External jugular vein cannulation is an integral part of modern medicine and is practiced in virtually every health care setting. Venous access allows sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products. This topic describes placement of an intravenous (IV) catheter into the external jugular vein. A similar technique can be used for placement of IV catheters at different anatomic sites.
Indications for external jugular vein cannulation include the following:
- Repeated blood sampling
- IV fluid administration
- IV medications administration
- IV chemotherapy administration
- IV nutritional support
- IV blood or blood products administration
- Intravenous administration of radiologic contrast agents (eg, for computed tomography [CT], magnetic resonance imaging [MRI], or nuclear imaging)
Note that many institutions will not allow administration of a high-pressure IV contrast agent into an external jugular vein.
No absolute contraindications exist for external jugular vein cannulation.
Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible.
Vesicant solutions can cause blistering and tissue necrosis if they leak into the tissue. Irritant solutions (pH < 5, pH >9, or osmolarity >600 mOsm/L, including sclerosing solutions, some chemotherapeutic agents, and vasopressors) also are more safely infused into a central vein. Therefore, these solutions should only be given through a peripheral vein in emergency situations or when central venous access is not readily available.
Veins with high internal pressure become engorged and are easier to access. The use of dependent positioning, proximal compression with a finger, “pumping” via muscle contraction and the local application of heat or nitroglycerin ointment can contribute to venous engorgement. The external jugular vein begins at the level of the mandible and runs obliquely across and superficial to the sternocleidomastoid (see the image below).
Some patients have double external jugular veins. Placing a patient in the Trendelenburg position, slightly tilting the head to the opposite side, and applying light pressure above the clavicle will help engorge the external jugular vein and facilitate its catheterization.
This topic describes the use of the over-the-needle type of IV catheter, in which the catheter is mounted on the needle (see the first image below). Such devices are available in various gauges (16-24 gauge), lengths (25-45 mm), compositions, and designs (see the second image below).
In general, it is advisable to select the smallest-gauge catheter that can be used for the prescribed therapy so as to prevent damage to the vessel intima and ensure adequate blood flow around the catheter, thus reducing the risk of phlebitis. In an emergency situation or when patients are expected to require large volumes infused over a short period of time, the largest-gauge and shortest catheter that is likely to fit the chosen vein should be used. The catheter chosen should always be slightly smaller than the vein.
Necessary equipment includes the following (see the image below):
- Nonsterile gloves
- Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol)
- Local anesthetic solution
- 1 mL syringe with a 30-gauge needle
- 2 × 2 gauze
- Venous access device
- Vacuum collection tubes and adaptor
- Saline or heparin lock
- Saline or heparin solution
- Transparent dressing
- Paper tape
Patient preparationAnesthesia Both intradermal injection of a topical anesthetic agent just before IV insertion and topical application of a local anesthetic cream about 30 minutes before IV insertion, have been shown to significantly reduce the pain associated with IV catheterization. One or the other should be used unless the situation is an emergency.
Make sure that there is adequate light and that the room is warm enough to encourage vasodilation. Adjust the height of the bed to make sure that you are comfortable and to prevent unnecessary bending. Make sure the patient is in a comfortable position. Most of the time, the pillow will have to be removed in order to facilitate visualization of the engorged external jugular vein. Place the patient in the Trendelenburg position, slightly tilting the head to the opposite side (see the image below). Application of light pressure above the clavicle (proximal to the vein entry point) will help to engorge the external jugular vein and assist in its catheterization.
The patient’s skin should be washed with soap and water if it is visibly dirty. Because infants and young children are unlikely to cooperate, it is recommended that an assistant aid in stabilizing the head and body during the procedure.
Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes. Cannulation of the external jugular vein is outlined in the following section and illustrated in the video below.
Insertion of intravenous catheter
As noted (see Patient Preparation), the patient is placed in the Trendelenburg position, with the head slightly tilted to the opposite side. Note that the external jugular vein tends to collapse during the patient’s inspiration, especially in patients who are volume-depleted (see the first image below). When this occurs, application of mild pressure over the vein just above the patient’s clavicle may help engorge the vein (see the second image below).
Select a proximal site for IV catheter insertion, preferably as far from the clavicle as possible so as order to avoid accidental lung puncture. If difficulty is encountered in finding an appropriate vein, one of the following techniques may be used: inspection of the opposite side, gravity (increased Trendelenburg), gentle tapping or stroking of the site, or applying heat (warm towel/pack).
Ultrasound guidance has been shown to facilitate peripheral venous placement in emergency department patients with difficult IV access. It should be used when appropriate veins are not readily visualized or palpable. Apply an antiseptic solution such as 2% chlorhexidine solution or 70% alcohol with friction for 30-60 seconds (see the image below). Allow it to air-dry for up to 1 minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin. Once the skin is cleaned, do not touch or repalpate it.
While the skin is allowed to dry, flush the saline or heparin lock with the appropriate solution. The syringe may be left attached to the tubing. If blood sampling via a syringe is planned, the saline/heparin lock should not be flushed, but an empty syringe may be connected to it. If the patient is interested in local anesthesia and the situation is not an emergency, infiltrate 0.5-1 mL of a local anesthetic using a 25- or 30-gauge needle to raise a wheal at the site of catheter insertion.
Stabilize the vein using your nondominant hand (thumb), applying traction to the skin distal to the chosen site of insertion. This will prevent the vein from rolling away from the needle. Stabilization should be maintained throughout the procedure. (See the image below.)
