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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2013  |  Volume : 24  |  Issue : 4  |  Page : 707-713
Ultrasound-guided internal jugular vein access: Comparison between short axis and long axis techniques


1 Department of Anesthesia, Faculty of Medicine, Suez Canal University Hospital, Egypt
2 Nephrology Division, Department of Internal Medicine, Faculty of Medicine, Tanta University Hospital, Tanta, Egypt
3 Department of Radiology, Nasr Hospital, Cairo, Egypt

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Date of Web Publication24-Jun-2013
 

   Abstract 

The use of real-time ultrasound (US) is advantageous in the insertion of central venous catheters (CVCs) in adults, especially in whom difficulties are anticipated for various reasons. The aim of the present study was to compare two different real-time 2-dimensional US-guided techniques [short axis view/out-of-plane approach (SAX OOP approach) versus long axis view/in-plane approach (LAX IP approach)] for internal jugular vein (IJV) cannulation. In this prospective study, 90 critical care and hemodialysis patients were assigned for insertion of CVCs using either the real-time US-guided (SAX OOP approach or LAX IP approach) or landmark technique (control group). Failed catheter placement, risk of complications from placement, failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization, incidence of central line-associated blood stream infection (CLA-BSI) and demographics of each patient were recorded. There were no significant differences in patient's demographic characteristics, side of cannulation (right or left) or presence of risk factors for difficult venous cannulation between the three groups of patients. Cannulation of the IJV was achieved in all patients by using US (SAX OOP and LAX IP approaches) and in 27 of the patients (90%) by using the landmark technique (P = 0.045). Average access time (skin to vein) and number of attempts were comparable between the SAX OOP and the LAX IP approaches while significantly reduced in both US groups of patients compared with the landmark group (P <0.001). In the landmark group, puncture of the carotid artery occurred in 16.7% of the patients, hematoma in 23.3% of the patients, pneumothorax in 3.3% of the patients and CLA-BSI in 20% of the patients, which were all significantly increased compared with the US group (P <0.05). The findings of this study suggest that the SAX OOP and LAX IP approaches were comparable for cannulation of IJV in critical care and hemodialysis patients. Furthermore, both US-guided techniques were superior to the landmark technique for insertion of CVCs.

How to cite this article:
Tammam TF, El-Shafey EM, Tammam HF. Ultrasound-guided internal jugular vein access: Comparison between short axis and long axis techniques. Saudi J Kidney Dis Transpl 2013;24:707-13

How to cite this URL:
Tammam TF, El-Shafey EM, Tammam HF. Ultrasound-guided internal jugular vein access: Comparison between short axis and long axis techniques. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Oct 16];24:707-13. Available from: http://www.sjkdt.org/text.asp?2013/24/4/707/113861

   Introduction Top


Internal jugular vein (IJV) catheterization is commonly attempted to obtain central venous access for hemodynamic monitoring (such as central venous pressure), long-term administration of fluids, antibiotics, total parenteral nutrition and hemodialysis. Many anatomical landmark (LM)-guided techniques for IJV puncture have been described. [1],[2] More than 5 million central venous catheters (CVC) are placed each year in the United States, with an associated complication rate of >15%. [1],[2] Mechanical complications such as arterial puncture and pneumothorax are seen in up to 21%, and up to 35% of the insertion attempts are not successful. [3],[4],[5] The risk of complications depends on several factors, including (but not limited to) operator experience, urgency of placement as well as patient factors such as obesity, prior difficult cannulation and coagulopathy. [4],[6],[7] It has been suggested that ultrasound (US) guidance could improve the success rate, reduce the number of needle passes and decrease complications. [4],[5] Although the US method has been favorably compared with the landmark technique, its widespread use has been hampered by the unavailability of equipment, such as the specially designed US device and the lack of trained personnel. Two different real-time 2-dimensional US techniques can be employed in the insertion of CVCs. The first technique involves real-time US-guided cannulation of the internal jugular vein (IJV) using a short axis/out-off-plane (SAX OOP) approach. The second one involves real-time US-guided cannulation of the IJV using a long axis/in-plane (LAX IP) approach. The purpose of this study was to compare two different real-time 2-dimensional US-guided SAX OOP and LAX IP approaches and to determine whether US guidance could improve the success rate and decrease the complication rate of IJV catheterization compared with the landmark technique.


