Central Venous Catheter (CVC) Insertion – Three-Finger Technique

When an ultrasound machine is not immediately available and central venous access via the right jugular vein is required, a simple three-finger technique for insertion of a central venous access line into the right internal jugular vein has proven to be a reliable method for accomplishing this task. This technique works well regardless of the body habitus of the patient or whether the patient can rotate their head to the left.

I. Indications

The three-finger technique for internal jugular vein cannulation is used for the same indications as standard CVC insertion, including:

• Administration of medications (e.g., vasopressors, chemotherapy).
• Fluid resuscitation.
• Hemodynamic monitoring.
• Renal replacement therapy.
• Parenteral nutrition.
• Difficult peripheral venous access.

II. Contraindications

Contraindications for the three-finger technique are similar to those for standard internal jugular vein cannulation:

• Absolute contraindications:
  • Infection at the insertion site.
  • Thrombosis of the internal jugular vein.
• Relative contraindications:
  • Altered anatomy.
  • Coagulopathy.
  • Carotid artery disease.

III. Procedure

The three-finger technique uses specific hand positioning to locate the internal jugular vein.

1. Patient positioning: Place the patient supine with their head turned slightly to the left.
2. Hand placement:
   • Place your left ring finger in the patient’s sternal notch.
   • Place your left middle and index fingers together, in the midline over the trachea.
   • Roll your fingers over the trachea and into the space between the trachea and the medial head of the sternocleidomastoid muscle.
   • Keep the pads of your three fingers in contact with the trachea. Your ring finger should now be in contact with the sternoclavicular joint.
   • The medial head of the sternocleidomastoid muscle will be bunched into a mound lateral to your fingers.
3. Needle insertion:
   • Insert the finder needle in the middle of this mound, at the level of your left index finger.
   • Insert the needle at a 45-degree angle to the skin, aiming toward the patient’s ipsilateral nipple.
   • Apply gentle suction to the syringe as you advance the needle.
4. Venous access confirmation:
   • Once you obtain venous blood return in the syringe, advance a larger introducer needle over the finder needle, using the same angle and direction.
5. Catheter insertion:
   • Introduce a guidewire through the introducer needle, and then insert the central venous catheter using the Seldinger technique.
6. Confirmation of placement:
   • Confirm CVC placement with a chest X-ray.

IV. Complications

The complications associated with the three-finger technique are similar to those of standard CVC insertion:

• Arterial puncture.
• Hematoma.
• Pneumothorax.
• Infection.
• Thrombosis.
• Air embolism.