Reliable venous access is a cornerstone of effective patient management across perioperative, emergency, and intensive care settings. However, obtaining peripheral venous access can be particularly challenging in patients with conditions like obesity, hypovolemia, chronic illness, or vascular damage from prior interventions. These cases, often categorized under Difficult Peripheral Venous Access (DPVA), are not uncommon in critical care environments. Wu and Lee highlighted that factors such as shock, burns, or chronic kidney disease contribute significantly to DPVA in emergency scenarios [1].

In such situations, Central Venous Catheterization (CVC) via internal jugular or subclavian veins is typically employed. Despite its widespread use, CVC carries a higher risk of complications such as pneumothorax, arterial puncture, and bloodstream infections, particularly when performed without real-time imaging. Kaur and Parmar emphasized that while central lines are essential, they require a higher degree of technical skill and time—often unavailable during emergencies [2].

Modern practice often favours ultrasound guidance for central venous access, given its ability to improve success rates and reduce complications. However, access to ultrasound machines and trained operators may be limited, particularly in resource-constrained or high-pressure settings. Wysocki and Derra noted that ultrasound-guided catheterization, although safer, involves additional preparation time, which may not always be feasible [3].

In this context, External Jugular Vein (EJV) cannulation presents a practical and often underutilized alternative. The EJV’s superficial anatomy allows for direct visualization, making it particularly suitable for landmark-based access even in the hands of junior clinicians. Sharma and Gupta described the EJV as offering procedural simplicity and fewer critical complications compared to deeper veins [4].

Studies have demonstrated high success rates with EJV access, often ranging from 76% to 90%, along with low complication profiles. Sam and Verma reported that EJV cannulation procedures generally require less time and are easier to teach to novice operators, especially in emergency departments [5].

Furthermore, its value as a training tool for junior clinicians has gained attention. Ahmed and Watson emphasized that EJV cannulation, when supervised properly, can serve as an effective skill-building exercise for junior doctors, improving their procedural confidence and clinical acumen [6].

Lastly, the safety and efficiency of EJV cannulation in emergency settings were reaffirmed by Riaz and Patel, who found that junior medical staff could achieve high success rates with minimal complications, especially when provided with basic orientation and procedural oversight [7].

In view of these observations, the present study was conducted to evaluate the procedural efficiency, first-attempt success rate, and complication profile of EJV cannulation when performed by junior clinicians in a tertiary care teaching hospital.

Aims and Objectives

Aim:

To evaluate the procedural efficiency, success rate, and safety profile of external jugular vein (EJV) cannulation when performed by junior clinicians in perioperative and critical care settings at a tertiary care hospital.

Primary Objective:

• To assess the overall success rate of EJV cannulation performed by junior residents using a landmark-based technique.

Secondary Objectives:

• To determine the first-attempt success rate of EJV cannulation.
• To measure the mean time required for successful EJV cannulation.
• To identify and document any immediate or delayed complications associated with the procedure, such as catheter malposition, insertion site swelling, arterial puncture, pneumothorax, or infection.
• To assess the feasibility of implementing EJV cannulation as an alternative central venous access route in resource-limited settings or emergencies where ultrasound guidance is not readily available.

Study Design and Setting

This prospective observational study was conducted over a 12-month period from June 2024 to May 2025 at Sukh Sagar Medical College and Hospital, a tertiary care centre in Central India. Data were collected from the Intensive Care Unit (ICU), Emergency Room (ER), and Operation Theatres (OT) of the institution.

Study Population

A total of 140 adult patients requiring central venous access were initially screened for eligibility. After applying exclusion criteria, 100 patients were enrolled for final analysis.

Inclusion criteria included adult patients (>18 years) presenting with difficult peripheral venous access (DPVA) due to:

• Obesity
• Chronic intravenous drug use
• Collapsed, fragile, or thrombosed peripheral veins
• Fibrosis due to chemotherapy
• Multiple failed peripheral cannulation attempts
• Anatomical challenges such as limb contractures
• Emergent clinical scenarios like septic shock, trauma, or cellulitis of limbs

Exclusion criteria were:

• History of neck surgery
• Active neck infection
• Suspected cervical spine trauma
• Patient refusal to undergo the procedure

Ethical Considerations

Ethical approval for the study was obtained from the Institutional Ethics Committee of Sukh Sagar Medical College, Jabalpur. Informed written consent was obtained from all participants or their legal guardians. The study adhered to the principles of the Declaration of Helsinki.