   Patients and Methods Top


Patients

This prospective study was conducted from December 2009 to November 2010 in 90 critical care and hemodialysis patients assigned for insertion of CVCs. Ethics committee approval was obtained and all patients gave written informed consent. Patients' refusal and local infections were exclusion criteria. The patients were randomly divided into three groups:

  1. Group 1: Thirty patients underwent real-time US-guided cannulation of the IJV with a SAX OOP approach.
  2. Group 2: Thirty patients underwent real-time US-guided cannulation of the IJV with a LAX IP approach.
  3. Group 3: Thirty patients underwent cannulation of the IJV with the landmark technique.
The patients were randomly assigned on a one-to-one ratio. Randomization was performed by means of a computer-generated random numbers table and patients were stratified with regard to age, gender and body mass index (BMI).

Before each procedure, an intravenous access and standard monitoring of electrocardiogram, non-invasive arterial blood pressure and pulseoximetry were established. Mechanical complications were defined as carotid artery puncture, hematoma formation, pneumothorax, hemothorax and catheter malposition. Carotid artery puncture was noted by forceful pulsatile expulsion of bright red blood from the finder needle. All mechanical complications were evaluated clinically by a chest X-ray and by means of ultrasonography, where appropriate.

Methods

Patients were placed in a supine position with the head rotated at a 30° angle in the Trendelenburg position. The patient was positioned with a rolled towel under the shoulders and the head turned to the opposite site for IJV cannulation. Physicians followed the standard sterile technique; the neck area including the top of the triangle between the sternal and the clavicular head of the sternocleidomastoid muscle was prepared with povidone-iodine before the placement of sterile drapes. Also, the sonographic probe was covered with ultrasonic gel and wrapped in a sterile plastic sheath (MicroTek Medical, Columbus, MS, USA).

Real-time ultrasound-guided method

The US-guided technique was performed using a portable unit (GE LogiqBook XP Portable Ultrasound Machine; General Electric Company, GE Healthcare - Americas, USA). Adjustments (depth, frequency and gain) were made to obtain optimal images for identifying the IJV and the surrounding anatomical structures using a 10 MHz linear-array US probe. Whatever the US approaches, the procedure proceeded with the standard Seldinger technique under real-time US guidance and continuous dynamic observation of the IJV and the carotid artery.

SAX OOP approach: Real-time 2D images were obtained by placing the transducer parallel and superior to the clavicle, over the groove between the sternal and the clavicular heads of the sternocleidomastoid muscle, imaging of the great vessels (the IJV and carotid artery) transversely (short-axis view), followed by percutaneous out-of-plane cannulation [Figure 1].
Figure 1: Visualization of the needle entering the anterior wall of the right internal jugular vein (RIJV) (short axis/out-of-plane approach) (white arrow). Visualization of the needle entering the venous lumen (long axis/in-plane approach) (black arrow).

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LAX IP approach: The transducer was placed perpendicular and superior to the clavicle over the groove between the sternal and clavicular heads of the sternocleidomastoid muscle, visualizing the IJV and carotid artery in the long-axis view. Using the in-plane technique, the needle was introduced at the superior end of the transducer and advanced into the plane, allowing all time visualization of the tip and shaft of the needle during the procedure [Figure 1].

Landmark technique

The "finder" needle connected to a 2 mL syringe was advanced through the skin at a 45° angle in the direction of the ipsilateral nipple. The return of venous blood into the syringe confirmed entry into the vessel. A 16- or 18-gauge needle of CVCs set was inserted using the guidance of the finder needle and, after that, the procedure proceeded with the standard Seldinger technique.

