Central venous catheterization: a randomized comparison between external and internal jugular access

Introduction

Central venous catheterization is a routine procedure in intensive care and the internal jugular access (IJA) is often used due to its high success rate. However, complications can happen in up to 4.2% of internal jugular punctures and IJA is contra-indicated in the presence of coagulopathy. The external jugular access (EJA) is underused, has low complications rates and is successful in up to 90% of cases. So far, there has been no randomized, controlled trial comparing both accesses.

Objective

To determine the success and early complication rates of internal and external jugular vein access.

Methods

A prospective, randomized study, performed in two adult general ICUs. Inclusion criteria: all patients who need central venous catheterization with a visible external jugular vein and no contraindication for the IJA. All included venous catheterizations were performed by the first-year and second-year critical care residents, supervised by a staff physician. Admission type, APACHE II score and outcomes were recorded.

Results

Sixty-nine patients were included. The mean APACHE II score was 22.8 (standard deviation = 6.4). Thirty-three patients (47.8%) were randomized to EJA and 36 (52.2%) to IJA. The percentage of success was 72.7% with EJA and 88.9% with IJA (risk ratio = 0.82; 95% CI = 0.64 to 1.04; P = 0.09). Complications occurred in 2/33 (6%) EJA patients and in 1/33 (3%) IJA patient (risk ratio = 2.1; 95% CI = 0.2 to 22.6; P = 0.28). Besides central venous catheterization failure, the only complications were carotid puncture (one patient in IJA) and external hematoma (two patients in EJA).

Conclusion

The external jugular venous access is a good alternative to internal venous catheterization and it is associated with minor and low complication rates. Our results show a lower but not significant probability of success with the EJA. However, considering that the procedure was done by physicians not familiar with the technique, we did not find definite evidence to indicate that IJA is superior to EJA.