External Jugular Line

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foodcoma

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So we had this elderly woman with no peripheral veins/heparinized so all extremities were blood-shot. We decided to place a line in the EJ, but my senior failed. Anyone have any tips for proper placement, ie. angle of entry, how to make the vein pop-out even tho we are not using a tourniquet, etc?
Thanks
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foodcoma said:
So we had this elderly woman with no peripheral veins/heparinized so all extremities were blood-shot. We decided to place a line in the EJ, but my senior failed. Anyone have any tips for proper placement, ie. angle of entry, how to make the vein pop-out even tho we are not using a tourniquet, etc?
Thanks
Click to expand...


Two little tricks I've found to make EJs a bit easier.
1. Fairly obvious trick, trendelenburg, lots, feet to the ceiling
2. Get a 10 cc syringe, pull out the plunger, have the patient blow through the now open end while you find and enter the vein.
 
Also take a long 14/16/or18 g jelco, not one of those safety pieces of ****. Bend it slightly near the hub so as to advance it and not have your hand against the jaw. Approx'ly a 15-20 degree bend. Put a 10 cc syringe on it and aspirate as you advance towards the EJ. Side the cath down once you get blood return. I also put pressure with my finger distally (just above the clavicle) to dilate the vein.
 
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MTGas2B said:
2. Get a 10 cc syringe, pull out the plunger, have the patient blow through the now open end while you find and enter the vein.
Click to expand...

Cool idea!

With the advent of the safety angiocaths, placing an EJ is more difficult with them IMHO. I think one of the keys is try and position the patient so your approach is as "flat" (as opposed to steep) as possible.

With the non safety angiocaths one could bend it a little to facilitate this.
 
Noyac said:
Also take a long 14/16/or18 g jelco, not one of those safety pieces of ****..
Click to expand...

HAHAHHAA

We were posting at the same time, Noy. My sentiments exactly. Unfortunately my hospital only has the safety angiocaths now. :barf:
 
jetproppilot said:
Cool idea!

With the advent of the safety angiocaths, placing an EJ is more difficult with them IMHO. I think one of the keys is try and position the patient so your approach is as "flat" (as opposed to steep) as possible.

With the non safety angiocaths one could bend it a little to facilitate this.
Click to expand...


Nice technique, but I beat you to it. :laugh:
 
Noyac said:
Also take a long 14/16/or18 g jelco, not one of those safety pieces of ****. .
Click to expand...

The old-fashioned 20g jelcos also made excellent art line cannulas. Some folks had better success with them than with the Arrow wire-guided spears.

I keep a few old 20g in my fanny pack, along with the kitchen sink.

Any former Tulane or LSU residents here? I've been accused of giving Dr. Riopelle (aka Dr. McGuyver) a run for his money. 🙄
 
trinityalumnus said:
Any former Tulane or LSU residents here? I've been accused of giving Dr. Riopelle (aka Dr. McGuyver) a run for his money. 🙄
Click to expand...

Not a chance, Trin.

You don't wear a jumpsuit, and I've seen you eat eggs from the store.

Riopelle only eats eggs from chickens able to "free roam".

And his fanny pack contents would be considered an entire anesthesia set-up in a third world country. 😀
 
1)Trendelenburg

2) Being a right hander, i've found it easier to cannulate the left EJV. That also allows you to leave the right side of the neck free for an IJV line later.

3) Once at the head end, stick your thumb under the clavicle. This stretches the skin and also makes the vein a bit more prominent. You can alternatively ask someone else to help you out with this move. Turn the patients head to the other side. You now have a nice taut neck, ready to be pierced!

4) Use a 16G cannula if you can. If the patient has a short neck, you may have to start higher up. The reason being if the cannula tip winds up very low, it starts to kink and you'll have to keep the patient's head in a particular position for a good flow. 20G cannulas are shorter, and you may not face this problem, but then.. they are 20G cannulas...
If your cannula tip is about an inch and a half above the clavicle.. you should have a good flowing line.

5) Many times, you would be inside the vein, but may not get the flash of blood in the chamber. So pull out the stylet and check.

6) If you aren't sure where you are, use a syringe to aspirate blood and work your way in.

Hope this helps !
 
MTGas2B said:
2. Get a 10 cc syringe, pull out the plunger, have the patient blow through the now open end while you find and enter the vein.
Click to expand...

I like that one.

