How can I access the internal jugular vein (IJV) without ultrasound guidance?

Internal Jugular Vein Access Without Ultrasound

While ultrasound guidance is now the standard of care and strongly recommended by multiple international guidelines, landmark-based internal jugular vein (IJV) cannulation remains a viable technique when ultrasound is unavailable in emergencies or in resource-limited settings. 1

Current Standard of Care Context

Ultrasound guidance should be used routinely for IJV catheterization unless in emergency situations or when the technology is unavailable. 1 Multiple guidelines from the Association of Anaesthetists of Great Britain and Ireland, international consensus statements, and systematic reviews demonstrate that ultrasound reduces complications by 71%, arterial puncture by 72%, and increases first-pass success by 57% compared to landmark techniques. 1, 2

However, landmark techniques remain relevant because:

• Ultrasound may be unavailable in true emergencies 1
• Resource-limited settings may lack ultrasound technology 1
• Understanding landmark anatomy remains foundational knowledge 1

Landmark-Based Technique for IJV Access

Patient Positioning

• Place patient in 15-30 degrees Trendelenburg position to distend neck veins and reduce air embolism risk 3
• Rotate head 30 degrees to the contralateral side - this is the optimal angle that maximizes the safe puncture window while minimizing IJV-carotid artery overlap 4
• Avoid excessive head rotation beyond 45 degrees, as this significantly increases the overlapping angle between the IJV and carotid artery, raising arterial puncture risk 4

Anatomical Landmarks - Central Approach

• Identify the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle 3
• The apex of this triangle is at the level of the cricoid cartilage 5
• Insert needle at the apex, lateral to the carotid artery pulsation 3
• Direct needle caudally toward the ipsilateral nipple at 30-45 degree angle to the skin 3
• Advance while maintaining gentle negative pressure on the syringe 3

Critical Safety Considerations

Carotid artery puncture is the most common complication, occurring in 2.3-33% of landmark-guided attempts depending on operator experience. 6, 3 To minimize this risk:

• Always palpate the carotid artery and insert lateral to the pulsation 3
• Recognize that the IJV is anterior to the carotid artery in 97% of cases, not truly lateral as traditionally taught 5
• The IJV position varies: on the right side it is more frequently anterolateral, while on the left it is more frequently anteromedial 5
• Limit attempts to 3-5 maximum before seeking alternative access or assistance 3

Expected Success Rates Without Ultrasound

Landmark technique in experienced hands achieves:

• 100% eventual success rate in standard patients 3
• 80-83% first-attempt success with experienced operators 6, 3
• Mean cannulation time of 6.89 ± 3.2 minutes 3
• 20% first-attempt success in less experienced operators 6

High-Risk Patients Requiring Special Caution

Landmark technique should be avoided or used with extreme caution in:

• Patients with coagulopathies (hepatic failure, anticoagulation, HELLP syndrome) 6
• Patients with no external landmarks (anasarca, obesity, short neck) 6
• Patients who cannot maintain horizontal position 6
• Patients with previous failed attempts 6

In these populations, ultrasound guidance achieved 100% first-attempt success with zero complications, compared to 20% first-attempt success and 33% carotid puncture rate with landmarks. 6

Site Selection Without Ultrasound

The right IJV is preferred over the left for landmark-based access because:

• More direct path to superior vena cava 1
• Lower risk of thoracic duct injury 1
• More predictable anatomy 5

Avoid subclavian vein in patients with advanced kidney disease - this causes central venous stenosis in a high proportion of patients, permanently precluding future arteriovenous fistula creation in the ipsilateral arm. 7

Avoid femoral vein unless contraindications exist to other sites due to significantly higher infection risk and thrombosis concerns. 1

Post-Procedure Verification

Radiologic confirmation of catheter tip position is mandatory with either:

• Intraoperative fluoroscopy, or
• Post-procedure chest X-ray 1

The desired catheter tip location is at the junction between the right atrium and superior vena cava. 1

Obtain chest X-ray if patient develops dyspnea or chest wall pain to rule out pneumothorax or hemothorax. 1

Training Considerations

In settings where ultrasound is widely available, it is no longer practical to train operators to full competency in landmark techniques alone. 1 However, understanding landmark anatomy remains useful for rare situations when ultrasound cannot be used. 1

Simulation-based training on phantoms or manikins should be routinely available to improve novice technique before attempting procedures on patients. 1

Common Pitfalls to Avoid

• Excessive head rotation (>45 degrees) increases IJV-carotid overlap and arterial puncture risk 4
• Multiple blind attempts - stop after 3-5 attempts and seek alternative access or assistance 3
• Assuming lateral IJV position - the vein is actually anterior to the carotid in 97% of cases 5
• Using subclavian approach in renal patients - this permanently damages future dialysis access options 7
• Proceeding without proper positioning - Trendelenburg and appropriate head rotation are essential 3, 4