurrent with vein localization before starting the procedure. (See "Catheter-related upper extremity venous thrombosis in adults", section on 'Duplex ultrasonography' and "Clinical features, diagnosis, and classification of thoracic central venous obstruction", section on 'Ultrasound'.)

INTERNAL JUGULAR VEIN CANNULATION — The internal jugular vein is generally accessed using one of three anatomic approaches (central, posterior, anterior). Following cannulation, internal jugular catheters are placed using an orderly sequence of steps (table 2).

Prior to preparing the patient, we identify the internal or external jugular vein using ultrasound and may mark its position using the following steps: (See "Basic principles of ultrasound-guided venous access", section on 'Ultrasound evaluation of vessels'.)

●Locate the jugular vein using care to distinguish it from the carotid artery (image 1).

●Mark the position of the vein on the skin surface with an indelible pen. Marking the borders of the sternocleidomastoid and clavicle may also be helpful for orientation.

●Remove the ultrasound transducer and gel.

Once the vein is localized using ultrasound, the skin markings can be used to guide jugular catheterization preferably using dynamic ultrasound guidance, or if ultrasound is not available, using landmark techniques.

Vein access — When equipment and expertise are available, we recommend that children and adults undergoing internal jugular vein access (regardless of approach or type of needle used) have the procedure guided by ultrasound rather than using anatomic landmarks alone. Ultrasound guidance improves cannulation success, reduces the number of attempts at cannulation, and reduces the incidence of inadvertent carotid cannulation [29].

Dynamic ultrasound-guided access — The basic principles of ultrasound-guided venous access, including ultrasound modes, types of probes, and equipment preparation, are discussed in detail elsewhere. It has a rapid learning curve and can diminish procedure time. (See "Basic principles of ultrasound-guided venous access".)

When using ultrasound to guide jugular venous access, the following steps should be performed (table 2):

●Confirm vein course, patency, and position relative to surface landmarks.

●Prepare the site with antiseptic cleansing and a sterile fenestrated drape (central line). (See 'General preparation' above.)

●Place the ultrasound gel and probe into a sterile sheath.

●Apply sterile ultrasound conduction medium (eg, water-soluble lubricant) to the external probe cover.

●Identify the jugular vein and center the image on the ultrasound screen (transverse view) or obtain a longitudinal view, using care to distinguish veins from arteries (image 1). (See "Basic principles of ultrasound-guided venous access", section on 'Ultrasound evaluation of vessels'.)

●Infiltrate the skin at the intended puncture site with 1% lidocaine.

●Insert the needle (preferably echogenic needle) loaded onto the syringe into the skin and slowly advance toward the vein. (See 'Access techniques' below.)

•If visualization of the needle tip is difficult using the transverse view, gently jiggle the needle up and down in the tissues to help identify the needle.

•If using the longitudinal (long axis) view, directly observe the needle penetrate the vein on the ultrasound monitor (image 2).

•While maintaining negative pressure on the syringe, advance the needle slowly until a free flow of blood return occurs. Monitor the depth of needle insertion. Although the tip of the needle may not be visualized, the depth of the vessel is shown on the ultrasound monitor and should guide the depth of needle placement.

●Remove the ultrasound transducer and complete cannulation in standard fashion as described below (table 2).

Access techniques — The internal jugular vein can be accessed using a standard introducer needle with or without the aid of a seeker needle, angiocatheter over needle combination, or micropuncture kit (picture 1). The general technique for each of these is described below. (See 'Venous confirmation' below.)

There is a learning curve for central venous access procedures [2]. Experienced operators enjoy greater success rates with fewer complications; among both experienced and inexperienced operators, an increased number of introducer needle passes correlates with increased complication rates, which are significantly higher after two to three unsuccessful passes [1]. If three needle pass attempts have been made, the needle should be completely removed and the site reassessed, a new access site chosen, or assistance obtained from a more experienced clinician [1,30,31].

Isolated arterial needle puncture is one of the most common complications of venous access but is typically uneventful if recognized [32]. If the carotid artery is inadvertently punctured, withdraw the needle and apply pressure over the site for 5 to 10 minutes. Jugular venous access can be reattempted provided anatomic and ultrasound landmarks are not distorted by hematoma. No additional studies are generally required in the absence of findings to suspect ongoing arterial bleeding.