Operator Details and Training

The procedure was performed by junior residents and interns who had prior experience with peripheral venous access. All operators underwent structured training on external jugular vein (EJV) anatomy and cannulation technique. Initial procedures were conducted under supervision to ensure safety and protocol adherence.

Procedure

Patients were positioned supine with the head turned contralateral to the cannulation site. A 10°–30° Trendelenburg tilt was applied when tolerated to engorge the vein and minimize air embolism risk.

The EJV was identified visually along the course of the sternocleidomastoid muscle. Site preparation was done using an alcohol-based antiseptic solution, followed by sterile draping. Vein occlusion above the clavicle was achieved with the non-dominant hand to distend the vessel. Using the dominant hand, a 16G or 18G intravenous cannula was inserted at a shallow angle (10°–20°) under direct vision. Blood flashback confirmed entry into the vein, after which the catheter was advanced and secured with sterile dressing. Patency was confirmed by flushing with 5 mL of normal saline.

Post-procedure monitoring included:

• Regular checks for patency
• Inspection for local complications (swelling, redness, infection)
• Monitoring for systemic complications such as pneumothorax or air embolism

In cases of failed EJV access, alternative methods such as ultrasound-guided cannulation on the contralateral side or conventional central venous catheter insertion by a senior clinician were employed.

Data Collection

Demographic data, indication for central access, site of cannulation (right/left), number of attempts, cannula size, time to successful placement, level of operator, and complications were documented in real-time. The cannula remained in situ as clinically indicated and was removed if no longer needed or upon complication.

Outcome Measures

Primary Outcome:

• Successful cannulation, confirmed by blood return and free saline flow

Secondary Outcomes:

• First-attempt success rate
• Mean time to cannulation
• Number of attempts
• Immediate complications including insertion site swelling, catheter malposition, arterial puncture, pneumothorax, and infection

Statistical Analysis

Data were analyzed using standard statistical software. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were represented as percentages. Comparisons between groups were made using the independent t-test or Chi-square test as appropriate. A p-value of <0.05 was considered statistically significant.

. Baseline Characteristics of the Study Population

A total of 140 adult patients were screened during the study period from June 2024 to May 2025. Of these, 100 patients met the inclusion criteria and were enrolled for final analysis. The most common indications for external jugular vein (EJV) cannulation included difficult peripheral venous access (DPVA) due to obesity, chronic intravenous drug use, chemotherapy-related venous fibrosis, and anatomical challenges such as limb contractures or cellulitis.

The majority of cannulations were performed in critical care settings, with patients distributed across the Intensive Care Unit (ICU), Emergency Room (ER), and Operation Theatres (OT). The right EJV was the preferred site of cannulation in most cases, selected based on operator discretion and vein prominence. Cannulation was performed using either a 16-gauge or 18-gauge intravenous catheter, selected according to vein size and operator assessment.

All procedures were conducted by junior clinicians, including junior residents and interns, following institutional training and supervision. Each operator had prior experience in peripheral venous access and was instructed on the anatomical landmarks and procedural steps specific to EJV cannulation.

Table 1 summarizes the demographic and clinical characteristics of the study population.

Table 1. Baseline Characteristics of the Study Population

                            *Note: DPVA = Difficult Peripheral Venous Access.

2. Cannulation Outcomes

Out of 100 patients who underwent attempted EJV cannulation, successful catheter placement was achieved in 79 patients, resulting in an overall success rate of 79% (95% Confidence Interval [CI]: 71.0% to 87.0%). Among these, 62 cases were successful on the first attempt, yielding a first-attempt success rate of 62% (95% CI: 52.5% to 71.5%).