I get a tongue blade and have someone hold the thin side of it against the neck to occlude the vein. And when I'm in hospital at night I always have a 16g jelco in my pocket.
 
jetproppilot said:
HAHAHHAA

We were posting at the same time, Noy. My sentiments exactly. Unfortunately my hospital only has the safety angiocaths now. :barf:
Click to expand...

Jet, even for 14's and 16's? If so, all I can say is "Ouch." I feel for you.

Where I trained our 18, 20, 22, 24 were safeties, but 14 and 16 were Jelco type catheters.

When I was a CA-1 we had some Jelco 18s and I hated them because they were longer and harder to thread. When I became more senior I appreciated the Jelcos more.

The hospital where I am at now, we have Jelcos down to 20 ga. What's really sweet is the 14 ga. is only 1.25". The 16 ga. is 1.75". Where I trained the 14s and 16s were 2". So I've actually placed more 14s as an attending than I did as a resident.
 
Antibiotix2006 said:
........
5) Many times, you would be inside the vein, but may not get the flash of blood in the chamber. So pull out the stylet and check.

6) If you aren't sure where you are, use a syringe to aspirate blood and work your way in.

Hope this helps !
Click to expand...

Hi Antibiotix. We've had similar experiences I think.

When I was an intern the team was sticking the EJ repeatedly of one particular lady in the ICU for blood draws. Her EJ was clearly visible and I knew I was in, but I never got a flash in the butterfly, until I hooked up the tube.

I've had the same problem occur when I try to insert an IV in the EJ with one of those safety needles. If I'm using a safety needle for an EJ I will invariably have to just thread the catheter and aspirate with a syringe.
 
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rsgillmd said:
Jet, even for 14's and 16's? If so, all I can say is "Ouch." I feel for you.

Where I trained our 18, 20, 22, 24 were safeties, but 14 and 16 were Jelco type catheters.

When I was a CA-1 we had some Jelco 18s and I hated them because they were longer and harder to thread. When I became more senior I appreciated the Jelcos more.

The hospital where I am at now, we have Jelcos down to 20 ga. What's really sweet is the 14 ga. is only 1.25". The 16 ga. is 1.75". Where I trained the 14s and 16s were 2". So I've actually placed more 14s as an attending than I did as a resident.
Click to expand...

I hear you!

Thankfully this is an old thread.

At my new gig of 3 years (wow time flies) theres angiocaths galore.
 
doozenberg said:
is it at all safe to use an external jugular iv that has its tip pointing superiorly?

while it's standard and common sense to have it pointing towards the heart, this being my intern year i have had low success rates attempting to approach with a shallow enough angle on pts with short necks combined with huge heads/chins (we only have those long retractable safety angiocaths where i work and it seems impossible to get their face out of the way). in desperate situations with no other quick alternatives, approaching from the base of the ej above the clavicle in these types of pts seems like it would be easier, but is it safe considering the potential for an infusion/injection to overcome cerebral venous pressure?
Click to expand...

You may have to bend your needle and start high, as others have suggested. I've bent safeties before without a problem.

I've never tried it (other than for a jugular bulb catheters in the IJ -- but you are not infusing through there), but I would not insert it retrograde for the very same reason you mentioned.

Worst case scenario, grab the ultrasound. I've done one EJ under ultrasound recently in a severely dehydrated (from vomiting) drug user because I could not see her EJV on the skin in Trendelenburg. It was very easily collapsible even on ultrasound. Of course I could have just as easily put in a central line, but I was trying to avoid it.
 
rsgillmd said:
You may have to bend your needle and start high, as others have suggested. I've bent safeties before without a problem.

I've never tried it (other than for a jugular bulb catheters in the IJ -- but you are not infusing through there), but I would not insert it retrograde for the very same reason you mentioned.

Worst case scenario, grab the ultrasound. I've done one EJ under ultrasound recently in a severely dehydrated (from vomiting) drug user because I could not see her EJV on the skin in Trendelenburg. It was very easily collapsible even on ultrasound. Of course I could have just as easily put in a central line, but I was trying to avoid it.
Click to expand...

Yes, I agree. Don't get cocky with EJs...when you are at that point, there is already an access problem...try once or twice, but then just grab the ultrasound, as if you were trying an US-guided IJ...even in crazy volume depleted patients, the EJ on ultrasound, when in Tburg, can be as big as some IJs in LOLs...

