The external jugular vein as the first choice for central venous access in critically ill patients with severe coagulopathy

Introduction

The external jugular vein (EJV) may be used for central venous access. It is a superficial vein, allowing easy control of hematomas and, differently from the internal jugular vein (IJV) access, with no risk for airway obstruction in patients with significant coagulopathies. Additionally, pneumothorax, a feared complication of the subclavian venous access, is unlikely to occur after the EJV access. The main disadvantage of the EJV catheterization has been considered its unpredictability of passage of the catheter to the central compartment.

Objective

To present our initial experience with the EJV approach in unstable patients with significant coagulopathies requiring central venous catheterization, in whom the internal jugular and sublavian vein punctures were contraindicated.

Method

From July 1999 to December 2000, 37 consecutive patients (23 males, 14 females), who were unstable and critically ill, requiring central venous access in the presence of significant coagulopathies (protrombin activity <40% and/or platelets <50.000), were included. The age varied between 35 and 93 years (mean 71.7 years). The main causes for the coagulopathy were septic shock in 17, anticoagulants in 10, chemotherapy in five, hepatic dysfunction in three, and disseminated intravascu-lar coagulation in two patients. Our initial approach was a visible and palpable right EJV, unless a larger left EJV was present. There were 32 double-lumen, three pulmonary artery and one Shilley catheters.

Results

From the 32 attempts to catheterize the right EJV, there were three failures due to lack of guidewire progression; in these three patients the left EJV was successfully catheterized. There were also three catheter malpositionings (two at the ipsilateral IJV and one at the contralateral IJV), which were repositioned successfully. All 11 attempts to catheterize the left EJV were successful, with no catheter malposition. Hematomas, arterial puncture, pneumothorax or hemothorax were not observed in this series.

Conclusion

We conclude that the EJV approach can be used efficiently and safely for central venous catheterization in unstable, critically ill patients with severe coagulopathy.