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Chapter 9

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152
Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade,
M. Foley, J. Phelan and G. Dildy. © 2010 Blackwell Publishing Ltd.
10
Vascular Access
Gayle Olson
1
& Aristides P. Koutrouvelis
2

1
Department of Obstetrics and Gynecology, Division of Maternal - Fetal Medicine, University of Texas Medical Branch,
Galveston, TX, USA

2
Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA
Introduction
Placement and maintenance of vascular access can be an impor-
tant adjunct in the care of the critically ill obstetric patient.
Arterial and venous access affords the clinician several advantages
(Table 10.1 ). Long - term central intravenous (IV) access may also
be indicated for gravidas with coexisting disease such as those
illustrated in Table 10.2 , for the administration of parenteral
nutrition, drugs, or antibiotics [1 – 4] .
Establishing central venous and arterial access are acquired
skills that require knowledge of catheter types, access routes,
insertion techniques and maintenance.
Catheter t ype
Choosing the venous catheter type and the site for insertion are
infl uenced by indication (Table 10.2 ), duration of use, urgency
of administration, and the composition of infusate (i.e., osmolar-
ity, tonicity, crystalloid, colloid). Catheters with shorter lengths
and larger diameters allow for more rapid fl ow rates. For example,
coupling of tube diameter (0.71 mm or 22 gauge vs 1.65 mm or
16 gauge) results in almost a quadrupling of the fl ow rate (25 mL/
min vs 96 mL/min) [5] . Multilumen catheters are routinely used
for central venous cannulation (Figure 10.1 ). The more com-
monly used triple - lumen catheter has an outside diameter of

2.3 mm (6.9 French) and provides three channels (three 18 -
gauge, two 18 - gauge plus one 16 - gauge). The opening of each
channel is separated from the other by 1 cm or more in order to
reduce mixing of infusates.
Intravenous catheters are considered to be short - or long - term
transcutaneous, or implantable subcutaneously (Table 10.3 ) as
well as peripheral or central. A peripheral location is distal to a
central vein and contains valves. In contrast, a centrally located
catheter contains no valves and is considered to be at the level of
the axillary or common femoral vein, and all other veins oriented
toward the heart from this level. The use of the terminology
“ peripheral ” and “ central ” is also based on the peripheral or
central location of insertion and the location of the catheter tip.
Central vein cannulation is required to accommodate the large -
bore catheters necessary for high - volume administration rates.
When administering highly osmolar, sclerotic, or thrombotic IV
fl uids, most clinicians agree that the catheter tip should be placed
near the heart in the superior or inferior vena cava, although
optimal placement has not been established in prospective human
studies [6] .
Short - term (less than 2 weeks) transcutaneous catheters are
constructed of polyethylene, polyurethane, polycarbonate, vinyl
chloride, or silicone and are available in multiple lengths, diam-
eters, and lumen numbers. Short - term transcutaneous catheters
are suitable for most obstetric patients in the “ diffi cult access ”
group (i.e. history of IV drug abuse, IV chemotherapy, hypovo-
lemia) and for others with rapidly resolvable clinical conditions.
Because of the intended short duration of use, sites on the lower
extremities, such as pedal, saphenous, and femoral veins, might
be selected; however, decreased mobility and increased risk of

