Wednesday August 9, 2006
External Jugular (EJ) approach to central venous line

Being an intensivist, it is important to know the pros and cons of EJ central venous catheterization.



Disadvantages

• EJ vein is not in a direct line with the right atrium.
• a valve is frequently present at the junction of the EJV and the SC vein.
• It has a circuitous course and less commonly it enters directly either in the subclavian vein or internal jugular vein.
• 10% of the time its hard to feel free flow of wire and to thread J-wires past the clavicle and also due to presence of valves in vessel 2.
• Hydrothorax has been described in literature with left EJ approach 1.

Due to above facts

• It is not a prefered approach.
• It is not a reliable way to do CVP (central venous pressure) monitoring.
• It is not a good approach if you decide to float pulmonary artery catheter later.
  

Advantages

* It is an approach for use in a heavily anticoagulated or thrombocytopenic patients because it is easy to apply pressure to the site of venepuncture - afterall the external jugular vein is a peripheral vein.

* Recently, a small study of 23 patients described the 'right' EJV as an acceptable and prefered access site when the right IJV is not available for central line due to various reasons such as existing Hickman catheter in the right IJV or nearby tracheostomy tube 3.


Bonus Pearl:There is an inverse correlation between the size of the external and internal jugular veins, so if you see a large EJV on patient's neck, expect potentially more difficult internal jugular venepuncture 4.

References: click to get abstract/article

1. Bilateral hydrothorax caused by left external jugular venous catheter perforation - J Clin Anesth. 1994 May-Jun;6(3):243-6
2. Shoulder manipulation to facilitate central vein catheterization from the external jugular vein - Anaesth Intensive Care.1991 Nov;19(4):567-8
3. Use of the Right External Jugular Vein as the Preferred Access Site When the Right Internal Jugular Vein Is Not Usable - Journal of Vascular and Interventional Radiology 17:823-829 (2006)
4. Prediction of a small internal jugular vein by external jugular vein diameter - Anaesthesia 1997 Mar;52(3):220-2