Written by: Samantha Knopp, MD (NUEM PGY-3) Edited by: Andrew Ketterer, MD (NUEM Alum '17) Expert commentary by: John Bailitz, MD
We’re all familiar with the “difficult access” patient: the nurses have tried all possible traditional peripheral routes, both ultrasound-guided and not, the resident has been in with the ultrasound and had no better luck, the EJ blew a few minutes after it was placed. The choices you seem to be left with are intraosseous access (certainly useful in an actual emergent situation, although having a spike drilled into their long bones is not something that most awake and alert patients are thrilled about) or gain central access via a central venous catheter (again, useful and appropriate in some circumstances, but poses increased risk for complications).
Fortunately, there is a third option! The ultrasound-guided catheterization of the IJ with a peripheral IV, a technique first described in the literature in 2009 , has been shown to be a safe and efficacious means of access when all else fails. [2,3]
What is it?
Ultrasound-guided placement of a standard single-lumen angiocatheter into the internal jugular vein.
When is it useful?
In patients who require an IV, and no suitable extremity or external jugular veins can be reliably accessed, assuming that:
the patient is not unstable requiring emergent resuscitation (in which case an IO is preferable), and
the patient does not require central venous access
How to do it
The perennially creative people over at EM:RAP have an excellent video demonstration of the peripheral IJ:
What you’ll need:
Ultrasound machine with linear transducer
Sterile ultrasound gel
Tegaderm x 2 (or other bio-occlusive dressing; 1 for dressing, 1 to cover ultrasound probe)
Single lumen angiocatheter (various studies have used varying sizes: 18-20 gauge, 4.8cm-6.35cm)
Loop catheter extension
How you'll do it:
Place patient is supine position (can also use Trendelenburg)
Use ultrasound to visualize IJ
Prep the area with chlorhexidine and drape the patient (limited draping, see video)
Cover probe with Tegaderm or sterile probe cover
Visualize vessel once again, using sterile jelly and have the patient perform Valsalva maneuver
Puncture the skin at a 45-degree angle and advance needle into the IJ lumen
Once flash is observed, advance the catheter into the lumen and withdraw the needle
Connect the loop catheter extension, ensure that blood draws back, then flush the tubing and apply dressing
Accessing the IJ with a peripheral venous catheter was first described in a 2009 letter to the editor in the Journal of Emergency medicine. Only a few studies were subsequently published between 2009 and 2016 regarding the procedure’s technique, its safety, or its efficacy. The few small case series that were published studied 37 patients in total; in all series, the procedure was noted to have a high success rate and on average took significantly less time than placing a central IJ catheter.[5,6,7] The past year has seen two additional prospective studies evaluating both the efficacy and the safety of the peripheral IJ, enrolling a total of 107 patients.[2,3] The first study noted no complications at 1 and 6 weeks associated with US-guided peripheral IJ catheterization. The second, a multicenter study, noted an 88% success rate and a 14% complication rate (the only complication being lost patency—of note, it is unclear whether or not this was considered a complication in the first study). In all studies, the time to insert the peripheral IJ was approximately 5 minutes or less. While the body of literature thus far is still relatively small, it would seem to suggest that the use of a peripheral IJ is a safe and suitable alternative in appropriately selected patients who have no other feasible routes of vascular access, and in whom the insertion of an IO or central line is otherwise unnecessary.
The placement of a peripheral IV into the internal jugular vein under ultrasound guidance has been described as efficacious and safe.
On average, it is not a time-consuming procedure. This is operator-dependent, but it takes significantly less time than placing a central venous catheter in most cases and is associated with fewer complications.
The rare but classic case remains the difficult vascular access patient with severe shortness of breath. Using either the long angiocatheter in the central line kit, and today a long peripheral intravenous catheter, an experienced clinician sonographer may be able to insert the catheter with the patient nearly upright. In such patients, either an infraclavicular subclavian or supraclavicular subclavian central line approach may result in a pneumothorax, quickly turning a bad situation into a nightmare for everyone. Instead, quickly placing a simple long peripheral catheter into the IJ using US guidance immediately establishes the vascular access needed to administer life saving medications. When the patient is stabilized, the traditional central line may then be placed if still required.
Necessity breeds invention! So it is exciting for new and experienced clinicians alike to now be able simply use the long peripheral IV catheter in both stable patients not needing central access, and the rare unstable patients who must remain upright, and only opening an expensive central line kit when needed.
John Bailitz, MD
Associate Professor of Emergency Medicine
How you cite this post
[Peer-Reviewed, Web Publication] Knopp S, Ketterer A (2018, August 27). Ultrasound-guided peripheral IJ catheter placement. [NUEM Blog. Expert Commentary by Bailitz J]. Retrieved from http://www.nuemblog.com/blog/peripheral-IJ
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Moayedi, Siamak, “Ultrasound-Guided Venous Access with a Single Lumen Catheter into the Internal Jugular Vein.” The Journal of Emergency Medicine. 2009;37(4):419
Kiefer D, Keller SM, Weekes A. “Prospective evaluation of ultrasound-guided short catheter placement in internal jugular veins of difficult venous access patients.” Am J Emerg Med. 2016 Mar;34(3):578-81
Moayedi S, Witting M, Pirotte M. “Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access” J Emerg Med. 2016Dec;51(6):636-42
Butterfield M, Abdelghani R, Mohamad M, Limsuwat C, Kheir F. “Using Ultrasound-Guided Peripheral Catheterization of the Internal Jugular Vein in Patients With Difficult Peripheral Access.” Am J Ther. 2015 Oct 8.
Teismann N, Knight R, Rehrer M, Shah S, Nagdev A, Stone M. “The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter” J Emerg Med. 2013Jan;44(1):150-54
Zwank, Michael. “Ultrasound-guided catheter-over-needle internal jugular vein catheterization.” Am J Emerg Med. 2012Feb;30(2):372-73