By contrast, dilation and cannulation of the carotid artery is a more significant problem, as it is associated with vessel injury, thrombosis, major stroke, and hemorrhage. While smaller standard catheters pose lower risk, larger-bore catheters, such as dialysis catheters, are associated with higher rates of vascular complications. If carotid catheterization is confirmed, the catheter should be left in place and a vascular surgery consultation obtained immediately [32]. (See "Vascular complications of central venous access and their management in adults", section on 'Inadvertent arterial puncture'.)

To avoid carotid complications, dynamic ultrasound monitoring of the advancing needle tip is recommended. The needle (or angiocatheter) tip is monitored during its passage through the subcutaneous tissue and into the vein. However, real-time visualization of the advancing needle tip can be challenging (eg, misinterpretation of the needle shaft for the advancing needle tip in the transverse view), and care must be taken to avoid unintended advancement of the needle into deeper structures.

Introducer needle — To access the jugular vein with the introducer needle:

●Insert the introducer needle into the skin and apply continuous negative pressure by on the syringe plunger. Penetration into the vein will go unrecognized unless negative pressure is applied, but only a small amount of continuous negative pressure is needed (approximately 1 cc of a 10 cc syringe) during forward advancement of the needle.

●Traditionally, when inserting the needle, the bevel is directed anteriorly (bevel up); however, orienting the bevel of the needle posteriorly (bevel down) may decrease the risk needle tip penetration of the posterior vein wall (ie, "past-pointing") [33].

●Always advance and withdraw the needle in the same vector. Lateral movement of an inserted needle can lacerate vessels and should not be done. Prior to any redirection of the needle, it should be withdrawn to the skin surface.

●Anticipate that venous backflow into the introducer needle will be sudden, and steady the position of your hand to avoid losing access when it occurs.

●The advancing introducer needle may compress the anterior wall, puncturing both walls simultaneously without entering the lumen. Failure to aspirate blood during needle advancement is common. Therefore, withdraw the needle slowly while maintaining continuous negative pressure. Up to one half of jugular punctures are recognized during needle withdrawal [33,34].

●Once access is achieved, stabilize the hub of the needle and carefully remove the syringe to avoid dislodging the introducer needle from the vessel.

●Cover the hub of the needle with a finger or thumb between manipulations and coordinate hub exposure with the patient's exhalation to avoid air entry during jugular access.

Seeker needle — A 3.5 cm small-caliber (21- to 22-gauge) exploratory seeker or finder needle (picture 2) or micropuncture kit (picture 1) is useful for initial localization of the internal jugular vein [30,35]. This technique minimizes injury in the event of inadvertent arterial puncture. When using landmarks to guide access, we recommend the seeker needle technique for internal jugular access. With ultrasound guidance to aid vein localization, a seeker needle may not be needed.

To use a seeker needle to aid introducer needle placement:

●As described above for large-bore needle access, insert the seeker needle while applying negative suction on the plunger of the syringe; more suction will be required (approximately 2 to 3 cc of a 10 cc syringe). Steady, unimpeded blood return confirms intraluminal venous placement.

●Once the needle enters the jugular vein, withdraw the seeker needle, noting the angle and depth needed to reach the vein. Alternatively, remove the syringe, leaving the seeker needle in place to anchor the vessel and provide a guide for venous access by the introducer needle [36]. While applying negative pressure to the syringe, advance the introducer needle in the same vector, or alongside the preceding seeker needle, into the vein.

Angiocatheter — An angiocatheter assembly composed of an 18-gauge plastic catheter mounted on a 20-gauge needle, can also be used for initial jugular access. The needle tip is exposed and extends 2 mm distal to the catheter tip. The angiocatheter (but not the needle) accommodates a standard 0.035" guidewire.

The angiocatheter cannula-over-needle technique is preferred by some operators but was associated with lower rate of first-pass needle and guidewire insertion success compared with use of the introducer needle in one randomized trial [37]. To use an angiocatheter for jugular venous access:

●Attach the catheter-over-needle unit to the syringe and advance it into the target vessel as described above.

●Once blood is aspirated, advance the needle another 2 to 3 mm to ensure intraluminal positioning of the catheter tip, then advance the catheter over the needle and into the vessel.

Specific approaches — Three approaches to the internal jugular vein are widely recognized and include central, posterior, and anterior approaches [38]. Any of these approaches are amenable to dynamic ultrasound-guided techniques.

