If 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 no matter the body habitus of the patient or whether the patient can or cannot rotate their head over to their left side. In essence, the practitioner creates the landmarks required for successful insertion of a central venous catheter by properly positioning their left three fingers on the patient's neck. In my experience, the complication rate is no higher than other methods commonly used and might equal that of using ultrasound for placement.
When looking at the anatomy, emphasize the need to roll off the trachea. Keep the fingers in contact with the trachea. The goal is to get the medial head of the sternocleidomastoid muscle to bunch up as much as possible by applying pressure posteriorly with the fingertips versus the fingertips laterally. If the finder needle is inserted and no blood obtained, one can very slightly redirect the needle more medially without crossing the middle of the muscle. Once the internal jugular vein has been entered by the finder needle, place the larger, introducer needle directly over the finder needle and insert at the same angle as the finder needle.
Central line catheter insertion indications include emergent and non-emergent reasons. Emergent indications include transvenous pacemaker placement, measurement of right atrial central venous filling pressures or pulmonary capillary wedge pressures, measurement of cardiac output, large volume fluid administration, administration of specific medications such as inotropic medications, cardiac catheterization, emergency or temporary hemodialysis, vascular access in the unstable patient when peripheral intravenous access is not easily attainable, and/or delivery of large volume of fluids.
Non-emergent indications include or administration of total parental nutrition, patient in need of frequent routine blood draw (e.g., someone who is admitted to the intensive care unit for diabetic ketoacidosis or gastrointestinal bleeding), or patients needing hypertonic saline solutions, large amounts of potassium, or calcium chloride.
Contraindications for central line venous access include severe coagulopathy or thrombocytopenia, an uncooperative or combative patient, or the area of cannulation is contaminated, burned, or traumatized. Additionally, an inexperienced operator should not attempt central line venous access.
Most hospitals have standard central venous catheterization kits. In general, sterile kits contain a list of the following items:
The operator will also need:
Explain risks and benefits, if possible. Risks include infection, pain, local bleeding or hematoma, or pneumothorax/hemothorax. Ideally, the patient should be placed on a cardiac monitor to detect any dysrhythmias triggered while advancing with wire. Sterilize the neck and clavicle area with chlorhexidine. Provide adequate local anesthesia. For the uncooperative patient, consider sedation.
General steps include:
This completes the central venous access via the right jugular vein procedure.
Check the post-procedure chest radiograph, by using mammography or blood gas for proper central venous line catheter placement.
Be knowledgeable of the common complications of accessing the jugular vein still apply with this method. These include carotid artery puncture, subclavian artery puncture, pneumothorax, hematoma formation, extravasation, and hemothorax. Rare complications include pseudoaneurysms, aortic puncture, cardiac tamponade, and injury to the vertebral artery and even death. Arrhythmias can occur if the guidewire contacts the endocardium. Injury to the thoracic duct is not seen with right-sided cannulation of internal jugular vein. 
By using this method for central venous access via the right jugular vein, one does not require the patient to have easily identifiable landmarks for placement of a jugular catheter as some patients with large or short necks may or may not have.
Although ultrasound is common in central venous access placement, there are specific barriers that still exist, for example, daily utilization at the bedside and limited availability of ultrasound equipment, especially in remote areas. Other barriers include operator comfort level in the use of ultrasound and the perception that using ultrasound will delay the overall time in completing the procedure. In a setting that does not have ultrasound access, this method for central venous access via the right jugular vein is ideal. 
Internal jugular vein cannulation is done by many healthcare professionals including the nurse anesthetist. Once the line is inserted, it is the nurse who is in charge of looking after it. The key with internal jugular line placement is to avoid a pneumothorax, which does add additional morbidity to the patient. Prior to line use, a chest x-ray should be obtained. Today, to prevent line site infection and other complications, most hospitals have a team assigned to insert and monitor these catheters.
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