Internal jugular vein can be canalized, and this reduces (but does not eliminate) the risk of pneumothorax, while adding the risk of carotid artery (2 – 10% [Intensive Care Med 2: 163, 218, 1987]) or thoracic duct injury. Awake patients will complain of reduced neck mobility, and agitated patients may occlude the catheter and vein secondary to excessive neck flexion. Lastly, patients with tracheostomies may be at increased risk of infection due to spread of secretions. When the head is turned to the opposite side, the IJV forms a straight line from the pinna to the sternoclavicular joint. The right side is preferred for cannulation. In the anterior approach, palpate the carotid artery in the triangle of the SCM heads and retract medially. Insert the needle into the apex of the triangle, advancing towards the ipsilateral nipple at 45° to the skin surface. If no venous blood by 5 cm, withdraw 4 cm and advance again more laterally. For the posterior approach, insert the needle (with the bevel at 3 o'clock) 1 cm above where the external jugular crosses the lateral edge of the SCM, advancing along the underbelly of the muscle and pointing towards the suprasternal notch. The IJV should be encountered within 5 – 6 cm. If blood is red and pulsating, remove the needle and apply pressure for 5 – 10 mins. If the carotid artery has been punctured by the needle, remove it and hold pressure for 5 mins. If the carotid as been actually cannulated, the catheter should be left in place and vascular surgery should be called. The only advantages of the IJ line are for pacemaker catheters and hemodialysis catheters, because of their straight course