catheter dislodgement are among the disadvantages of lower -
extremity access locations.
Long - term (weeks to months) transcutaneous catheters are
usually constructed of more fl exible and less thrombogenic deriv-
atives of silicone, and are passed through a subcutaneous tunnel
between the points of venous insertion and exit from the skin
[7,8] . Frequently, these catheters incorporate a Dacron cuff just
proximal to the skin exit site. Catheter tunneling and the Dacron
cuff promote tissue ingrowth and fi xation and limit the spread of
skin exit - site colonization or infection. Long - term catheters may
incorporate a Groshong valve tip [9,10] . Such catheters are blind -
ended, but incorporate a side slit near the catheter tip. Positive
pressure exerted through the catheter blows the slit walls open
outwardly for fl uid or medication administration, while negative
pressure draws the slit walls inward for blood sampling. At rest,
Vascular Access
153
the catheter is closed, theoretically obviating the need for hepa-
rinization between periods of catheter use. Venous sites com-
monly used for long - term catheter use include the subclavian,
external and internal jugular, basilic, and greater saphenous
veins. When the femoral, greater saphenous, or basilic veins are
used, the catheter is tunneled to allow for port placement onto
the lower chest, abdominal wall, thigh or forearm [11] .
Peripherally inserted central venous catheters (PICCs), intro-
duced in 1975 [12] , are increasingly popular due to the ease of
insertion compared with traditionally placed surgical catheters
(e.g. Hickman ports, central venous ports) with potentially fewer
complications [13] .
Totally implantable venous access systems (TIVAs), generi-

cally known as portacath, utilize catheters attached to reservoirs
placed into subcutaneous pockets. These systems are indicated
for very long - term use (months to years), typically in patients
requiring intermittent medications. During catheter use, the res-
ervoir is accessed with the use of a special Huber - point needle
that uses a non - coring tip. Though surgical insertion is required
for implantable catheters, the early and late complications asso-
ciated with venous access are reduced with implantable catheters
[14] . Ideally, reservoirs for implantable catheters should be
placed in a secure, fl at, non - mobile area, preferably overlying a
rib.
Arterial catheters should be used for specifi c purposes and for
short time intervals. Arteries that are accessible to palpation and
that can usually be cannulated include (in order of preference)
the radial, dorsalis pedis, femoral, axillary, and brachial. In
general, for an artery to be suitable for continuous monitoring of
intraarterial pressures: (i) the diameter should be large enough to
accommodate the catheter without occluding the lumen; (ii)
Table 10.1 Advantages of vascular access in the critically ill obstetric patient.
Vascular access site Advantages
Artery Continued access for:
blood pressure monitoring
frequent arterial sampling
Central venous Rapid fl uid and blood administration
Hemodynamic monitoring
Table 10.2 Indications for prolonged venous access.

Parenteral nutrition and drug therapy

Hyperemesis gravidarum

Infl ammatory bowel disease
Gastroparesis
Pancreatitis
Cystic fi brosis
Short bowel syndrome
Heparin (heart valves, deep vein thrombosis)
Antibiotics (bacterial endocarditis, osteomyelitis)
Chemotherapeutic agents for malignancy
Magnesium sulfate

Lack of peripheral access

Previous intravenous drug abuse
Previous prolonged chemotherapy

Hemodialysis

Figure 10.1 Multilumen catheter insertion set - up.
From left to right: small fi nder needle, larger needle,
guidewire, scalpel, dilator, triple lumen catheter,
anchor and suture.
Chapter 10
154
well on dirty skin [20,21] . The most popular antiseptic agents are
chlorhexidine gluconate and the povidone - iodine preparation
betadine. Betadine is a water - soluble complex of iodine with a
carrier molecule. Iodine is slowly released from the carrier mol-
ecule, thus reducing any irritating effects. Due to this slow release,
the preparation should be left in contact with the skin for at least
2 minutes [20 – 22] . In one study, a 2% aqueous solution of cho-

