Central Venous Catheterization via External Jugular Vein

Primary Recommendations

The external jugular vein (EJV) is an acceptable alternative access site for central venous catheterization when the internal jugular vein is unavailable, though central catheter positioning can be technically more difficult through this route, as recommended by the American Society of Anesthesiologists 1, 2
The American Journal of Kidney Diseases suggests that the right EJV is preferred over the left EJV when IJV access is not feasible, as it provides a more direct anatomical course to central veins 3, 4

Central catheter positioning through the EJV can be difficult due to the anatomical course and valve structures, with a recommendation for post-insertion chest X-ray to verify proper catheter tip position, as stated by the American Society of Anesthesiologists 1, 2
The catheter tip should be positioned in the lower superior vena cava (SVC) or upper right atrium, parallel to the vessel wall, as recommended by the American Society of Anesthesiologists 1, 2

The American Society of Anesthesiologists recommends that the right IJV remains the preferred first-line access site due to its straighter course to the SVC and easier catheter positioning 1, 2, 3, 4
The American Journal of Kidney Diseases suggests that subclavian access should be avoided in patients who may need future permanent vascular access due to high risk of central venous stenosis 3, 5
The Anesthesiology society recommends that upper body insertion sites (including EJV) are preferred to minimize infection and thrombotic risks 1, 6
The American Society of Anesthesiologists states that femoral catheters should not remain in place longer than 5 days and should only be used in bed-bound patients, with a recommendation for upper body sites to reduce infection and thrombotic complications 5, 6

The American Society of Anesthesiologists advises against assuming the EJV will provide easy central catheter positioning—the anatomical course makes tip placement more challenging than IJV 1, 2
The American Journal of Kidney Diseases recommends always verifying catheter tip position with chest X-ray after insertion 1, 3
The American Society of Anesthesiologists suggests avoiding the use of the EJV as first-line access when the right IJV is available and patent 3, 4

The use of ultrasound imaging for external jugular vein cannulation offers opportunities for cannulation that may not be possible with anatomical landmarks alone, and can assess vessel size, depth, patency, and proximity to vital structures, as recommended by the Intensive Care Medicine guidelines 7

Pre-cannulation ultrasound examination can be used to assess vessel size, depth, patency, and proximity to vital structures, according to the Intensive Care Medicine guidelines 7

The external jugular vein (EJV) is recognized by the Association of Anaesthetists of Great Britain and Ireland as an alternative visible vein for vascular access, presenting unique technical challenges compared to traditional peripheral sites 8, 9
The EJV can be used for both peripheral-type access and as a route for central venous catheter placement, though central catheter positioning through this route is technically more difficult 8, 9

The Association of Anaesthetists of Great Britain and Ireland recommends considering EJV access in specific clinical scenarios, including difficult peripheral IV access in surgical patients requiring large-bore venous access, and patients requiring resuscitation fluids and drugs when standard peripheral access fails 8, 9
The American Society of Anesthesiologists is not mentioned, however the Association of Anaesthetists of Great Britain and Ireland suggests that if attempting to thread a central catheter through the EJV, one should expect technical difficulty due to anatomical course and valve structures—always verify tip position with chest X-ray 8

Do not use EJV for infusions requiring central venous administration (high osmolality, pH <5 or >9, or access >2 weeks) unless a central catheter is properly positioned, as recommended by the Association of Anaesthetists of Great Britain and Ireland 10, 11
The relative safety of vasopressors/inotropes through peripheral EJV access is contentious and depends on vein size, blood flow, infusion rate, and drug dilution—exercise caution, according to the Association of Anaesthetists of Great Britain and Ireland 10, 11

Intra-osseous access is faster than central access and should be familiar to all acute care clinicians for emergencies when IV access is difficult, as suggested by the Association of Anaesthetists of Great Britain and Ireland 8, 9, 10
Ultrasound-guided peripheral venous cannulation in upper arm veins is a recommended alternative access option 11
Midline catheters (10-20 cm) inserted into upper arm veins for short to medium-term access are also a viable option 11