Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture

We undertook a prospective laboratory study to examine the effect of head position on the relative positions of the carotid artery and the internal jugular vein (IJV). Volunteers (n = 12) from departmental staff, 18-60 yr of age, who had never undergone cannulation of the IJV underwent imaging of their IJV and carotid artery. With the subject in a 15 degrees Trendelenburg position, two-dimensional ultrasound images of the IJV and the carotid artery were obtained on the left and right sides of the neck at 2 and 4 cm from the clavicle along the lateral border of the sternal head of the sternocleidomastoid muscle at 0 degrees, 40 degrees, and 80 degrees of head rotation from the midline. The percent overlap of the carotid artery and IJV increased significantly at 40 degrees and 80 degrees head rotation to both the right and left (P < 0.05). Data from 2 and 4 cm above the clavicle did not differ and were pooled. The percent overlap was larger on the left than the right only with 80 degrees of head rotation (P < 0.05). The increased overlap of carotid artery and IJV with head rotation > 40 degrees increases the risk of inadvertent puncture of the carotid artery associated with the common occurrence of transfixion of the IJV before it is identified during needle withdrawal. The IJV frequently collapses with needle insertion. This may result in puncture of the posterior wall of the vessel, and thus of the carotid artery when the two vessels overlap. To decrease this risk, the head should be kept in as neutral a position as possible, that is < 40 degrees rotation, during IJV cannulation.