rhexidine gluconate demonstrated superior antiseptic properties
compared to 10% providone - iodine and 70% alcohol [16] .
However, different concentrations of chorhexidine gluconate
may not have the same effi cacy. Shaving at catheter insertion sites
is not recommended as it abrades the skin and promotes bacterial
colonization. If hair removal is necessary, it should be clipped.
After the catheter has been inserted and secured, a dressing
should be placed over the site. Gauze or transparent dressings
may be used as both approaches have similar rates of catheter -
related infection.
Catheterization t echniques – g eneral
Three catheterization techniques are available to obtain vascular
access: direct, modifi ed and classic Seldinger techniques. The
direct approach involves palpation and direct needle puncture,
usually with the advancement of a Tefl on catheter over the needle
and into the vessel. The Seldinger [23] technique involves the use
of a guidewire. This approach is used to replace the needle during
percutaneous arteriography. Once the vessel has been punctured
and the return of blood fl ow (pulsatile in cases of arterial punc-
ture) is achieved, needle advancement ceases and a fi ne, fl exible
there should be adequate collateral circulation; (iii) the site
should be such that catheter care can be facilitated; and (iv) the
site should not be prone to contamination.
Preparing for c atheter i nsertion
Before cannulation of any vessel, it is necessary to assure patency
of the vessel. Contraindications to vessel cannulation include
infection or infl ammation at the site, arterial – venous or aneurys-
mal malformations, and arterial graft. Coagulopathy is a relative
contraindication to cannulation. In the presence of coagulopathy,
the use of Doppler to identify the location of vessels reduces

complications. Catheter insertion has been demonstrated in 242
patients with corrected coagulopathy and 88 with uncorrected
coagulopathy. In these cases, most bleeding after cannulation was
controlled with a suture at the catheter insertion site, and the only
variable signifi cantly associated with a bleeding complication was
a platelet count < 50 × 1 0
9
/L (P = 0.02) [15] . In addition, local
pressure and use of topical thrombin spray may be used to control
peripheral but not central bleeding.
Skin p reparation
Cutaneous antisepsis is paramount. This includes but is not
limited to handwashing, education of personnel, and the use of
sterile technique to include large sterile drape, gown and gloves
[16 – 19] . Antiseptic agents that reduce skin microfl ora for skin
preparation include alcohol, iodine, chlorhexidine gluconate, and
hexachlorophene. Alcohol has a broad spectrum of antibacterial
activity but has no detergent action, and therefore may not work
Table 10.3 Central venous catheter types.
Type Short term Long term Implantable
Location Transcutaneous Transcutaneous Subcutaneous
Duration Less than 2 weeks 4 weeks or longer Months to years
Venous site Peripheral
Pedal
Saphenous
Femoral
Central
Subclavian
External jugular
Internal jugular

Cephalic
Facial
Saphenous
Femoral
Same as central long term.
Huber point needle required for access to reservoir
Material Polyethylene, polyurethane, vinyl chloride, silicone Silicone
Cuff No cuff Dacron
Lumen Varies Single/double
Indication Diffi cult access Chronic illness Chronic illness
Risks/benefi ts Dislodgement of catheter
Decreased patient mobility
Increased patient mobility
Tip Open Groshong valve
Vascular Access
155
wire is inserted through the needle and into the lumen of the
vessel. The sharp needle is then removed and a polyurethane - type
catheter is threaded over the wire and into the vessel. Commercially
produced catheters that incorporate an integral guidewire and
employ the modifi ed Seldinger technique are also available.
Beards and associates [24] compared these three insertion tech-
niques in 69 critically ill patients. The direct puncture technique
was associated with the highest failure rate, followed by the modi-
fi ed and classic Seldinger techniques, respectively. The direct
puncture technique also took signifi cantly longer, used more
catheters, and required more punctures per successful insertion
than did the modifi ed or classic Seldinger techniques. These
authors also observed that polyurethane catheters were signifi -
cantly less likely to block and require reinsertion than were the