The standard Seldinger technique

After infiltration with 1% lidocaine, the IJV was punctured with a 16- or 18-gauge, 10 cm needle (Cook, Bloomington, IN, USA). The needle was advanced with continuous negative pressure on a 10 mL syringe attached to it. Once blood return was noted, the syringe was removed and a guide wire was advanced through the needle into the internal jugular vein. The needle was removed and the dilator was carefully advanced using to-and-fro rotations and then a vascular catheter (FlexTip, Arrow International Inc., Reading, PA, USA; K-Flow Catheter Dual and Triple Lumen Temporary Hemodialysis, Kimal plc Arundel Road Uxbridge Middlesex UB8 2SA England) was advanced over the wire to 12 cm at the skin and was fixed and secured with a transparent dressing.

All US-guided and landmark-guided catheterizations were performed by well-trained attending anesthetists, nephrologists or intensivists with similar experience (ten years of experience in IJV catheter placements) to minimize the effect of operator experience on the success rate and the rate of mechanical complications. Furthermore, the physicians who performed the US-guided method were well trained and had at least five years of experience in performing this method. In most patients in whom the first attempt (one pass of the introducing needle) at catheterization failed, another physician performed the next attempt. The insertion of a CVC is followed by chest radiography for verification of the catheter's course and the position of its tip after the procedure. Examination was performed by another observer.

Data collection

Forms containing patients' characteristics and all the pertinent fields for each technique were filled out in a timely fashion. The following data were also recorded: Side of catheterization (either right or left) and the presence of risk factors for difficult venous cannulation, such as prior catheterization, limited sites for access attempts (other catheters, pacemaker and local surgery or infection), previous difficulties during catheterization (more than three punctures at one site, two sites attempted and failure to gain access), previous mechanical complication, known vascular abnormality, untreated coagulopathy (international normalization ratio >2, activated partial thromboplastin time >1.5 and platelets <50 × 10 9 per liter), skeletal deformity and cannulation during cardiac arrest. [3],[8] The outcomes assessed were the access time, the average number of attempts before successful placement (defined as separate skin punctures), the success of placement, the rate of mechanical complications and the incidence of central line-associated blood stream infection (CLA-BSI). Access time was defined as the time between penetration of skin and aspiration of venous blood into the syringe. Preparation times for both techniques were quite similar. The access time was measured in seconds by a stopwatch by other physicians, and the number of attempts and complications were recorded. It is of note that every effort was made to ensure the application of evidence-based catheter insertion practices in both methods. [9] All patients were receiving antibiotic treatment during the study period. CLA-BSIs were defined as only those blood stream infections for which other sources were excluded by careful examination of the patient record and in which a culture of the catheter tip demonstrated substantial colonies of an organism identical to those found in the blood stream. [9]


   Statistical Analysis Top


Data were expressed as mean ± standard deviation. The one-way ANOVA test for independent means or Pearson's chi-square test, where appropriate, were used to identify differences between the two groups. A P-value (two-sided in all tests) of <0.05 was considered significant. SPSS software, version 16.0, was used (SPSS Inc., Chicago, IL, USA).


   Results Top


There were no significant differences between the three groups of patients in gender, age, BMI, side of catheterization or presence of risk factors for difficult venous cannulation, such as prior catheterization, limited sites for access attempts, previous difficulties during catheterization, previous mechanical complication, known vascular abnormality, untreated coagulopathy, skeletal deformity and cannulation during cardiac arrest [Table 1]. In all patients in the US groups (SAX OOP and LAX IP groups), the IJV was visualized and cannulated. Furthermore, three patients in the landmark group in whom catheterization was unsuccessful were converted to the US method [Table 2]. Thrombosis was identified in two cases (which led to anticoagulation of these patients) and anatomical variation of the IJV in the other patient, and these were very likely the reasons for which the landmark method failed. Average access time and number of attempts were both significantly reduced using US compared with the landmark technique (P <0.001) [Table 2]. Meanwhile, no significant difference was found in the SAX OOP group compared with the LAX IP group (P = 0.94 and P = 0.84, respectively).
Table 1: Baseline characteristics of the studied groups.