Also, in volume-depleted patients, the Valsalva/hold your breath stuff doesn't work too well, as mental status often isn't that great...call me a pansy, but "humming" works well...even demented prunes often will hum on command...it sounds crazy, but there is at least one or two papers showing equivalent or greater IJ size increase with humming vs. other distension techniques...and IJ dynamics are very similar to EJ dynamics...one of the papers has R. Wang as the lead author, I believe...I am too sleepy for PubMed now...

Crazy Tburg, Valsalva, humming...and, if it all fails, ultrasound

HH
 
To me the unprotected Jelco vs the long safety Braun angiocaths is sort of a generational thing. Having trained with the protected angiocaths, I have no more difficulty placing an EJ (bending it) or a radial a-line with a protected angiocath vs an unprotected one.

Although many people bend the angiocath for placing an IV in the EJ, I personally don't bend it (that way, it is the same angle *every* time, for consistency's sake).

Unless 1) this is day surgery, or 2) I need a single IV to go to sleep and then will look for more access later, I also have a low threshold in these situations to place a CVC, Cordis or MAC. My perspective is as follows: 1) Your EJ is now tegadermed right over your entry point for your IJ. 2) Consider the institutional hangups your floor nurses have with peripheral IVs in thumbs, lower extremities, and necks. Floor nurses suck at taking care of these IVs even when they do go to the floor. I've even had patients sent back down to the OR with the remains of an EJ uncapped and open to air! So I tend to place fewer EJs than many other people.
 
Antibiotix2006 said:
1)Trendelenburg

2) Being a right hander, i've found it easier to cannulate the left EJV. That also allows you to leave the right side of the neck free for an IJV line later.

3) Once at the head end, stick your thumb under the clavicle. This stretches the skin and also makes the vein a bit more prominent. You can alternatively ask someone else to help you out with this move. Turn the patients head to the other side. You now have a nice taut neck, ready to be pierced!

4) Use a 16G cannula if you can. If the patient has a short neck, you may have to start higher up. The reason being if the cannula tip winds up very low, it starts to kink and you'll have to keep the patient's head in a particular position for a good flow. 20G cannulas are shorter, and you may not face this problem, but then.. they are 20G cannulas...
If your cannula tip is about an inch and a half above the clavicle.. you should have a good flowing line.

5) Many times, you would be inside the vein, but may not get the flash of blood in the chamber. So pull out the stylet and check.

6) If you aren't sure where you are, use a syringe to aspirate blood and work your way in.

Hope this helps !
Click to expand...

"2) Being a right hander, i've found it easier to cannulate the left EJV. That also allows you to leave the right side of the neck free for an IJV line later."
Can you explain please?
2win
 
2win said:
Not a big fan either but I can use it...
Very very rarely...
Thrombosis, infiltration, valve damage.
Click to expand...

Valve damage? Do you mean heart valve? Maybe I'm just post-call confused, but I thought neck/facial veins didn't have valves.
 
rsgillmd said:
Valve damage? Do you mean heart valve? Maybe I'm just post-call confused, but I thought neck/facial veins didn't have valves.
Click to expand...

"[FONT=arial,sans-serif][SIZE=-1]The external jugular vein (v. jugularis externa) receives the greater part of the blood from the exterior of the cranium and the deep parts of the face, being formed by the junction of the posterior division of the posterior facial with the posterior auricular vein. It commences in the substance of the parotid gland, on a level with the angle of the mandible, and runs perpendicularly down the neck, in the direction of a line drawn from the angle of the mandible to the middle of the clavicle at the posterior border of the Sternocleidomastoideus. In its course it crosses the Sternocleidomastoideus obliquely, and in the subclavian triangle perforates the deep fascia, and ends in the subclavian vein, lateral to or in front of the Scalenus anterior. It is separated from the Sternocleidomastoideus by the investing layer of the deep cervical fascia, and is covered by the Platysma, the superficial fascia, and the integument; it crosses the cutaneous cervical nerve, and its upper half runs parallel with the great auricular nerve. The external jugular vein varies in size, bearing an inverse proportion to the other veins of the neck, it is occasionally double. It is provided with two pairs of valves, the lower pair being placed at its entrance into the subclavian vein, the upper in most cases about 4 cm. above the clavicle. The portion of vein between the two sets of valves is often dilated, and is termed the sinus. These valves do not prevent the regurgitation of the blood, or the passage of injection from below upward."

I COULD BE WRONG ....But I remember something about that...
To much academics...In PP I never thought about that - so you're not absolutely wrong.

[/SIZE].
 
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