Te fl on catheters. As a result, they strongly endorsed use of the
classic Seldinger technique and polyurethane catheters.
During catheterization, proper positioning of the patient is
important. The patient should be in the Trendelenburg position
and rolled slightly to the left in the later stages of pregnancy when
the inferior vena cava is susceptible to compression by the
enlarged uterus. If the patient is intolerant of the Trendelenburg
position, the legs can be raised. Local anesthetic is infi ltrated into
the site for needle insertion, incisions or dissection for subcutane-
ous pockets. After venous puncture, the syringe is removed care-
fully, while the operator covers the needle hub to prevent excessive
bleeding and entry of air. Covering the needle hub is especially
important with central venous punctures. With the Seldinger
technique a guidewire is placed through the needle, and the
needle is withdrawn. Next, a stiff dilator is generally threaded
over the wire and passed one or more times in order to dilate the
tract to the vein, after which a dilator – catheter assembly is
threaded over the wire into correct position, and the wire and
dilator are removed. Correct placement is supported by confi rm-
ing free aspiration of blood from the catheter and free fl ow (by
gravity alone) of an appropriate crystalloid solution through the
catheter.
Long - term transcutaneous catheters are generally placed using
a peel - away sheath modifi cation of the Seldinger technique. After
dilation of the tract, a dilator – sheath assembly is advanced over
the wire into the chosen vein, and the wire and dilator are
removed. A Silastic catheter is then threaded through the peel -
away sheath. Upon proper positioning, the handles on the peel -
away sheath are rotated perpendicular to its long axis until the
sheath cracks. Pulling the sheath handles apart, the sheath is then

simultaneously peeled in half along its long axis and removed
while the catheter is carefully held in place.
In cases of arterial cannulation, successful line placement can
be confi rmed by the appearance of pulsatile blood fl ow or, if any
doubt exists, by blood gas analysis. Vessels suitable for cannula-
tion include radial, femoral, brachial, axillary, dorsal pedis and
superfi cial temporal arteries. For blood pressure monitoring, the
catheter is connected to a transducer with a three - way stopcock
and high - pressure tubing which is connected to a pressure bag
containing normal saline and heparin (1500 U/500 mL). The
high - pressure tubing is necessary to prevent damping of blood
pressure readings. The heparinized saline is administered through
the pressurized bag at a rate of approximately 2 – 5 mL/h to prevent
the catheter from clotting off. It is critically important to purge
all pressure lines and stopcocks before connecting the arterial line
to prevent arterial air embolism. All set - ups should also have a
purge or fl ush device that can be used to clear any blood that may
back up into the pressure tubing as well as to clear the catheter
itself and the stopcock after blood sampling. Complications of
arterial cannulation include vessel spasm, infection, thrombosis,
bleeding, and hematoma.
Special t echniques for c atheter i nsertion
Several authors have described utilizing real - time ultrasound to
facilitate the location of a vein and to lessen the incidence of
mechanical complications related to central catheter insertion
[25,26] . The use of ultrasound during the central venous access
placement, particularly in diffi cult patients, is becoming more
commonplace. The placement of the transducer in the area of
interest, whether internal jugular (Figure 10.2 ) or femoral, facili-
tates identifi cation of the venous vessel. The dramatic enlarge-

ment of the superior vena cava during a Valsalva maneuver
readily identifi es the enlarged and yet compressible venous vessel
as compared to the non - compressible, pulsating artery.
Schummer et al. conducted a study demonstrating a mechani-
cal complication rate of 12% during catheter insertion using the
Seldinger technique [27] . The complications encountered by this
experienced group included inadvertent arterial puncture, pneu-
mothorax, malposition, and failed cannulation. Ultrasound has
the potential to decrease this complication rate. Fluoroscopic
guidance has also been reported to be of assistance with catheter
placement. Finally, right arterial electrocardiography can be used
to facilitate proper catheter tip placement [6] .
Complications – g eneral
A wide range of immediate and delayed complications can be
associated with central venous and arterial catheters (Tables 10.4
& 10.5 ). Specifi c complications related to catheter use are dis-
cussed individually within each subsection.
Catheter m alposition
Catheter malposition can be a complication of any vascular can-
nulation. Optimal catheter tip location has not been established
via prospective human studies but most practitioners believe the
superior vena cava, proximal to the right atrium, to be the ideal
location [6] . Catheter tips located in smaller, more proximal
veins are more likely to be associated with venous thrombosis and
stenosis, while catheter tips positioned in the heart may be associ-
ated with cardiac arrhythmias, perforation, tamponade, valvular
injury, or endocarditis. PICC catheter tip malpositioning from an
Chapter 10
156
Carotid Artery