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Table 2: Outcome measures in the ultrasound groups versus the landmark group of patients.

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The success rate was significantly lower and the rate of mechanical complications was significantly higher in the landmark group of patients as compared with the US groups (P <0.05) [Table 2]. Furthermore, in the landmark group, only one case of pneumothorax that required therapeutic intervention occurred, but no hemothorax was observed in all the studied groups. All landmark-guided and US-guided catheterizations were performed by well-trained attending nephrologists, anesthetists and inten-sivists with similar experience (ten years of experience in IJV catheter placements); therefore, the effect of operator experience on the success rate and the rate of mechanical complications was non-significant (P < 0.05). Number of CLA-BSIs in the landmark group was similar to that documented in the US groups (SAX OOP and the LAX IP approaches) (P = 0.421) [Table 2]. The type of micro-organisms responsible for the CLA-BSIs in the US group of patients versus those responsible for the CLA-BSIs in the landmark group was similar: Coagulase-negative Staphylococci (50%), Staphylococcus aureus (25%) and Enterococus species (16.7%), being responsible for the CLA-BSIs in both procedures.


   Discussion Top


CVC cannulation is associated with a number of technical complications. The common ones are arterial puncture (10.6-13%) and hematoma formation (4-8.4%). [7],[10] Using US, Denys and Uretsky found that 8.5% of 200 patients had abnormal IJV anatomy, with a small fixed IJV in 3%, no right IJV at all in 2.5%, an IJV medial to the carotid in 2% and an IJV lateral to the carotid with no overlap in 1%. [11] The position of the IJV in relation to the carotid artery shows high variability. In the majority of patients, the IJV lies lateral to the carotid artery; as one moves more cranially, it comes closer and sometimes even anterior to the carotid artery. In up to 5%, the position might even be medial to the carotid artery. These common anatomic variants may explain the higher complication rates and need for multiple attempts to achieve success using the landmark technique alone.

Real-time US guidance of CVC insertion provides the operator with visualization of the desired vein and the surrounding anatomic structures prior to and during the insertion of the catheter. This method appears to improve the success rate and decrease the complication rate associated with CVC placement. [4],[12],[13]

Using the landmark method, we found that the success rate of IJV cannulation was 90%, which is in consistent with the success rates documented in previous reports ranging from 85% to 99%. [13],[14],[15] The incidence of arterial puncture of the carotid artery using the landmark method (16.7%) was comparable with larger studies [13] but higher than those reported (3-6%) in other series. [14] Also, the incidence of hematoma and pneumothorax (23.3% and 3.3%, respectively) using the landmark method was in the range of previous studies. [13],[14]

The incidence of mechanical complications using the US-guided techniques was negligible, which is in agreement with the previous reports. [6],[13],[15] Using US guidance, the incidence of carotid puncture and hematoma was very low and (as shown before) no cases of hemothorax and/or pneumothorax were observed. [13],[15]

The clinical notion that the additional equipment and manipulation associated with the US method might have increased the rate of catheter-related infection was not confirmed by the present data. We found that the incidence of CLA-BSI in the US group of patients was insignificantly lower compared with that documented in the landmark group. The number of CLA-BSIs was significantly correlated to the number of needle passes in the total study population. We could speculate that repeated attempts might lead to a break-down of the aseptic technique and more colonization of skin-related pathogens. [9]

The use of real-time US guidance prevents the insertion of the catheter into a vein complicated by thrombosis or into a small vein. [8] In our study, IVJ catheterization was not successful in two patients in the landmark group and was performed by the US guidance. In a previous study, ultrasonography imaging detected venous thrombosis in 33% of critical care patients; in approximately 15% of these patients, the thrombosis was catheter related. [16] Also, attempts to cannulate thrombotic veins usually are unsuccessful even when the anatomy is normal. [8]

The present study did not show significant differences between the two different US approaches (SAX OOP and the LAX IP); however, it supports the superiority of real-time US-guided IJV cannulation as compared with the landmark technique in mechanically ventilated, critical care patients. During the US-guided procedure, the IJV can be compressed completely by the needle before the vessel is actually penetrated. Then, the needle must be advanced a little deeper and retracted slightly to be positioned in the center of the lumen. In accordance with this, we recommend to use 2D US images recorded on both short and longitudinal axes during the IJV cannulation. Visualization of the IJV on the short axis was particularly useful for catheterization of the small vessels, whereas the primary advantage of the longitudinal view is to visualize the advancing needle tip.