The mean number of attempts required for successful cannulation was 1.5 per patient. The mean time to successful cannulation was 148 ± 35 seconds, with a 95% CI ranging from 141.1 to 154.9 seconds.

These results demonstrate that even in the hands of junior clinicians using a landmark-based approach without ultrasound guidance, EJV cannulation can be performed with a high rate of success and acceptable procedural time.

Table 2. Cannulation Success and Procedural Metrics

3. Comparison across Subgroups

Subgroup analysis was conducted to explore differences in cannulation success rates and procedural time based on operator level, cannula size, and side of cannulation.

 Operator Level

Among the 100 procedures, 60 were performed by junior residents and 40 by interns. The overall success rate was slightly higher among junior residents (83%) compared to interns (72.5%), though this difference did not reach statistical significance (p > 0.05, Chi-square test). First-attempt success was also more frequent among junior residents (66%) than interns (55%).

 Cannula Size

Cannula size was selected based on vein visibility and patient anatomy, with 60 patients receiving 18G and 40 patients receiving 16G cannulas. The mean time to cannulation did not differ significantly between the two groups (p = 0.18, independent t-test), although 18G cannulas were associated with a slightly higher first-attempt success rate (65% vs. 57.5%).

Side of Cannulation

The right external jugular vein was cannulated in 70 cases, while the left side was used in 30 cases. Success rates were comparable between the two groups (80% for right vs. 76.6% for left; p = 0.65), suggesting no significant impact of side selection on procedural outcome. Mean cannulation time was also similar between right and left EJV access (147.3 vs. 149.9 seconds, respectively; p = 0.42). Table 3 summarizes subgroup outcomes.

Table 3. Comparison of Cannulation Outcomes across Subgroups

Box plot comparing the time required for successful external jugular vein (EJV) cannulation between junior residents and interns. Junior residents demonstrated slightly lower median times and narrower variability compared to interns. No statistically significant difference was observed between the groups (p > 0.05, independent t-test).

4. Complication Profile

Among the 100 patients who underwent external jugular vein (EJV) cannulation, a total of 4 complications were recorded, reflecting an overall complication rate of 4%.

The most common complication was insertion site swelling, observed in 3 patients (3%). This was managed conservatively with no further intervention required. One case (1%) of catheter malposition was identified based on poor flow and was corrected by reinsertion. Importantly, no serious adverse events were reported. There were no cases of arterial puncture, pneumothorax, or procedure-related infection, either during catheter dwell time or within 48 hours of removal.

Table 4 provides a summary of the complications recorded during the study.

Table 4. Complications Associated with EJV Cannulation (n = 100)

5. Cannula Maintenance and Removal

All successfully placed EJV cannulas were maintained in situ for the duration of clinical need, ranging from 1 to 5 days, depending on patient condition and therapeutic requirements. Daily assessments were conducted to monitor for patency, signs of local inflammation, and catheter-related complications.

The average dwell time was approximately 2.8 days, although exact day-wise stratification was not recorded. Insertion sites were monitored until 48 hours after cannula removal for delayed adverse events. No new complications, including infection, phlebitis, or site-related pain, were observed during the post-removal observation window.

Cannulas were removed either upon transition to peripheral access, resolution of the critical indication, or scheduled patient discharge. In cases where complications such as swelling or malposition occurred, the cannulas were removed immediately and alternative access was secured as per clinical judgement.

6. Summary of Key Findings

This prospective observational study evaluated the procedural efficiency and safety of external jugular vein (EJV) cannulation performed by junior clinicians in critical care and perioperative settings. Among 100 patients enrolled:

• The overall success rate was 79%, with a first-attempt success rate of 62%.
• The mean number of attempts was 1.5, and the mean cannulation time was 148 ± 35 seconds.
• No serious complications such as arterial puncture, pneumothorax, or infection were observed.
• The overall complication rate was low (4%), including minor issues such as insertion site swelling (3%) and catheter malposition (1%).
• Subgroup analysis showed no statistically significant differences in success or complication rates based on operator level, cannula size, or side of cannulation.
• Cannulas were safely maintained in situ for up to 5 days, with no delayed complications reported within 48 hours after removal.

