Introduction: Central venous catheterization is a vital intervention in critically ill patients. The proper route of insertion is essential for its success. The purpose of this study was to compare the procedural parameters and complications associated with anterior and posterior approaches to internal jugular vein catheterization under real-time ultrasound guidance in critically ill patients. Materials and methods: In this prospective randomized study, 90 patients admitted in various ICUs were randomly allocated two groups of 45 each, including both males and females aged between 18 and 80 years of age requiring central venous catheterization for various indications. Demographic data was comparable between both groups. The first attempt success rates, venous visualization time, venous puncture time, duration of catheterization, and complications of each route were compared. Results: The first attempt success rates were comparable between both groups. The venous visualization time was 38.52 seconds in group I and 14.65 seconds in group II (p < 0.001). The venous puncture time and the duration of catheterization was found to be 47.60 sec and 2 minutes in group I, respectively, and 24.16 sec and 1 minute 32 sec in group II, respectively (p < 0.001). No statistically significant differences were found between the two groups in terms of incidence of carotid arterial puncture, hematoma formation, and catheter displacement. Conclusion: It was concluded that the posterior approach is better than the anterior approach of ultrasonogram (USG) guided internal jugular vein catheterization as it improves the accuracy, reduces the access time and duration of catheterization, and fewer incidences of immediate complications like carotid arterial puncture and hematoma formation.