Right
I.J.
Figure 10.2 Ultrasound image of the IJV. The IJV
can be visualized beneath the sternocleidomastoid
muscle and adjacent to the carotid artery.
Table 10.4 Complications of central venous catheters.
Immediate Delayed
Insertion failure Venous thrombosis
Malposition Pulmonary embolism
Air embolism Superior vena caval syndrome
Catheter embolism Venous stenosis
Cardiac arrhythmia Arteriovenous fi stula
Pneumothorax Arterial pseudoaneurysm
Hemothorax Catheter thrombosis
Hydrothorax/chylothorax Catheter dislodgement/breakage
Tracheal/esophageal injury Catheter - related infection
Femoral nerve injury Endocarditis
Brachial plexus injury Cardiac perforation
Phrenic nerve injury Cardiac tamponade
Vagus nerve injury Suppurative thrombophlebitis
Recurrent laryngeal nerve injury Clavicular osteomyelitis
Stellate ganglion injury
Table 10.5 Complications of arterial catheters.
Hematoma
Hemorrhage
Catheter occlusion
Catheter dislocation
Infection
Embolism
Ischemic injury

Thrombosis
Pseudoaneurysm
Arteriovenous fi stula
antecubital approach is the most frequently seen with a rate of
21 – 55% [28] . Among the most devastating consequences of cath-
eter malposition is cardiac tamponade. This uncommon yet
potentially catastrophic complication must be considered after
insertion of all central catheters. Postinsertion chest radiographs
are universally recommended, with possibly the exception of the
image - guided central venous catheter insertion [29 – 32] . These
radiographic studies should demonstrate midline placement of
the catheter tip in the center of the SVC, and not abutting the
arterial or ventricular wall.
Thrombosis, s tenosis and o cclusion
Thrombosis of the great veins is frequently asymptomatic and
therefore under - recognized and under - reported [33] . In SCV
catheterization, the complication is clinically diagnosed with a
frequency of less than 5%, but is diagnosed by contrast venogra-
phy in 20 – 40% of patients [29] . Thrombosis appears to be related
to several factors. The fi rst consideration is the relative diameters
of the catheters and vessel. Generally, the smaller the diameter of
the catheter relative to the vessel size, the lower the incidence of
thrombosis. Additional factors include duration of use, catheter
material, shape of catheter tip, number of cannulation attempts,
low cardiac output, hypotension, use of vasopressors, peripheral
vaso - occlusive processes, and Raynaud ’ s disease [24,34] .
Catheter occlusion can result from the formation of a fi brin
plug at the catheter tip. This is part of a fi brin sleeve that forms
around essentially all IV catheters present for more than a week
[29,35] .

When withdrawing blood samples, the dead space in the
system should be appreciated, and a suffi cient quantity of blood
to account for this should be withdrawn and discarded before
actual specimen collection. It also is very important to purge the
Vascular Access
157
maintained in a 20 – 30 ° Trendelenburg position. This maintains
the head in a “ down ” position, distending the IJV and minimizing
air entrapment. A trianglular region created by two heads of the
SCM and the clavicle is then identifi ed (Figure 10.3 ). The carotid
artery is palpated medial to the IJV and medial and posterior to
the SCM and is retracted medially. An 18 - gauge cannulating
needle, attached to a syringe, is inserted at the apex of the triangle,
bevel facing up, and at a 30 – 45 ° angle to the skin (Figure 10.4 ).
The needle is advanced toward the ipsilateral nipple. If the vein
is not encountered by a depth of 5 cm, the needle is withdrawn
4 cm and advanced again in a more lateral direction. When a
vessel is entered a fl ash of blood is noted at the catheter hub. If
the blood is pulsating, you have entered the carotid artery. In this
situation, remove the needle and tamponade the area for 5 – 10
minutes. When the carotid artery has been punctured, no further
attempts should be made on either side because puncture of both
arteries can have serious consequences.
system after specimen collection, lest the line clot off. Clots
adherent to the catheter tip, or even the vessel lumen, can be
dislodged during fl ushing. Flushing protocols, with and without
heparin, have been devised to reduce catheter thrombosis [33,36] .
The use of a fi brinolytic agent administered through the catheter
has also been shown to be successful in reopening thrombosed
catheters [37 – 41] . Additional treatment of catheter - related deep

