The jugular approach

Rodrigo, Maria Teresa

doi:10.1016/j.dialis.2012.06.005

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Peripheral IV placement of the jugular vein is one of the most commonly used methods and allows for longer survival of the catheter in patients under haemodialysis, using both temporary and permanent or tunnelled catheters. The jugular vein takes up intracranial blood and exits at the base of the cranium through the jugular foramen located at the middle of the mastoid process (Figure 1). It goes down the neck taking blood from the face and neck, and at the thorax it connects to the subclavial vein to form the brachiocephalic trunk, which then drains into the superior vena cava. It descends parallel to the carotid artery, within the same sheath, by the most external and anterior zone, given that there are several cranial nerves and the vagus nerve between them. In the anterior zone it is covered by the sternocleidomastoid muscle and rests on the scalene muscles in the posterior zone. It enters the thorax just behind the clavicle near the joint with the sternum. The sternocleidomastoid muscle inserts into the clavicle via two fascicles, the main or sternal (mid) and clavicular (external fascicles. Between them and the clavicle, Sedillot's triangle is formed, which serves as a reference point for IV placement

Figure 1.

Anatomy of jugular vein.

(0,61MB).

Anatomical variants

As regards normal size and localisation, we distinguish the variants of small vein, partially or completely overriding and the reversal of the norm (figure 2).

Catheterisation routes

Depending on the position with respect to the sternocleidomastoid muscle and the height where it is performed, different approaches are available:

Anterior: At the height of the cricoid cartilage, just on the medial edge of the sternocleidomastoid and in the direction of the ipsilateral nipple, at approximately 30-45° elevation with respect to the skin.
Anterior: In a slightly more cranial zone, feeling the carotid the puncture is made in the direction of the flow between the carotid and the sternocleidomastoid muscle.
Medial: in the upper area of the triangle, in the direction of the breast and the needle at an angle of 45-50°.
Medial: in the lower area of the triangle, in the direction of the flow and at an angle of 50-60° with respect to the skin.
Posterior: At two fingers from the clavicle and next to the posterior edge of the external fascicle of the sternocleidomastoid muscle, in the direction of the sternal cross and at an angle of 10-20° with respect to the skin.

Considerations prior to puncture

1.
PATIENT POSITION: In supine position, arms stretched and close to the body, in the Trendelenburg tilt position (a pillow can be placed below the shoulders to put the neck in hyperextension) and with the head in neutral position or slightly turned contra-laterally. Patient monitoring is appropriate: SO2, BP, heart rate, etc.
2.
HEAD POSITION. Although the tendency is to turn the head 90° in a contra-lateral direction, doing this creates the risk of placing the carotid artery below the jugular vein with the danger of going through it and creating an arteriovenous fistula.
3.
PUNCTURE ANGLE. The most common one was between 50 and 60°, although recent articles comment that it should be greater.

Types of catheterisation

Catheterisation can be guided by anatomical references and also by ultrasound scan and fluoroscopy.

1.
Puncture guided by anatomical references
2.
Ultrasound-guided puncture
3.
Puncture with fluoroscopic control

Injections guided by anatomical references

The classical method, which uses anatomical references to catheterise the vein.

Although nowadays it is not the method of choice the anatomical references should be known to enable the puncture point and the needle direction to be localised.

It is based on the anatomical description and physical examination of the patient. Carried out in a room with aseptic conditions. PERSONNEL: doctor (trained at 50 catheterisations), nurse and nursing auxiliary.

Ultrasound-guided injections

Punctures guided by ultrasound are used with growing frequency for their safety and efficacy and is the recommended technique in many guides. It offers more safety and efficacy and should be habitually used. Before commencing, an examination should be made to check that the vein is permeable and clearly visible in terms of the track of the vein and the location of the artery to avoid it interposing in the posterior trajectory of the needle. The vein is distinguished from the artery because it can easily be compressed with the transducer to the left or right. After examining the neck, the transducer is protected with a sterile system and the vein is then catheterised. The transducer can be placed in a transversal position (allows the depth at which the vein is and its position with regard to the artery to be assessed) or a longitudinal one (allows insertion of the needle to be seen). However, this is difficult to achieve in a low puncture because of the interposition of the clavicle. After examining the neck and establishing the track of the vein, it is important to avoid errors by not modifying the position of the patient in any way so as not to lose the references that were taken. On some occasions, either because the puncture zone is very low or due to preference, direct vision ultrasound is not used in real time, a blind puncture is made instead, following the references taken beforehand. With this type of puncture, although the location and morphology of the vein is known, complications at the moment of the puncture are not discounted. When catheterising, the most common thing is to manage the transducer with one hand and use the other to guide the needle under direct ultrasound control. Once the vein is catheterised, the transducer is released and the procedure continues as per normal.

Fluoroscopy-guided injections

Habitually used by vascular radiologists. The vain and artery can be seen and the injection point modified if access is different because of a variation of normality or anatomical anomaly.

The insertion of the guide, catheter, etc, can be seen. It also facilitates localisation in cses where the anatomical references are poorly visible (obese patients, thick necks, operated patients, etc). 4 or 5 F Micropuncture needles are used that cause less injury if the carotid artery is accidentally punctured.

Considerations after injection

For temporary catheters, insertion of guide, dilator and then catheter and support. For permanent catheters, insertion of guide, tunnelling, dilator and then catheter via the dilator-peeler and support.

A control X-ray should be carried out. May require immediate use. Assess use of a prophylactic antibiotic. Aseptic measures are necessary from the beginning along with use of an additional restraining device.

Severe complications from jugular approach in haemodialysis.

•
Dysfunction from incorrect position
•
Haemorrhage
•
Arterial puncture
•
Dissection and/or occlusion of carotid artery
•
Gas embolism
•
Arrhythmia
•
Pneumothorax
•
Haemothorax
•
Hemomediastinum
•
Atrial perforation and/or cardiac tamponade

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