This prospective observational study assessed the procedural efficiency and safety of external jugular vein (EJV) cannulation performed by junior clinicians using a landmark-based technique. Our results—79% overall success, 62% first-attempt success, mean cannulation time of 148 ± 35 seconds, and a 4% complication rate—demonstrate that EJV cannulation is a practical alternative to central venous access in patients with difficult peripheral venous access (DPVA), particularly in emergency or resource-limited settings.

The overall success rate of 79% (95% CI: 71.0%–87.0%) falls within the internationally reported range of 76–90% for landmark-guided EJV cannulation [8,9]. Sam and Verma, in a review of EJV practices in critical care, described success rates of approximately 80% for landmark techniques in the absence of ultrasound [8]. Mehta and Das similarly reported success rates from 78% to 86%, varying by operator experience and patient factors [9]. Our findings support these benchmarks and validate the use of EJV access even among less experienced providers.

The first-attempt success rate of 62% (95% CI: 52.5%–71.5%) is consistent with reports involving junior clinicians. Williams and Johnson noted first-pass success rates ranging from 55% to 65% in non-ultrasound settings for novice operators [10]. While ultrasound guidance often elevates this figure beyond 85% [12], our results emphasize that with proper anatomical instruction and supervised practice, even landmark-guided cannulation can yield clinically acceptable outcomes.

Our reported mean cannulation time of 148 ± 35 seconds (95% CI: 141.1–154.9 seconds) aligns closely with prior literature. Roberts and Brown identified a similar range of 120–180 seconds for EJV placement in emergency departments using landmark techniques [11]. Notably, Patel and Naik’s meta-analysis showed ultrasound use can reduce needle insertion time by 10–30 seconds, though this advantage is minimized when including full procedural setup time [12]. This reinforces the feasibility of EJV access as a time-efficient option, especially when ultrasound is unavailable.

Subgroup comparisons revealed that junior residents had a higher success rate (83%) compared to interns (72.5%), though this difference was not statistically significant (p > 0.05). Prior studies have demonstrated a learning curve effect. Tewari and Prakash reported that success rates and cannulation times improved after 10–15 supervised attempts among junior staff [13], and our data appear to support this trajectory. The box plot analysis in Figure 2 illustrated less variability and a lower median cannulation time among junior residents, suggesting greater procedural consistency with experience.

Our complication rate of 4% included only minor issues: 3% insertion site swelling and 1% catheter malposition. This closely mirrors the findings from a 9,482-case retrospective review, which reported a 0.7% rate of minor swelling and no serious complications with EJV access [15]. In contrast, landmark-guided internal jugular vein (IJV) cannulation is associated with higher complication risks, including arterial puncture (6–10%) and pneumothorax (2–3%) in the absence of ultrasound [16]. The absence of major complications in our study supports the relative safety of EJV access even in less experienced hands.

Cannula dwell time ranged from 1 to 5 days, with an average of approximately 2.8 days. No delayed infections or thrombotic events were noted within 48 hours after removal. Figure 3 demonstrates that complication occurrence was not significantly correlated with dwell time, which supports prior findings that short-term EJV access is safe and stable [14].

In totality, these findings underscore the clinical and educational value of EJV cannulation. With a success profile comparable to published standards, short procedure times, and a low complication burden, EJV cannulation is an ideal procedural skill for junior trainees and an excellent fallback option when peripheral access is difficult or when ultrasound is unavailable.

Limitations

This single-centre study lacked a control group and was limited to landmark-guided EJV cannulation, without ultrasound comparison. Operator variability was not formally assessed, and follow-up was limited to 48 hours post-removal, which may underestimate delayed complications.

External jugular vein (EJV) cannulation using a landmark-based technique demonstrated a high success rate, acceptable first-attempt success, and a low complication profile, even in the hands of junior clinicians. These findings support its role as a practical and safe alternative for central venous access, particularly in emergency settings and resource-limited environments where ultrasound may not be available. Incorporating EJV cannulation into early clinical training can enhance procedural confidence while maintaining patient safety.

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