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Percutaneous cannulation of the central veins is an essential technique for both long-term and emergent medical care. Access to the major veins of the torso allows rapid high-volume fluid resuscitation, administration of concentrated ionic and nutritional solutions, and hemodynamic measurements.

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The tip of the central venous catheter must lie in the superior or inferior vena cava and never in the right atrium. The thin wall of the right atrium may easily be perforated by the catheter tip, resulting in hemorrhage and cardiac tamponade. The central venous anatomy is shown in Figure 38-1. The superior vena cava is accessed through the internal jugular veins, the subclavian veins, and less commonly via the external jugular veins. The inferior vena cava is accessed through the femoral veins. These access routes are discussed in greater detail in the corresponding sections below. The advantages and disadvantages of each route for central venous access are summarized in Table 38-1.

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FIGURE 38-1
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The anatomy of the central venous system.

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Table Graphic Jump Location
Table 38-1. Characteristics of the Various Routes of Central Venous Cannulation
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Internal Jugular Vein

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The internal jugular vein is not directly visible from the surface of the skin. A thorough knowledge of its anatomic relationships is essential for successful cannulation. The internal jugular vein exits the skull through the jugular foramen, just anteromedial to the mastoid process.1 It joins the subclavian vein deep and just lateral to the head of the clavicle1 (Figure 38-2). The surface projection of the internal jugular vein runs from the earlobe to the medial clavicle, between the sternal and clavicular heads of the sternocleidomastoid muscle. The internal jugular vein increases in diameter as it descends. It is joined by tributary veins in the upper neck, making it easier to cannulate below the level of the cricoid cartilage.

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FIGURE 38-2
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Anatomy and surface relationships of the internal jugular vein.

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The internal jugular vein is collapsible (Figure 38-3). It has a very small diameter in low-flow states, as during cardiopulmonary resuscitation (CPR) and when the patient is upright. The vein is easily compressible and will collapse with gentle external pressure from a palpating finger ...

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