The primary surface landmarks for internal jugular cannulation relate to the borders of the sternocleidomastoid muscle (figure 1B). Palpation of the two origins of the sternocleidomastoid muscle (ie, sternal and clavicular heads) defines a triangular gap just above the medial clavicle. The medial sternal head is more easily palpated than the broad, flat clavicular head. These landmarks can be accentuated by muscle flexion via asking the patient to raise the head off the bed or turn away from the access site to aid identification during procedure preparation. We do not recommend these maneuvers during cannulation. The vein normally courses deep to the muscle and emerges along the medial border of the clavicular head.

Central — The central approach to the internal jugular vein is most commonly used (figure 3 and figure 1B). The apex of the triangle formed by the heads of the sternocleidomastoid is approximately 5 cm superior to the clavicle and marks the preferred needle insertion site. To access the internal jugular vein with a central approach:

●Introduce the needle lateral to the carotid pulsation at an angle 30 to 45 degrees to the skin.

●Direct the needle lateral to the sagittal plane toward the ipsilateral nipple. This path typically traverses alongside or beneath the lateral head of the sternocleidomastoid.

●The medial to lateral approach to the jugular vein may lower the incidence of carotid puncture. If used in combination with ultrasound, this facilitates more complete visualization of the needle in its entirety as it is advanced [39].

●If blood is not aspirated within 2.5 cm, withdraw the needle slowly while maintaining continuous negative pressure and watching for blood return.

●If the first needle pass fails, promptly withdraw the needle to the skin surface and redirect the needle 10 degrees medially.

Posterior — Turning the head to the contralateral side accentuates muscular landmarks and may improve access for the posterior approach (figure 2). To access the internal jugular vein with a posterior approach:

●Insert the needle along the posterior edge of the sternocleidomastoid at the junction of the middle and lower third of the muscle [38]. This point is approximately 5 cm above the clavicle and is commonly marked by presence of the external jugular vein.

●Introduce the needle beneath the posterior sternocleidomastoid and advance anteromedially toward the sternal notch.

●Any subsequent changes in needle orientation should follow a systematic approach of lateral to medial needle passes [1].

Anterior — As the name implies, the anterior technique accesses the internal jugular vein from an insertion point anterior to the sternal head of the sternocleidomastoid. To access the internal jugular vein with an anterior approach:

●Palpate the course of the carotid artery.

●Introduce the needle 5 cm above the sternum, at the midpoint of the anterior border of the sternocleidomastoid.

●Direct the needle lateral to the carotid pulsation along a plane aimed at the ipsilateral nipple.

Venous confirmation — Venous confirmation aims to verify vein puncture and exclude arterial instrumentation. Intraluminal position of the needle is first confirmed by observing needle entry into the vein with ultrasound-guided access coupled with a steady flow of dark blood into the syringe.

●Bright red and high-pressure pulsatile bleeding are important but imperfect clues to inadvertent arterial puncture, which can still occur under ultrasound-guided access attempts [40]. Moreover, the absence of these signs is not reliable for excluding arterial puncture. Dark or nonpulsatile backflow of blood may be seen with arterial puncture in the face of oxygen desaturation, hypotension, or needle malposition.

●Ultrasound visualization of the advancing needle tip to guide confirmation of vein puncture is important. Ideally, the needle (or angiocatheter) tip is monitored during cannulation. However, real time visualization of the advancing needle tip can be difficult, as the needle tip may advance outside of the ultrasound beam field and into deeper unintended structures.

Ultrasound confirmation of guidewire placement within the vein is an easy maneuver achieved by repositioning the ultrasound probe over the site to confirm venous position following guidewire insertion and prior to skin tract dilation [41-43].

●If there is any additional doubt, the needle's location can be confirmed by pressure transduction.

As an alternative, a blood gas can be drawn from the accessed venous site and compared with an arterial sample; however, blood gas analysis is more time consuming. To transduce the blood pressure:

•Attach the needle directly to the pressure tubing system.

•Alternatively, replace the needle over a guidewire with a 6-cm, 18-gauge single-lumen transduction angiocatheter (without any intervening dilation). Connect the transduction catheter to a pressure line and transducer and evaluate the pressure and waveform tracings on the monitor. Typical venous waveforms should be seen (figure 4).

•If a pressure transduction system is not available, attach a short length of saline-filled intravenous tubing to the needle and extend it vertically to measure the pressure, which should approximate expected central venous pressure (generally <12 cm) and demonstrate respiratory variation.

