Ultrasound-guided Placement of Peripheral Intravenous Lines in the Internal Jugular Vein.
Phase: NA
Conditions: IV Access
Sponsor: University Medical Center of Southern Nevada

CLINICAL PROTOCOL 
 
 
Ultrasound-guided Placement of Peripheral Intravenous Lines in the Internal 
Jugular Vein 
 
NCT03231345  
 
Last updated April 1, 2017 
 
INTRODUCTION: 
 
Intravenous (IV) access in the emergency department (ED) patient is essential for 
medication delivery, IV fluid resuscitation, rapid serum laboratory diagnostics, and 
administration of IV contrast for CT scans. Some patients, such as those with obesity, IV 
drug abuse, chronic illnesses, or vascular pathology may have difficult IV access. These 
patients are problematic for the busy ED nurse and physician as this can lead to a time 
consuming process, which slows efficiency and patient care.  
 
Previously, patients with difficult IV access often ended up getting central venous 
catheterization, a procedure that can result in a number of serious complications (1).  
More recently, ultrasound guidance has been touted as an effective means to achieve 
peripheral IV access on these patients (2).  In one study (2), there was a 73% first attempt 
cannulation rate, which seems respectable, but not excellent.  Additionally, 8% of the 
successful IVs failed within one hour (2).  Another study compared ultrasonographically 
guided peripheral IVs to non-ultrasonographically guided IVs, and it found that using 
ultrasound did not decrease the amount of time or the number of attempts it took to 
successfully place a peripheral IV (3).         
 
It seems that we still have room to improve our ability to obtain difficult IV access, and a 
relatively new technique may be the answer.  Ultrasound guided IVs are typically 
attempted in the upper extremities, targeting the brachial or basilic veins, but a recently 
described technique ---  the “peripheral IJ” --- involves placement of a peripheral IV 
catheter in the internal jugular vein (4,5).  
 
The peripheral IJ is gaining popularity in our ED as a solution to the difficult vascular 
access patient. In our clinical experience, it is a quick and easy procedure that is also safe, 
tolerated well by patients, and requires fewer resources.  Several small studies have 
concluded that this is a fast and safe procedure and a feasible alternative to central access 
in the difficult vascular access patient (4-7).  These studies mention the theoretical risks 
as being similar to central venous access such as carotid artery puncture, hematoma, 
pneumothorax, and line infection, however none of these have actually been reported (4-
7).  
 
We feel it is important to continue to contribute to the knowledge about the safety, speed, 
and feasibility of ultrasound-guided internal jugular vein peripheral cannulation. We 

propose a prospective evaluation of peripheral IJ placement on a convenience sample of 
emergency department patients who require IV access and have difficult IV access.  
Therefore, we seek primarily to determine the average number of attempts to cannulation 
for ultrasound-guided peripheral IJ placement.  Secondarily, we wish to determine: 1) the 
prevalence of potential complications related to this procedure 2) the average time it 
takes the emergency physician to complete the procedure  3)  the patient’s satisfaction 
with the procedure.  This data will be compared to the existing literature on ultrasound-
guided peripheral IV placement using other techniques.  
 
METHODS: 
 
This will be a prospective study at a single, urban, academic emergency department 
evaluating the placement of peripheral IJs on a convenience sample of patients with 
difficult IV access ED patients who require IV access for medical management. 
 
Inclusion criteria:  
*  At least two unsuccessful attempts at peripheral IV access by ED nursing staff. 
*  Age >18. 
 
Exclusion criteria: 
*  Critically ill patients with clinical indications for emergent central venous access. 
*  Overlying skin infection. 
*  External jugular vein easily visible for cannulation. 
*  Patients in law enforcement custody. 
*  Patients who are pregnant. 
*  Patients who lack decision-making capacity 
 
ED residents and attending physicians will perform ultrasound-guided cannulation of the 
IJ using aseptic technique.  A biopatch and sterile dressing will be placed.  This is similar 
to the technique used to place traditional central venous catheters. Standard catheter over 
needle method will be used, and the catheter will be secured in typical fashion as for a 
standard IV start.  
 
A data collection form will be available for completion by a trained observer (who will 
observe the physician placing the IV). Data collection will include location, number of 
attempts, time to successful completion, post-procedure portable chest x-ray results, 
immediate complications, catheter type used, time to discontinuation of catheter, reason 
for catheter removal, delayed complications, and patient demographics. 
 
For patients who end up getting admitted, data regarding discontinuation of the catheter, 
reason for removal, and delayed complications will be obtained from the inpatient 
nursing charts.  
 
Although many of our ED physicians already use the peripheral IJ technique, all residents 
and attending physicians involved in this study will be required to attend a mandatory 

training session about the placement of peripheral IJs to ensure adequate baseline 
knowledge of the technique.  
 
The largest study to evaluate the placement of peripheral IJs had 33 patients (4).  We 
hope to enroll 50 patients.  Each patient will sign a written consent form. 
 
In order to protect the privacy of the research subjects and to maintain the confidentiality 
of data, all data will be handled only by research assistants or investigators and will be 
stored only in secure cabinets in locked research offices.  
 
 
REFERENCES: 
 
(1) Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. 
International Journal of Critical Illness and Injury Science. 2015;5(3):170-178. 
doi:10.4103/2229-5151.164940. 
 
(2) Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial 
and basilic vein cannulation in emergency department patients with difficult intravenous 
access. Ann Emerg Med 1999;34:711–4.  
 
(3) Stein, J., George, B., River, G., Hebig, A., & Mcdermott, D.  Ultrasonographically 
Guided Peripheral Intravenous Cannulation in Emergency Department Patients With 
Difficult Intravenous Access: A Randomized Trial. Annals of Emergency Medicine. 
2009; 54(1), 33-40.  
 
(4) Teismann, N. A., Knight, R. S., Rehrer, M., Shah, S., Nagdev, A., & Stone, M. 
(2013). The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization 
using a Standard Intravenous Catheter. The Journal of Emergency Medicine, 44(1), 150-
154. 
 
(5) Butterfield, M., Abdelghani, R., Mohamad, M., Limsuwat, C., & Kheir, F. (2015). 
Using Ultrasound-Guided Peripheral Catheterization of the Internal Jugular Vein in 
Patients With Difficult Peripheral Access. American Journal of Therapeutics, 1. 
 
(6) Kiefer, D., Keller, S. M., & Weekes, A. (2016). Prospective evaluation of ultrasound-
guided short catheter placement in internal jugular veins of difficult venous access 
patients. The American Journal of Emergency Medicine, 34(3), 578-581. 
 
(7) Zwank, M. D. (2012). Ultrasound-guided catheter-over-needle internal jugular vein 
catheterization. [Letter to the Editor]. The American Journal of Emergency Medicine, 
30(2), 372-373. 
 
(8) Ash, A., & Raio, C. (2016). Seldinger Technique for Placement of “Peripheral” 
Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal 
of Emergency Medicine WestJEM, 17(1), 81-83.