This study showed that the short axis/out-of-plane approach was comparable to the long axis/in-plane approach for catheterization of the IJV, and could improve the success rate and lower the mechanical complication rate compared with the landmark technique. Interestingly, CLA-BSIs in the landmark group were similar to those in the US groups.

 
   References Top

1.English IC, Frew RM, Pigott JF, Zaki M. Percutaneous catheterisation of the internal jugular vein. Anaesthesia 1969;24:521-31.  Back to cited text no. 1
    
2.Hayasi H, Ootaki C, Tsuzuku M, Amano M. Respiratory jugular vasodilation. A new landmark for right internal jugular vein puncture in ventilated patients. J Cardiothorac Vasc Anesth 2000;14:40-4.  Back to cited text no. 2
    
3.Digby S. Fatal respiratory obstruction following insertion of a central venous line. Anaesthesia 1994;49:1013-4.  Back to cited text no. 3
    
4.Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta analysis of the litarature. Crit Care Med 1996:24:2053-8.  Back to cited text no. 4
    
5.Bond DM, Champion LK, Nolan R. Real time ultrasound imaging aids jugular venipuncture. Anesth Analg 1989:68;700-1.  Back to cited text no. 5
    
6.Hayasi H, Amano M. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Prospective randomized comparison with landmark guided puncture in ventilated patients. J Cardiothorac Vasc Anesth 2002;16:572-5.  Back to cited text no. 6
    
7.Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Crit Care 2006;10:R162.  Back to cited text no. 7
    
8.Hatfield A, Bodenham A. Portable ultrasound for difficult central venous access. Br J Anaesth 1999;82:822-6.  Back to cited text no. 8
    
9.Center for Disease Control and Prevention DC. National Nosocomial Infections Surveillance (NNIS) System Report, Data Summary from January 1992-June issued August 2001. Am J Infect Control 2001;29:404-21.  Back to cited text no. 9
    
10.Martin MJ, Husain FA, Piesman M, et al. Is routine ultrasound guidance for central line placement beneficial? A prospective analysis. Curr Surg 2004;61:71-4.  Back to cited text no. 10
    
11.Denys BG, Uretsky BF. Anatomical variations of internal jugular vein location: Impact on central venous access. Crit Care Med 1991;19: 1516-9.  Back to cited text no. 11
    
12.Malloy DL, McGee WT, Shawker TH, et al. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Chest 1990;98:157-60.  Back to cited text no. 12
    
13.Dennys BG, Uretsky BF, Reddy S. Ultrasound-assisted cannulation of the internal jugular vein a prospective comparison to the external landmark-guided technique. Circulation 1993;87: 1557-62.  Back to cited text no. 13
    
14.Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146: 259-61.  Back to cited text no. 14
    
15.Gordon AC, Saliken JC, Johns D, Owen R, Gray RR. US-guided puncture of the internal jugular vein: Complications and anatomic considerations. J Vasc Interv Radiol 1998;9:333-8.  Back to cited text no. 15
    
16.Hirsch DR, Ingenito EP, Goldhaber SZ. Prevalence of deep venous thrombosis among patients in medical intensive care. JAMA 1995; 274:335-7.  Back to cited text no. 16
    

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Correspondence Address:
Eid M El-Shafey
Department, of Internal Medicine, Tanta University Hospitals, Tanta
Egypt
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DOI: 10.4103/1319-2442.113861

PMID: 23816718

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