vein thrombosis may also involve catheter removal [42,43] .
Embolism
Air embolism is a rare but potentially fatal complication of central
venous catheters with an estimated incidence of less than 1% but
with a mortality rate as high as 50%. If the air embolus is of the
magnitude of 50 mL or greater, the outcome is more likely to be
fatal. Symptoms of an air embolus can include seizures, hemipa-
resis, and focal neurologic signs. An air embolus may be reduced
by aspirating through the central line or placing the patient in
Trendelenburg and in the left lateral decubitus position in the
hopes of containing the air in the right ventricle until other mea-
sures can be enacted. In stable patients, treatment can be sup-
portive and include administration of 100% oxygen. Rewiring
central venous catheters can also be particularly hazardous.
Attention to technique and position must also be employed
during this seemingly innocuous procedure.
Vesely [44] reviewed complications for 11 583 central venous
catheter insertions. Air embolism only occurred in 15 cases, the
majority of which had undetectable, mild, or moderate symp-
toms that resolved with supplemental oxygen. Only one case in
their series was fatal.
Specifi c v enous a ccess s ites
Internal j ugular v ein ( IJV )
The IJV is located under the sternocleidomastoid muscle (SCM),
and, at its junction with the subclavian vein (SCV), helps form
the brachiocephalic vein. Anatomic variation in the course of the
IJV has been noted, and the relationship between the IJV and the
carotid artery may be abnormal in 10% of the population [45] .
Typically, when the head is turned away from the intended side
of cannulation, the IJV forms a line from the pinna of the ear to

the sternoclavicular joint and brings the IJV to a more anterior
position relative to the carotid artery [8,46] . The IJV is a common
route for central venous access. Its advantages include the ease by
which this vessel can be compressed in the case of hemorrhage
and the decreased risk of pneumothorax. The right IJV is pre-
ferred because the thoracic duct is avoided as well as providing a
more direct course to the right atrium [45] . The anatomic rela-
tionship of the left IJV to the left brachiocephalic vein makes it
diffi cult to negotiate vessel angles and increases the risk of steno-
sis and thrombosis.
Two insertion techniques, the median and posterior approaches
are available for IJV cannulation. With the median approach the
head is turned away from the cannulation site with the body
Figure 10.3 Positioning for internal jugular vein cannulation. The head is
turned away from the insertion site. A triangle is formed by the junction of the
heads of the SCM at the apex, and their insertions at the clavicle.
Figure 10.4 Anterior approach to internal jugular vein cannulation. The carotid
artery is palpated and retracted medially while the needle is inserted at the tip of
the triangle and advanced toward the ipsilateral nipple.
Chapter 10
158
Neurologic complications are rare, but have been documented
in association with IJV catheterization. The close anatomic rela-
tionship between the lower brachial plexus and the IJV can con-
tribute to the potential for nerve damage, and is more commonly
associated with a traumatic cannulation attempt [50] .
External j ugular v ein ( EJV )
The EJV is formed by the junction of the retromandibular and
posterior auricular veins. It runs obliquely across the SCM along
a line extending from the angle of the jaw to mid - clavicle. The

