External Jugular Venous Catheter

                                                5/6/03 version

 

The external jugular vein is a peripheral vein that generally is neither collapsed (with a patient in a Trendelenberg position) nor thrombosed. This site is often difficult for the patient because the catheter entrance and the dressing are on the patient's neck. The external jugular vein may be the site of last resort when a patient needs peripheral access but other veins are not usable. The external jugular vein may be used for non-sclerosing fluid administration. Note that, as with other IV sites, shorter catheters of a given caliber can deliver more fluid than a longer catheter, and shorter catheters may be preferred in the situation where large amounts of fluid are being given emergently.

 

Indications:

• Placement of a venous access line when other peripheral sites are unavailable. Placement of a large-bore venous catheter in an emergent situation to deliver a high flow of fluid or blood products
• Rarely, for central venous pressure measurement or other CVP catheter uses
• (transvenous pacemaker, pulmonary wedge catheter, etc.)

 

Contraindications:

• Infection over the insertion site
• Lack of anatomic landmarks due to neck size, shape or deformities
• Suspected or proven fracture of the cervical spine
• With coagulopathies, other more easily compressible sites should be considered.
• Patients unable to tolerate a Trendelenberg position
• Unsuccessful contralateral attempt at insertion with resultant hematoma

 

Materials:

• Universal precaution material
• Tape and dressings
• Lidocaine (1 % lidocaine mixed 50:50 with sodium bicarbonate will lessen the sting of the lidocaine)
• Syringe (5 cc) and 25 gauge needle
• IV tubing
• IV fluid
• Prep wipes for the neck
• Large bore IV catheter over needle (for adults, 14 to 18 gauge)

 

Preprocedure patient education:

• Obtain informed consent
• Inform the patient of the possibility of major complications and their treatment . Explain the major steps of the procedure
• Explain the necessity of a prolonged Trendelenberg position

Procedure:

• Use Universal Precautions and sterile technique
• Attach the IV tubing to the IV fluids and place at the bedside on an IV pole
• Place the patient in a Trendelenberg position (15 to 30 degrees head down) to reduce the chance of an air embolism
• Turn the patient's head away from the side chosen for insertion
• Prep and drape the entire side of the neck chosen
• Identify the vein
• Patient Valsalva may help engorge the vein
• The vein runs from the angle of the mandible infero-Iaterally to the clavicle, crossing the sternomcleidomastoid muscle 5 cm above the clavicle
• Choose a site at about the midpoint of the vein
• Make a skin wheal with the lidocaine and a 25 gauge needle at the chosen site
• Stretch the skin over the external jugular vein cephalad with your free hand
• Using the other hand, insert the catheter over needle aiming along the axis of the vein toward the clavicle (the vein is generally shallower than one might think)
• When a flash of blood returns, advance the catheter over the needle and remove the needle
• Attach the IV tubing to the catheter and secure the catheter to the neck with tape . Turn on the IV fluids to ascertain that there is good flow.

·        For an additional check to ascertain good flow into the vein, remove the IV solution from the pole and lower the bag below the level of the patient to establish that there is blood return from the vein.

·        Return the solution bag to the IV pole and regulate the flow of the fluid as necessary.

 

Complications, Prevention and Management:

·        Local hematoma

o       Prevention: going too deep might lacerate the deep wall of the vein or too superficially the superficial wall of the vein. To prevent this, take care to strictly follow the axis of the vein during insertion.

o       Management: Local pressure (but never circumferentially applied)

·        Laceration of the deeper internal jugular vein

o       Prevention: Do not insert the needle deeply for this procedure

o       Management: Local pressure as above

·        Infection:

o       Prevention: Sterile procedure, and never through infected skin

o       Management: Appropriate antibiotics

·        Air embolism

• Prevention: Maintain a Trendelenberg position, have the patient exhale while advancing the catheter, and maintain a "closed" system
• Management: Place the patient in a left lateral decubitis, head down position to minimize the chances of an air embolism to the brain

Documentation in the medical record:

• Consent if obtained
• The indications and any contraindications for the procedure on this patient . The procedure

      used including prep, anesthetic, type of needle

• Any complications or "none"
• Who was notified about any complication (family, attending physician, etc.)

 

Helpful hints:

• Before removing the needle, slightly bend the IV catheter upwards in its sterile sheath. This "prebending" of the needle allows you to enter the vein in a more shallow fashion, reducing the chances of going too deeply (the external jugular vein, in average sized people is surprisingly shallow)

 

Items for evaluation of person learning this procedure:

• Anatomy of the external jugular vein
• Indications for this procedure
• Contraindications for this procedure
• Interaction between the professional and the patient, family, etc.
• Use of sterile procedure and Universal Precautions
• Technical ability
• Appropriate documentation
• Understanding of potential complications and their correction