What are the recommendations for external jugular venous cannulation?

External Jugular Venous Cannulation

The external jugular vein (EJV) is an acceptable alternative access site for central venous catheterization when the internal jugular vein is unavailable, though it presents technical challenges in achieving proper central catheter tip positioning and should not be considered a first-line approach. 1

Site Selection Hierarchy

The right internal jugular vein remains the preferred first-line access site due to its straighter anatomical course to the superior vena cava and easier catheter positioning. 1 When the internal jugular vein is not accessible, the right EJV is preferred over the left EJV because it provides a more direct anatomical route to central veins. 1

Upper body insertion sites (including EJV) should be prioritized over femoral access to minimize infection and thrombotic complications. 1 Specifically, femoral catheters should not remain in place longer than 5 days and should only be used in bed-bound patients. 1

Technical Considerations and Challenges

Central catheter positioning through the EJV is technically more difficult than through the internal jugular vein due to the anatomical course and valve structures. 1 This is a critical pitfall—do not assume the EJV will provide easy central catheter positioning. 1

Procedural Technique

• Position the patient in Trendelenburg when clinically appropriate to increase vein distension. 2
• Use maximal sterile barrier precautions including cap, mask, sterile gown, sterile gloves, and sterile full body drape. 2
• Select the smallest catheter diameter appropriate for the clinical situation to reduce vein trauma. 2
• Use a catheter with the minimum number of ports or lumens essential for patient management. 2

Ultrasound Guidance

While the evidence base for ultrasound guidance focuses primarily on internal jugular vein cannulation, ultrasound imaging offers cannulation opportunities for the external jugular vein that may not be possible with anatomical landmarks alone. 3 Pre-cannulation ultrasound examination can assess vessel size, depth, patency, and proximity to vital structures. 3

Confirmation of Placement

Always verify catheter tip position with chest X-ray after insertion. 1 This is non-negotiable for EJV cannulation given the technical difficulty in achieving proper positioning. The catheter tip should be positioned in the lower superior vena cava or upper right atrium, parallel to the vessel wall. 1

After insertion, confirm venous access using methods such as ultrasound, manometry, pressure-waveform analysis, or venous blood gas measurement. 2 Do not rely solely on blood color or absence of pulsatile flow to confirm venous placement. 2

Comparison with Alternative Sites

When comparing success rates using landmark technique, a 2024 study found internal jugular vein cannulation had an 88% success rate versus 78% for external jugular vein (though this difference was not statistically significant). 4 However, EJV cannulation was comparatively quicker. 4 Complications occurred in 28% of EJV cases versus 20% of internal jugular cases, though complications were more severe in the internal jugular group. 4

Critical Pitfalls to Avoid

• Never assume the EJV will provide easy central catheter positioning—the anatomical course makes tip placement more challenging than internal jugular vein. 1
• Do not use the EJV as first-line access when the right internal jugular vein is available and patent. 1
• Always obtain post-insertion chest X-ray to verify proper catheter tip position. 1
• Be vigilant about air embolism risk through open hubs of EJV cannulas—this catastrophic complication has been reported and requires adequate precaution in the operating theater, intensive care unit, or wards. 5
• Promptly remove any intravascular catheter that is no longer essential. 2