Usefulness of the Internal Jugular Venous Route for Cardiac Catheterization in Children Monica L. Garrick, MD, William H. Neches, MD, Frederick J. Fricker, MD, Elfriede Pahl, MD, and Jose A. Ettedgui, MD ardiac catheterization is an important tool in the diagnosis and managementof heart diseasein chilC dren. The femoral artery and vein are the usual routes of accessfor this procedure. In the past, use of the internal jugular vein for cardiac catheterization hasbeenreserved for those children in whom femoral venous accesswas limited by obstruction, such asileofemoral venousthrombosis or congenital absenceof the hepatic portion of the inferior vena cava. Latson et al’ reported useof this vein in 14 pediatric patients, in each for reasons of either inferior vena caval obstruction or the desireto maintain a central venous line after catheterization. At the Children’s Hospital of Pittsburgh, the internal jugular vein has been used as a primary site for cardiac catheterization in patients undergoing endomyocardial biopsy after cardiac transplantation. This report describesour experience and technique. From May 1982 through April 1989,internal jugular venousaccessfor cardiac catheterization was attempted I76 times in 36 patients. Patients ranged in agefrom 2 months to 18 years and in weight from 4 to 87 kg. Nineteenpatients were undergoing evaluation and endomyocardial biopsy after cardiac transplantation. Five patients had a presumptive diagnosis of myocarditis and From the Division of Cardiology, Department of Pediatrics,Children’s Hospital of Pittsburgh, and the University of Pittsburgh School of Medicine, 3705 Fifth Avenue, Pittsburgh, Pennsylvania 15213. Manuscript received September 21, 1989; revised manuscript received and acceptedDecember 27,1989.

underwentcatheterizationfor hemodynamicassessment and biopsy. An additional 12patients had other congenital defects. Premeditation varied in that infants received none, while older children usually received an intramuscular injection of 2 mglkg of meperidine (maximum 75 mg) combined with 0.5 mg/kg each of promethazine and chlorpromazine (maximum 25 mg of each). This was administered 45 minutes before the procedure. Local anesthesiawas obtained with 1% lidocaine without epinephrine. A few children who had undergone multiple procedures preferred to forego the premeditation and tolerated the procedure well with local anesthetic only. Patients are positioned with a pillow beneath the shoulders and with their arm at their sides. The head is turned toward the left and the entire right anterior neck prepped and draped in sterile fashion. Landmarks for identifying the anterior triangle of the neck are shown in Figure 1. The triangle is bordered by the medial and lateral headsof the sternocleidomastoid muscle and by the clavicle. The internal jugular vein courses through this triangle in an orientation from the apex of the triangle toward the patient’s right nipple. Local anesthesiais administered with a 25-gauge needle, puncturing the skin at the apex of the triangle and infiltrating along the expected course of the vein. Others have described a “low” approach to the vein, puncturing the skin at the base of the triangle near the clavicle.1,2The approach from the apex has been used in our institution.

RGURE 1. Limhmrks by which intemd jqgularveinistdenthd.CCA=common awottd artery; UV = internal Jugdar vain; SCM=-8StOi!lmurds.

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Two methods may be used to enter the vein. In the cases because of the desire to measure cardiac output by thermal dilution. first, a 21 -gauge needle attached to a 3 ml syringe (filled Right-sided cardiac catheterization is carried out in with heparinized flush solution) is used to locate the vein. The needle enters the skin and is advanced in the the usual manner. When biplane cineangiography isperdirection previously described while maintaining an an- formed, it is necessary to reposition the patient’s arms above the head. At the completion of the procedure, the gle of 45”. Constant negative pressure is applied until free flow of blood is obtained. Once the vein has been catheters are removed and hemostasis achieved with entered, the syringe is removed and the needle left in firm hand pressure, followed by a light gauze dressing. Children were returned to their rooms and received place as a guide to its location and to the angle of inserroutine postcatheterization care. Observation in an intion of the larger needle. Bleeding or air aspiration tensive care setting was not required. Ambulation was through this needle is not a problem due to the small caliber. A 19-gauge, I S-inch thin walled needle with an permitted once the patients were fully awake. Patients attached syringe is then used to puncture the skin imme- were usually discharged the following morning, aldiately behind this guide needle. When the vein is en- though a few were discharged later the same day. Internal jugular venouscatheterization wassuccessful tered, the syringe is removed and a guidewire advanced to the right atrium under jluoroscopic guidance. The 2 in 168of 176attempts (95%) in 36 patients. Eight proceneedles are removed and the subcutaneous tissues dilatdures in 7 patients were unsuccessful.Thrombosis of the ed with a Medicut plastic needle (Argyle) or a hemostat. vein wasdocumentedby angiography in 3 proceduresand A scalpel blade may be necessary to nick the skin adja- in the other 5 proceduresit could not be documented. cent to the wire in some cases when multiple priorproceThree of these7 patients had only 1 attempted cannuladures have resulted in scar tissue (in our series, adequate tion. Two patients had successfulsubsequentand 2 others dilation enabled sheath insertion in all cases). A venous had successfulprior internal jugular venouscatheterizasheath and dilator may then be advanced over the guide- tion. Thirty-seven procedureswere performed in patients wire. Side-port sheaths are used to accommodate various catheter sizes and to enable frequent irrigation of the weighing