CATHETER PLACEMENT — Most catheters and other central venous devices are placed using the modified Seldinger technique, which refers to the intermediate step of guidewire insertion into a vessel to provide a conduit for intravascular device placement [11]. Seldinger first described the guidewire technique for arterial cannulation in 1953, and it was subsequently adopted for venous access procedures [11].

Guidewire handling — Once the jugular vein has been successfully accessed, a flexible tip guidewire is advanced through the needle or angiocatheter. Multiple types of wires are available to assist with venous access procedures. The most commonly used wire for initial jugular venous access is a flexible J-tip guidewire, favored because it negotiates curvatures and minimizes vessel trauma during passage (picture 3).

Orientation of the needle bevel and J-tip medially facilitates guidewire passage from the jugular vein into the superior vena cava rather than into the ipsilateral subclavian vein.

The guidewire should always pass smoothly and easily through the needle, dilator, or catheter without resistance. Methods to address resistance to guidewire advancement or withdrawal are discussed below.

To place the guidewire:

●Position the tapered plastic introducer to straighten the distal J-tip of the guidewire (picture 4). The orientation of the bevel tip of the introducer needle and the J-tip of the wire can help facilitate guidewire direction during advancement.

●Maintain the residual length of guidewire (50 cm standard length) under constant manual control to maintain sterility and avoid its loss off the operating field.

●Advance the guidewire only as far as needed to allow passage of the catheter over the wire. The atriocaval junction averages approximately 18 cm from most upper body access sites, and positioning guidewires and catheters any deeper is rarely needed [44,45]. These average values vary depending upon stature. In an Asian study, average distances were slightly shorter at 15 cm for the right internal jugular vein and 18 cm for the left internal jugular vein [46]. Advancing the guidewire deeper risks intracardiac or inferior vena cava (IVC) wire placement with the potential for cardiac arrhythmia, perforation, and snaring of other intravascular devices [47].

●Never forcefully advance the guidewire, as this can kink and permanently deform the wire and risk vessel injury. The guidewire should always pass smoothly and easily thorough the needle, dilator, or catheter without resistance. Resistance to guidewire passage can be due to needle dislodgement, compression of the guidewire against the vessel wall, or anatomic obstruction. Rotating the needle and/or guidewire to reorient the bevel or J-tip may relieve impingement of the guidewire on the posterior vessel wall.

●If resistance persists, remove the guidewire and aspirate blood to confirm intraluminal needle position. Reducing the attack angle of the needle to the skin may facilitate guidewire passage.

●Once the guidewire is appropriately advanced into position, secure it firmly in place and remove the needle.

●Resistance during guidewire withdrawal relative to the needle (or dilator) typically signifies a kinked guidewire. Do not forcefully withdraw the guidewire through the needle, as this can shear off the wire tip, allowing it to embolize [48]. The correct action is removal of the needle and then the wire or simultaneous removal of the needle and indwelling wire. Continued resistance to guidewire withdrawal may indicate entrapment and warrants diagnostic radiography to evaluate the wire appearance and position.

Tract dilation — Central venous catheters are substantially larger caliber than the needle and guidewire used for venous access. Dilation of the subcutaneous tissue tract is required for catheter insertion and is accomplished by threading a single stiff tapered dilator or series of dilators over the wire to expand the subcutaneous tissue and vein. The skin and fascia catheter tract should be dilated carefully with gentle pressure. Only the soft tissue and vein wall need to be dilated. Overzealous advancement and guidewire kinking (especially with stiff dilators) can lead to traumatic vein laceration. (See "Vascular complications of central venous access and their management in adults", section on 'Surgical and endovascular management'.)

To place the dilator for a standard central catheter:

●Once the guidewire is in place, make a controlled 3 mm stab incision in the skin at the entry site with a #11 blade to prevent the dilator from catching.

●Thread the stiff tapered dilator over the wire, making certain the guidewire does not advance and is not pulled out at the skin exit site. The guidewire and dilator should never be advanced as a single unit, to avoid venous injury. The wire should serve as an immobile monorail guide over which the dilator (or catheter) is passed. Cephalad traction of the skin may be needed to provide tension if there is redundant skin to avoid kinking of the wire as it traverses tissue planes.

●Hold the wire just above the dilator hub, grasp the dilator just above its tip, and advance it over the guidewire with a firm corkscrew motion (picture 5). Mild resistance is normal. Excessive resistance may represent an inadequate skin incision, malpositioned guidewire, or guidewire or dilator deformation. Kinking of the guidewire against the dilator is associated with vessel trauma and puncture [49]. Smooth, easy withdrawal of the guidewire through the dilator for several centimeters serves to confirm the absence of a kinked guidewire.

