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CASE 6.1 INTERNAL JUGULAR CATHETERIZATION

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Patient Presentation

A 40-year-old male is admitted to the emergency department complaining of severe diarrhea, vomiting, dehydration, weakness, and weight loss. He is malnourished and a central venous catheter is placed to provide parenteral nutrition.

Relevant Clinical Findings History

The patient reported losing 25 lb during the past 9 months. The patient has a history of Crohn disease, with two previous resections of his small intestine. This has resulted in short-bowel syndrome, characterized by malabsorption, diarrhea, steatorrhea, fluid and electrolyte disturbances, and malnutrition.

Clinical Note

Crohn disease is a chronic, autoimmune, inflammatory disease that affects the gastrointestinal tract, usually the intestines. It results in transmural fibrosis and obstructive symptoms.

Physical Examination

Noteworthy vital signs:

  • Height: 5′ 10″

  • Weight: 120 lb

Results of physical examination:

  • Diffuse abdominal tenderness

  • Firmness in the right lower abdominal quadrant (consistent with appendicitis; or Crohn disease, which most commonly involves the terminal ileum)

Laboratory Tests
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Test Value Reference value
Erythrocyte (count) 3.6 4.3–5.6 × 106/mm3
Hematocrit 32.2 38.8–46.4%
Hemoglobin 10 14–17 gm/dL
Serum albumin 3.2 4.0–5.0 mg/dL
Imaging Studies
  • Placement of a central venous catheter, introduced via the right internal jugular vein, was confirmed radiographically.

Clinical Problems to Consider
  • Internal jugular vein catheterization

  • Subclavian vein catheterization

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LEARNING OBJECTIVES

  1. Describe the anatomy of the internal jugular vein.

  2. Describe the anatomy of the subclavian vein.

  3. Explain the anatomical basis for these procedures.

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RELEVANT ANATOMY

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Internal Jugular Vein
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The internal jugular vein (IJV) is formed at the jugular foramen, where it is the continuation of the sigmoid venous dural sinus (Fig. 6.1.1). It ends in the root of the neck, where it joins the subclavian vein to form the brachiocephalic vein. The right brachiocephalic vein is shorter and more vertical. The right and left brachiocephalic veins unite posterior to the right sternoclavicular joint to form the superior vena cava (SVC).

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Figure 6.1.1

Anterior view of the anatomy of the internal jugular and subclavian veins.

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In addition to the brain, the IJV drains blood from the face, neck viscera, and deep neck muscles. Its main tributaries include:

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  • Sigmoid dural venous sinus

  • Inferior petrosal dural venous sinus

  • Facial vein

  • Lingual vein

  • Pharyngeal vein

  • Superior and middle thyroid veins

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The IJV may also connect with the external jugular via the common facial and divisions of the retromandibular veins.

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The venous angle is formed by the intersection of the IJV and subclavian. This usually lies posterior to the medial end of the clavicle. Lymph is returned to the venous circulation at this location.

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  • The thoracic duct joins the left venous angle.

  • The right lymphatic duct joins the right venous ...

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