Anatomy Msk · Year 1 · from Anatomy Msk
Case 2: Central Line Placement Using Anatomical Landmarks
Clinical Image
Source: Wikimedia Commons - Neck Anatomy - CC BY-SA 4.0
Case Presentation
A 62-year-old man with septic shock requires central venous access for vasopressor administration and hemodynamic monitoring. Peripheral IV access is difficult due to prior IV drug use. The right internal jugular vein approach is selected. The patient is positioned supine in slight Trendelenburg to distend the neck veins. Surface anatomy landmarks are identified: the sternal and clavicular heads of the sternocleidomastoid muscle form a triangle with the clavicle at its base. The internal jugular vein runs within this triangle, lateral to the carotid artery. The carotid pulse is palpated and the point of needle insertion identified at the apex of the triangle, approximately 3 cm above the clavicle. Under ultrasound guidance (current standard of care), the internal jugular vein is visualized as a compressible, thin-walled structure lateral to the non-compressible carotid artery. The vein is accessed using the Seldinger technique with real-time ultrasound visualization. The guidewire is passed, the tract dilated, and a triple-lumen catheter is placed. Position is confirmed with blood aspiration from all ports and chest X-ray showing the catheter tip at the cavoatrial junction without pneumothorax.
Key Learning Points
- The internal jugular vein lies within the carotid sheath, lateral to the common carotid artery
- Surface landmarks: triangle formed by the two heads of SCM and clavicle; IJ vein at apex of triangle
- The external jugular vein is superficial and crosses the SCM obliquely; it can be used if IJ is not accessible
- Ultrasound guidance is now standard of care, reducing complications (arterial puncture, pneumothorax)
- Anatomical knowledge remains essential for interpreting ultrasound images and understanding complications