What is the procedure for external jugular vein cannulation?

From the Guidelines

External jugular cannulation should be performed with caution and as a last resort, considering the potential risks and limitations, and prioritizing ultrasound-guided internal jugular central venous catheter insertion when possible, as recommended by the Association of Anaesthetists of Great Britain and Ireland in 2016 1. To perform external jugular cannulation, the following steps can be taken:

• Position the patient in a Trendelenburg position (head down at 15-30 degrees) with the head turned away from the side being cannulated
• Identify the external jugular vein, which runs from the angle of the jaw to the middle of the clavicle
• Clean the site with chlorhexidine or povidone-iodine
• Apply traction below the insertion site to prevent vein collapse
• Insert a 16-18G catheter at a 30-degree angle in the direction of blood flow (toward the heart)
• Aspirate to confirm placement, then advance the catheter while withdrawing the needle
• Secure the catheter with transparent dressing and document the procedure However, it is essential to note that the use of ultrasound should be considered early if arterial or peripheral venous cannulation proves difficult, as stated in the recommendations by the Association of Anaesthetists of Great Britain and Ireland 1. The limitations and potential risks of external jugular cannulation, including lower success rates than internal jugular approaches, risk of pneumothorax, and potential for air embolism, should be carefully weighed against the benefits of the procedure. In emergency situations or when peripheral access is difficult, external jugular cannulation may be a valuable option, but it is crucial to prioritize safe and effective vascular access, as emphasized by the Association of Anaesthetists of Great Britain and Ireland 1.

From the Research

External Jugular Cannulation

• External jugular vein cannulation is a viable alternative to internal jugular vein cannulation, with a success rate of 78% compared to 88% for internal jugular vein cannulation 2.
• The external jugular vein cannulation was found to be quicker than internal jugular vein cannulation, with a significant difference in cannulation time (p = 0.01) 2.
• The use of ultrasound guidance for central venous catheterization, including external jugular vein cannulation, has been shown to reduce complications and improve success rates 3, 4, 5, 6.

Ultrasound Guidance

• Ultrasound guidance for internal jugular vein cannulation has been shown to reduce the rate of mechanical, infectious, and thrombotic complications by 57%, and reduce the failure rate by 86% 4.
• The use of ultrasound guidance for external jugular vein cannulation has been evaluated, with mixed results, and further studies are needed to determine its effectiveness 5.
• Different transducer orientation approaches for ultrasound-guided internal jugular venous cannulation have been compared, with the oblique-axis approach showing a higher first needle pass success rate and lower mechanical complication rate 6.

Complications and Success Rates

• The internal jugular vein group had a total of 20% complications, while the external jugular vein group had 28% complications, although the complications were more severe in the internal jugular vein group 2.
• The success rate of central cannulation via the external jugular vein approach was 42% in one study, with no significant difference between the conventional surface anatomy landmark technique and the ultrasound-guided technique 5.
• The first needle pass success rate for ultrasound-guided internal jugular venous cannulation was higher for the oblique-axis approach (73.6%) compared to the short-axis (69.9%) and long-axis (52%) approaches 6.