I was recently helping the resus resident with establishing peripheral IV access in a hemodynamically stable patient who needed to be urgently loaded with keppra. Multiple attempts by myself and 3 other providers were unsuccessful. I couldn’t see an EJ (the patient turned out to be severely dehydrated, which explained the lack of viable veins). To try and better visualize the EJ, I put a probe on her neck, and was met with a whopping IJ. If only I could cannulate that sans CVC…

 

Enter the Easy IJ: cannulating the IJ with a peripheral IV catheter (ie, 18G) under US guidance.

 

Strayer does it, and that’s good enough for me. But if you or your attending are still wary, RebelEM recently did a great summary of evidence supporting the Easy IJ’s safety and efficacy.

 

When to use:

Consider it in patients who don’t yet have an indication for a TLC, but are difficult to access peripherally and require urgent medication administration. I think it is a viable alternative to an IO. Studies on this have shown it can be placed (on average) within 4-5 minutes.

 

What to use:

  • Aseptic technique: chlorhexidine, sterile US gel and probe cover, and sterile gloves. Full sterile drape coverage of the patient was not employed in the studies.  
  • 3 of the studies used 18 or 20G catheters that were at least 2 inches long, but one study used our “long” angiocaths (that we use for US guided IVs), which are 1.88 inches.
    • Elmhurst has these even-longer catheters in the cardiac room drawer labeled “Procedural Caths.”
    • To my knowledge, Sinai does not have peripheral angiocaths longer than 1.88 inches.
    • Just be sure to measure the IJ depth prior to attempting insertion.
  • Drs. Strayer and Shearer point out you can use the catheter that comes in the CVC kit (Shearer likes to also draw back on the syringe as he enters to confirm placement), the femoral A-line catheter, or any long catheter you come across.

 

Length of stay:

This is meant to be temporary. One study recommended 24 hours, but allowed the physician and patient to decide if they wanted to keep it in longer. Another saw a mean of 49 hours. Another had an average of 3.2 days with a maximum of 7 days.  

 

Complications:

Risks are similar to CVC placement and include pneumothorax, hematoma, bloodstream or site infection, and carotid artery puncture. None of these complications have been reported in the current literature.

 

Questions:

PA Dang asked – can you use vasopressors through the Easy IJ?

This has not been studied. Butterfield et al states “to remain cautious, we do not recommend giving vasoactive agents through these catheters for fear of potential complications.”

>If the patient decompensates and needs pressors, place a central line.

 

Comments:

Dr. Shearer would also like to point out that he takes credit for this. Though his recollection of the conversation is “cloudy,” he thinks he taught the technique to Strayer.

 

Concerns:

How did I get in the middle of Shearer and Strayer?

 

Take Home Message:

Consider incorporating the Easy IJ – a well-tolerated, safe, and effective means of access – into your armamentarium. But, talk to your attending first since this is not (yet) widely practiced.

 

Thank you:

Drs. Strayer, Shearer, O’Halloran, and PA Dang.

 

 

Butterfield M, et al. Using ultrasound-guided peripheral catheterization of the internal jugular vein in patients with difficult peripheral access. Am J Ther. 2015. PMID 26469683

 

Moayedi S et al. Safety and efficacy of the “easy internal jugular (IJ)”: an approach to difficult intravenous access. J Emerg Med. 2016; 51(6): 636-642. PMID 27658558

 

Kiefer D, et al. Prospective evaluation of ultrasound-guided short catheter placement in internal jugular veins of difficult venous access patients. Am J Emerg Med. 2016; 34(3): 578-581. PMID 26776533

 

Teismann NA et al. The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. J Emerg Med. 2013; 44(1): 150-154. PMID 22579025