Hold the venous access device in your dominant hand, with the bevel up. This will ensure smoother catheterization because the sharpest part of the needle will penetrate the skin first. Release the needle from the catheter and replace it, confirming that the catheter was not damaged or fragmented. This will ensure smooth advancement once the venous access device is inside the vein. The angle of the needle entry into the skin will vary according to the device used and the depth of the vein. Because the external jugular vein is usually very superficial, it is best accessed at an angle of 10º-25º (see in the image below).
Upon entry into the vein, the practitioner might feel a “giving way” sensation, and blood should appear in the chamber of the venous access device (ie, flashback; see the image below). The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should then be advanced gently and smoothly an additional 2-3 mm into the vein.
If no blood is observed in the flashback chamber, the device should be withdrawn to just beneath the skin level, and another attempt to recatheterize the vein should take place. Flashback may stop if the device punctured the posterior wall of the vein or if the patient is extremely hypotensive. If swelling develops, withdraw the device, release the tourniquet, and apply direct pressure for 5 minutes as a hematoma developed.
If venous catheterization is unsuccessful, the needle should never be reintroduced into the catheter, because this could result in catheter fragmentation and embolism. While maintaining skin traction with your nondominant hand after the hub of the venous access device was dropped to the skin, hold the needle grip portion of the venous access device in place between your dominant thumb and middle finger, while using your dominant index finger to slide the hub of the catheter over the needle and into the vein. (See the image below.)
While using your nondominant middle finger to apply pressure over the catheter to prevent blood spill and holding the hub in place using your nondominant index and thumb fingers, use your dominant hand to withdraw the needle and secure it in its safety cover, a dedicated biohazard sharps container, or both. If blood sampling is needed, use a syringe or attach an adaptor or a syringe to the hub, and obtain the required samples. While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before, disconnect the blood sampling adaptor or syringe, and securely attach the preflushed saline or heparin lock to the hub of the venous access device. (See the image below.)
Using the saline or heparin flush syringe, withdraw a small amount of blood to confirm that the catheter is still inside the vein, then immediately flush the tubing with the remaining solution. Slide the plastic tubing lock and continue to lock the tubing, if such a lock is available. (See the image below.)
Secure the venous access device to the skin using the transparent dressing and tape (see the first image below). Finish securing the tubing to the skin using tape (see the second image below). Place a label indicating date, time, and other facility-required information over the transparent dressing.
Removal of intravenous catheter
Stop the infusion solution and disconnect the tubing, leaving just the saline/heparin lock tubing connected to the venous access device. Release the adhesive tape and transparent dressing from the skin. Withdraw the catheter outside of the vein and apply direct pressure with gauze for at least 5 minutes. Inspect the catheter for fragmentation and document in the patient’s chart the date, time, and reason for catheter removal and the integrity of the catheter as inspected. Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the IV insertion site, and instruct the patient to continue manual pressure for 10 more minutes to minimize hematoma formation.
To minimize pain, whenever possible, an anesthetic cream should be applied 30 minutes before an insertion attempt, an anesthetic solution should be subcutaneously infiltrated before peripheral IV insertion, or both should be done.
Collapse of the vein, inadequate skin traction, incorrect positioning, and incorrect angle of penetration can all lead to a failed attempt. Either attempt insertion at a different site or, if you believe that the selected vein should be accessible, withdraw the venous access device to just beneath the skin and reattempt insertion.
If blood stops flowing into the flashback chamber, the cause might be vein collapse, venospasm, needle hub position against a venous valve, or penetration of the posterior wall of the vein. Observation of a developing hematoma will necessitate removal of the catheter. Release and then reapply the venous tourniquet, and attempt to gently stroke the vein to engorge it with blood and release venospasm. Finally, attempt to withdraw the needle a few millimeters to move it away from a valve.
If there is difficulty advancing the catheter over the needle and into the vein, the cause might be failure to release the catheter from the needle before insertion, encountering a venous valve, removing the needle too far with the catheter being too soft to advance into the vein, poor skin traction, or venous collapse. Release the tourniquet, then reapply it to help engorge the vein. Connect a syringe with normal saline (0.9%) solution to the hub, then attempt to “float” the device in place by flushing the catheter and advancing it at the same time.
If there is difficulty flushing after the catheter was placed in a vein, the cause might be positioning of the catheter tip against a venous wall or a valve, a blood clot, or piercing of the venous wall. Observation of a hematoma will necessitate removal of the catheter. Withdraw the catheter slightly to release it from a wall/valve, and attempt to flush it back in.
Palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. Because the external jugular vein is superficial to the internal jugular vein and the carotid artery, make sure to enter the skin at a shallow angle (~10 º). Maintain this angle or an even more acute one as you advance the catheter. If an accidental arterial puncture occurs, as evidenced by arterial pulsation of blood out of the catheter, remove the catheter and apply direct pressure using gauze for at least 10 minutes.
Thrombophlebitis can be caused by either thrombus formation with subsequent inflammation and/or infection. Pain to the IV site along the path of the catheter, skin erythema and/or induration, swelling, drainage from the skin puncture site, or presence of a palpable venous cord are the signs of thrombophlebitis. If you suspect an infectious etiology, remove the catheter and treat with appropriate antibiotics.
Regularly and at least daily inspect the site of insertion for signs of infections. Some sources recommend the routine replacement of peripherally inserted IV catheters every 3-4 days, whereas others suggest that with proper antiseptic technique and at least daily monitoring of the insertion sites, less frequent replacement may be safe, as long as no signs of phlebitis are present.
Some vesicant and irritant solutions may cause severe soft-tissue damage if they extravasate outside of the vein and into the surrounding tissue.