●Advance the dilator only to the anticipated depth of the jugular vein, not the entire length of the dilator. For the jugular site, the dilator need only be advanced 3 to 4 cm depending upon the thickness of the patient's neck.

●Withdraw the dilator while maintaining the guidewire position within the vessel. Apply direct pressure to the exit site (and indwelling guidewire) to maintain hemostasis prior to catheter insertion and control the guidewire.

Some indwelling tunneled jugular catheters are placed through a peel-away sheath. To place these devices, the dilator-sheath combination is placed over the wire after the tract has been dilated. The dilator and guidewire are then removed, and the catheter is placed through the sheath. Once the catheter is in place, the sheath is peeled away from the catheter and discarded. The dilator-sheath combination for large-bore tunneled catheters is stiff, and placement is facilitated with fluoroscopy, which allows imaging of the tip of the dilator and sheath, ensuring that it is placed no further into the vein than is necessary. (See 'Equipment' above.)

Positioning the catheter — After the subcutaneous tissues and vein have been dilated, the catheter is placed over the wire and advanced into position (picture 6).

To place and position the catheter, thread the guidewire back through the end-hole of the catheter until it emerges from the distal port, and advance the catheter over the wire into the vessel (picture 7). If any resistance is met with forward advancement, withdraw the catheter and re-dilate the tract.

The initial catheter insertion depth for most adults should be 16 to 18 cm for right-sided and 20 cm for left-sided jugular catheters [30]. Height-based formulas to determine insertion depth have been reported for adults and children, but there are no well-controlled studies supporting their use [50-52].

Placing a jugular venous catheter too deeply can result in serious sequelae including central vein and atrial perforation. Rare case reports implicate intracardiac catheter tip placement as a cause of cardiac tamponade [53,54]. (See "Vascular complications of central venous access and their management in adults".)

In contrast to right-sided catheters, catheters inserted from the left negotiate the angulation of the brachiocephalic vein to enter the superior vena cava. For large-bore catheters used for hemodialysis or oncology, advancement under fluoroscopic guidance helps minimize the risk of central venous laceration. The risk of complications is related to the angle of catheter impingement on the superior vena cava [30]. From the left, catheters positioned above the pericardial reflection can abut the weak lateral wall of the superior vena cava and risk erosion and perforation [55-58]. As such, left-sided catheters should be inserted to an appropriate length to lie parallel in the long axis of the superior vena cava. This may require catheter tip placement in the upper right atrium [59-61]. It is also important to realize that catheter tips are not fixed and migrate 2 to 3 cm with head and arm movement and change in body position [62].

Catheter flushing and fixation — Once the catheter is in place, the proper function of the catheter should be confirmed by aspirating blood and subsequently flushing each port with saline (picture 8) [30,63].

The catheter should then be sutured into place. The short cutaneous tract (often less than 2 cm) of jugular central venous catheters requires secure catheter fixation at the skin insertion site to avoid catheter movement along the skin tract, which carries the potential for movement of the contaminated external portion of the catheter insertion into the vessel during head movement (picture 9).

The catheter can be secured using 2-0 or 3-0 nylon or silk sutures (picture 10). If more than 2 cm of catheter remains exposed, it should also be sutured at the skin exit site via the additional catheter anchor (box-clamp) that is often included in the catheter kit. A sterile transparent dressing is placed over the catheter exit site to protect it from contamination. A number of proprietary securement devices are currently available and may be standard hospital care.

CONFIRMATION OF JUGULAR CATHETER POSITION — Confirmation of jugular catheter tip location can use one or more of the following methods: chest radiography, ultrasound, fluoroscopy, and transesophageal echocardiography (typically intraoperative setting) [41,64-71]. Chest radiography and fluoroscopy are the most commonly used methods. In general, jugular catheters function well with the tip situated in any major vein. However, suboptimal tip position may be related to delayed complications, as described below.