EJV joins the SCV at an acute angle under the area of the clavicle
[46] . The primary advantage of using the EJV for venous access
is the decreased risk of pneumothorax. The disadvantages include
diffi culty in advancing a catheter, and vein perforation due to the
acute angle with the SCV.
The patient is placed supine or in the Trendelenburg position
and the head is turned away from the side of insertion. The vein
can best be identifi ed by applying pressure just above the clavicle
and allowing the vein to engorge. Unfortunately, even under the
best of conditions, 15% of patients will not have an identifi able
EJV [51] . Once identifi ed, the vein should be stabilized between
the thumb and forefi nger at a level midway between the clavicle
and jaw and the catheter inserted with the bevel up. The length
of the catheter should not exceed 15 cm. Undue force at the time
of catheter insertion can result in perforation of the EJV at the
angle in which is enters the SCV. Manipulation of the shoulder
may facilitate passage of the J - wire past the clavicle without
asserting undue pressure [52] . In addition, upon meeting resis-
tance at the EJV - SCV junction, the J - wire can be withdrawn
approximately 0.5 cm proximal to the junction. The triple - lumen
catheter may then be slowly advanced over the J - wire. The success
of this maneuver may lie in the smaller diameter of the catheter
tip [53,54] . Complications of EJV cannulation include thrombo-
sis, superior vena cava perforation, and hydrothorax [47,55] .
Subclavian v ein ( SCV )
The SCV is often used to gain central access. As a continuation
of the axillary vein, the course of the SCV runs underneath the
clavicle and along the outer surface of the anterior scalene muscle.
At the level of the thoracic inlet, the SCV joins the IJV to form
the brachiocephalic vein [8,46] . To cannulate the vein, the patient

is placed in the supine position, maintaining a 15% Trendelenburg
position, with the head facing toward the site of insertion and the
arms pronated, slightly fl exed, and down at the sides. One helpful
approach for catheter insertion is to place a rolled towel under
the spine and shoulder. This type of positioning serves to widen
the path between the fi rst rib and the clavicle. Next, the operator
should visualize the path of the subclavian artery divided into
medial, middle, and lateral thirds along the clavicular line (Figure
10.6 ). Using this method, the junction of the medial and middle
segment approximates the lateral aspect of the SCM insertion on
the clavicle. Using this point for needle insertion may decrease
the risk for pneumothorax. The bevel should initially be pointing
upward. The catheter tip is “ walked ” along the underside of the
With the posterior approach, the body position is the same but
the physician should plan an insertion site 1 cm superior to the
point where the external jugular vein (EJV) crosses over the
lateral edge of the SCM. In the posterior approach, the needle is
then inserted at the 3 o ’ clock position, with the bevel up, and is
advanced along the underbelly of the SCM and then aimed
toward the SCM at its sternal insertion and the suprasternal notch
(Figure 10.5 ). The IJV should be encountered 5 – 6 cm from the
skin surface with this approach. If the advancing attempt does
not produce a fl ash of blood in the hub of the needle, applying
slow continuous negative pressure while withdrawing the needle
potentiates identifi cation of venous blood, thus identifying the
vein. However, the absence of pulsatile blood fl ow does not nec-
essarily ensure venous access has been achieved. Ideally, a pres-
sure wave should be transduced to confi rm a venous waveform
[45,47] .
In addition to the previously described approaches, tunneled

central venous catheters have also been described using the IJV
versus the SCV. The IJV approach was easier to perform with
fewer complications [48] . Complications of IJV cannulation
include hematoma, carotid artery puncture, nerve damage, air
embolus, and cardiac tamponade.
As previously noted, ultrasound guidance for vessel location is
favored by many physicians. Investigations utilizing ultrasound
guidance for access of the IJV provide the most compelling evi-
dence in support of this approach. Karakitsos et al. [49] per-
formed a prospective randomized trial of 900 subjects, evaluating
cannulation of the IJV using ultrasound guidance versus standard
landmark methods. After controlling for multiple factors, real -
time ultrasound - guided catheter insertion of the IJV was signifi -
cantly associated with reductions in carotid puncture hematoma,
hemothorax, pneumothorax, catheter - related infection, access
time from skin to vein and number of attempts when compared
to standard landmark methods.
Figure 10.5 Posterior approach to internal jugular vein cannulation. In the
posterior approach the needle is advanced along the underbelly of the SCM
aiming at the suprasternal notch.