Approaches to the internal jugular vein Three approaches to

the internal jugular vein are widely recognized and include central,
posterior, and anterior approaches [39]. The landmarks and needle
placement for each of these approaches are presented below.
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Central The central approach to the internal jugular vein is

commonly used (figure 3 and figure 1B). The apex of the triangle
formed by the heads of the sternocleidomastoid is approximately 5
cm superior to the clavicle and marks the needle insertion site. To
access the internal jugular vein with a central approach:
Introduce the needle lateral to the carotid pulsation at an
angle 30 to 45 degrees to the skin.
Direct the needle lateral to the sagittal plane toward the
ipsilateral nipple. This path typically traverses alongside or beneath
the lateral head of the sternocleidomastoid.
The medial to lateral approach to the jugular vein may lower
the incidence of pneumothorax and carotid puncture. If used in
combination with ultrasound, this facilitates more complete
visualization of the needle in its entirety as it is advanced [40].
If blood is not aspirated within 2.5 cm, withdraw the needle
slowly while maintaining continuous negative pressure and watching
for blood return.
If the first needle pass fails, promptly withdraw the needle to
the skin surface and redirect the needle 10 degrees medially.
Posterior Turning the head to the contralateral side accentuates
muscular landmarks and may improve access for the posterior
approach (figure 2). To access the internal jugular vein with a
posterior approach:
Insert the needle along the posterior edge of the

sternocleidomastoid at the junction of the middle and lower third of

the muscle [39]. This point is approximately 5 cm above the clavicle
and is commonly marked by presence of the external jugular vein.
Introduce the needle beneath the posterior
sternocleidomastoid and advance anteromedially toward the sternal
notch.
Any subsequent changes in needle orientation should follow
a systematic approach of lateral to medial needle passes [1].

Anterior As the name implies, the anterior technique accesses

the internal jugular vein from an insertion point anterior to the sternal
head of the sternocleidomastoid. To access the internal jugular vein
with an anterior approach:
Palpate the course of the carotid artery
Introduce the needle 5 cm above the sternum, at the
midpoint of the anterior border of the sternocleidomastoid.
Direct the needle lateral to the carotid pulsation along a
plane aimed at the ipsilateral nipple.
Approaches to the subclavian vein The subclavian vein can be
approached from above or below the clavicle. The landmarks and
needle placement for each of these approaches are presented
below.
Infraclavicular approach Three insertion points are described
for the infraclavicular approach to the subclavian vein. The midpoint
approach is the most commonly used technique [3,21].
.

For the midpoint approach, the needle is inserted 2 to 3 cm

inferior to the midpoint of the clavicle (approximately 1 to 2 cm lateral
to the bend of the clavicle) and directed just posterior to the
suprasternal notch (figure 2 and picture 3).

Alateralneedleinsertion(lateraltothemidclavicularline)takesadvantage
ofthethinanteriorconvexityof the clavicle to facilitate a level coronal
approach, which may improve safety if the vessel can be reached by
the cannulating needle [21,22,36].
.

The medial insertion point is along the inner third of the

clavicle. The needle is directed cephalad toward the suprasternal
notch to penetrate the vessel at the broad confluence of the great
veins. The downside of this method is that medial positioning
requires a steep approach beneath the thick medial clavicle and
passage through intervening soft tissue including the costoclavicular
ligament. After the needle has penetrated the skin, the clavicle may
be initially contacted. Take care not to push the needle into the
periosteum, as bone plug can occlude the lumen of the needle. The
needle should be gently walked deeper to reach the underside of
the clavicle. The needle should remain parallel to the clavicle (in the
coronal plane) to allow it to pass cleanly beneath the bone and
minimize the risk of pleural puncture. As the needle passes beneath
the junction of the middle and medial thirds of clavicle, it should
enter the vein. If the first needle pass is unsuccessful, orient the
needle more cephalad on subsequent attempts. An observational
study at a large trauma center evaluated the most common errors
during the placement of infraclavicular subclavian venous access
[37]. The most frequently observed errors during videotaped
assessment of venous cannulation in 86 patients included improper
or inadequate identification of anatomic landmarks, improper needle
insertion site, too shallow a needle trajectory, and insertion of the
needle through the

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periosteum of the clavicle.

Supraclavicular approach The supraclavicular approach aims to
puncture the subclavian vein near its junction with the internal
jugular vein. The insertion of the clavicular head of the

sternocleidomastoid is the access landmark for this approach (figure

3A and figure 3B).
The subclavian vein is 1 to 1.5 cm deep to the skin and easily
reached using a seeker needle [38]. The needle should be inserted 1
cm posterior to the sternocleidomastoid and 1 cm cephalad to the
clavicle. The needle is depressed 10 to 15 degrees below the
coronal plane and oriented to bisect the angle between the clavicle
and the sternocleidomastoid (picture 4). The needle is advanced
toward the venous confluence behind the medial clavicle along a
trajectory aimed just inferior to the contralateral nipple.
Axillary approach This approach is an uncommonly used
technique accessing the vessel at the junction of the subclavian and
axillary veins via an ultrasound-guided infraclavicular approach.
FEMORAL

The midinguinal point lying half-way between the anterior superior

iliac spine and the symphysis pubis marks the normal location of
the femoral artery. The femoral vein lies just medial to the artery.
Remember that pulsations will be felt in the femoral vein in cardiac
arrest patients receiving chest compressions.
The common femoral vein lies superficial and medial to the femoral
artery. When accessing the vein, orient the needle with the bevel
up and introduce it angled 20 to 30 degrees to the skin. Insert the
needle 1 to 2 cm inferior to the inguinal ligament and just medial
to the femoral artery. The vessel is normally reached within 2 to 4
cm but may be deeper in obese or edematous patients.