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Benjamin Mogni, MS-IV
University of Kentucky College of Medicine
Terren Trott, MD
Critical Care Fellow
Cooper Hospital University
Jugular venous catheters allow for central administration of medications, frequent blood draws and central venous sampling. While standard of care for placement of central venous catheters (CVCs) involves ultrasound guidance, physicians should be aware of the traditional landmark approach to line placement. This means having a detailed knowledge of the anterior and posterior triangles of the neck, specifically the division of the sternocleidomastoid into the clavicular and sternal heads, as shown in Figure 1 and Figure 2. This review will summarize the anatomy involved in the placement of a jugular venous catheter and possible complications.
Figure 1: Anterior and posterior triangles of the neck demonstrating the division of the sternocleidomastoid into the sternal and clavicular heads. (Credit: Wikipedia)
Figure 2: Anterior triangles of the neck demonstrating the anterolateral location of the jugular vein to the carotid artery. (Credit: Wikipedia)
|Figure 3: Borrowed with permission from Dr. Jacob Avila, Five Minute Sono. Image of the right anterior neck, showing the anterolateral orientation of the internal jugular vein when compared to the common carotid artery. |
The surface landmarks for the placement of a jugular venous catheter are a horizontal line from the thyroid cartilage drawn straight across the neck and the sternocleidomastoid muscle. Where these bisect, the sternocleidomastoid muscles divides into the clavicular and sternal heads. The internal jugular vein normally proceeds laterally to the sternal head of the sternocleidomastoid muscle. The carotid artery normally lies directly beneath this head of the sternocleidomastoid. There are variants to these locations and ultrasound can elucidate if a patient’s anatomy varies from the norm. Once the physician establishes these landmarks, they can start the procedure.
Figure 4: Borrowed with permission from Dr. Jacob Avila,
Five Minute Sono. Image of the right anterior neck,
showing a needle tip inside of the internal jugular vein 
Although this procedure is normally conducted successfully, a minority of the time there will be complications. The rate of these complications is study-dependent and appears to be related to catheter size and operator experience.[8, 9] The complications from jugular venous catheter placement include infection, thrombosis, occlusion, and pneumothorax. A pneumothorax may occur if cannulation of the guidewire or catheter pierces the parietal pleura. This will cause air to enter the parietal cavity between the parietal pleura and visceral pleura. If the pneumothorax is less than 15% of the parietal cavity, the pathology can be managed with close observation and high flow oxygen. If a tension pneumothorax occurs, needle decompression/chest tube placement is necessary.
Physicians in emergency medicine and critical care must know the anatomical gap created by the sternal head and clavicular head of the sternocleidomastoid. This gap allows for quick access for central line placements in most patients. Without proper knowledge of this area, costly complications may occur and hinder patient care.
1. Marieb E, Wilhelm P, Mallatt J. Human Anatomy, Vol 6. San Francisco, CA: Pearson Education; 2011.
2. Avila J. Central Line Placement. 5 Min Sono Vids. Available at http://5minsono.com/cvc/. Updated September 24, 2015.
3. Agur A, Dalley A. Grant’s Atlas of Anatomy, 12e. Philadelphia, PA: LWW; 2009.
4. Turba UC, Uflacker R, Hannegan C, Selby JB. Anatomic relationship of the internal jugular vein and the common carotid artery applied to percutaneous transjugular procedures. Cardiovasc Intervent Radiol. 2005. 28(3):303-6.
5. Parry G. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Can J Anaesth. 2004. 51(4):379-81.
6. Giordano CR, Murtagh KR, Mills J, Deitte LA, Rice MJ, Tighe PJ. Locating the optimal internal jugular target site for central venous line placement. J Clin Anesth. 2016. 33:198-202.
7. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953;29(5): 368-76.
8. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986;146(2):259-61.
9. Tsotsolis N, Tsirgogianni K, Kioumis I, et al. Pneumothorax as a complication of central venous catheter insertion. Ann Transl Med. 2015;3(3):40.
10. Kornbau C, Lee K, Hughes G, Firstenberg M. Central line complications. Int J Crit Illn Inj Sci. 2015;5(3):170-8.