Following jugular catheter placement, a postprocedure chest radiograph is commonly performed to confirm catheter position and exclude pneumothorax. However, investigators have questioned the need for routine radiography for uncomplicated right internal jugular catheters placed on the first needle pass [69,72,73]. When using fluoroscopy for placement, a routine chest radiograph is unnecessary unless clinical suspicion of pneumothorax or hemothorax is high. If fluoroscopy has not been used, we often obtain a postprocedure chest radiograph to confirm catheter course and tip position prior to using jugular catheters in non-life-threatening situations. If immediate catheter use is needed, venous positioning (but not tip position) can also be confirmed with transduction of the central venous pressure, display of the central venous waveform, or with ultrasound. Bedside ultrasound is under investigation as an alternative modality to confirm catheter placement and detect pneumothorax [74].

The distal tip of jugular catheters should generally lie in the lower superior vena cava [1,45]. However, optimal catheter tip position for jugular venous catheters is controversial, and controlled studies are lacking. To minimize the likelihood of cardiac complications, some guidelines recommend catheter tip position outside the right atrium and above the pericardial reflection. The right superior heart border on chest radiography is not a reliable determinant of right atrial position [75]. The carina and right tracheobronchial angle represent reliable landmarks for the pericardial reflection, and right-sided catheters should generally be positioned above this point [75-77].

Malposition occurs in up to one-third of jugular catheter insertions but varies depending upon the definition of malposition. If a catheter is malpositioned within the venous system, it can be used for fluid and drug administration under emergency circumstances but should be repositioned as soon as feasible.

●If a jugular catheter tip is positioned too deeply, it can be withdrawn at the bedside using sterile technique. Remove the sutures, withdraw the catheter, and resecure the catheter into place.

●If a catheter is not in far enough or is misplaced into the contralateral subclavian or internal jugular vein, it will need to be replaced entirely or replaced over a guidewire under sterile conditions. The portion of a catheter left out of the body is unsterile and should never be advanced into the patient, not even if it is under a sterile dressing.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access".)

SUMMARY AND RECOMMENDATIONS

●Jugular venous access – The jugular veins are common access sites for central venous access, which provides dependable intravenous access and enable hemodynamic monitoring and blood sampling. Jugular catheters are placed using an orderly sequence of steps incorporating the modified Seldinger technique (table 2). The borders of the sternocleidomastoid muscle provide important anatomic landmarks for internal jugular cannulation using one of three common approaches (central, posterior, or anterior). (See 'General preparation' above and 'Internal jugular vein cannulation' above and 'Catheter placement' above.)

●Patient positioning – Patient positioning that maximizes the diameter of the internal jugular vein is associated with increased cannulation success. For jugular venous cannulation, these include Trendelenburg position, slight head elevation, and the use of Valsalva. These maneuvers may also reduce the risk of venous air embolism. (See 'Positioning' above.)

●Ultrasound guidance – When equipment and expertise are available, we recommend that children and adults undergoing jugular vein cannulation should have the procedure guided by ultrasound rather than using landmark technique alone. Ultrasound guidance improves initial cannulation success. (See 'Dynamic ultrasound-guided access' above and "Central venous access in adults: General principles", section on 'Internal jugular'.)

●Inadvertent arterial puncture – Carotid artery puncture is a well-recognized complication of attempted internal jugular vein cannulation and can be managed by withdrawing the needle and applying pressure over the site for 5 to 10 minutes. Venous access can be reattempted, provided there is minimal distortion of surface and ultrasound-based landmarks from hematoma. The greatest risk of serious carotid injury complications occurs with inadvertent dilation and cannulation of the artery, which can cause thrombosis and major stroke. A number of steps are described above to avoid arterial cannulation and confirm venous puncture. If arterial catheterization is confirmed, the catheter should be left in place and a vascular surgery consultation obtained immediately. (See 'Venous confirmation' above and "Vascular complications of central venous access and their management in adults", section on 'Inadvertent arterial puncture'.)

●Catheter tip confirmation – Following placement of jugular venous catheters, we often obtain a postprocedure chest radiograph to confirm correct catheter position and assess for pneumothorax. The need to confirm placement in all patients undergoing jugular venous access is controversial. Radiographic confirmation can likely be omitted following procedures performed with ultrasound or fluoroscopy guidance, particularly if access was achieved in a single needle pass. (See 'Confirmation of jugular catheter position' above.)

●Catheter malposition – The distal tip of jugular catheters should lie in the lower superior vena cava.

•If an internal jugular catheter is placed too deeply, it can be withdrawn at the bedside using sterile techniques.

•If the catheter is not placed deeply enough or is malpositioned, the catheter should be replaced over a guidewire under sterile conditions. The portion of a catheter left out of the body is unsterile and should never be advanced into the patient. (See 'Catheter placement' above.)