| Abstract|| |
Aims and objectives: Landmark-guided internal jugular vein (IJV) cannulation is a basic procedure, which every anesthetist is expected to acquire. A successful first attempt is desirable as each attempt increases the risk of complications. The present study is an analysis of 976 IJV cannulations performed in adults undergoing cardiothoracic surgery. Materials and Methods: The IJV was cannulated with a triple lumen catheter using the anatomical landmarks. The following data were recorded: Patient demographics, age, sex, body mass index, diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, external jugular vein), number of attempts and duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray and any complications. Results: The success rate of IJV cannulation was 100%. In 809 (82.9%) patients, cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 patients, the residents were successful in inserting the catheter and in 25 they failed after 5 attempts, hence, they were cannulated by the consultant. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. Carotid artery puncture was the most common complication, it occurred in 22 (2.3%) patients. Conclusion: IJV cannulation with landmark technique is highly successful with minimal complications in the adult patients undergoing cardiothoracic surgery. Basic training of cannulating the IJV by landmark technique should be imparted to all the traines as ultrasound may not be available in all locations.
Keywords: Cardiothoracic surgical patients, Internal jugular vein cannulation, Landmark-guided IJV cannulation
|How to cite this article:|
Tempe DK, Virmani S, Agarwal J, Hemrajani M, Satyarthy S, Minhas HS. The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery. Ann Card Anaesth 2013;16:16-20
|How to cite this URL:|
Tempe DK, Virmani S, Agarwal J, Hemrajani M, Satyarthy S, Minhas HS. The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery. Ann Card Anaesth [serial online] 2013 [cited 2013 Dec 9];16:16-20. Available from: http://www.annals.in/text.asp?2013/16/1/16/105364
| Introduction|| |
Establishment of a central venous (CV) access is imperative in patients undergoing cardiac surgery. It helps in hemodynamic monitoring, infusion of fluids, blood and blood products, medication as well as measurement of cardiac filling pressures. Internal jugular vein (IJV) is commonly used for cannulation and traditionally, anatomical landmark technique is used for identification of the IJV. Lately, however, portable ultrasound has been introduced in clinical practice and is being used to guide the vascular access. , In 2002, National Institute for Clinical Excellence (NICE) recommended the use of ultrasound for CV cannulation as the preferred method for elective insertion of CV catheters in adults and children.  However, this advocation of ultrasound guided CV cannulation does have a potential for deskilling in the landmark technique that may be required in emergency situations, or when equipment is not available. Also, an opposite view has been reported on its usefulness for regular practitioners more so in pediatric patients.  There are also reported disadvantages of ultrasound guided catheterization, in that the equipment is expensive, procedure is time consuming and requires expertise.  CV cannulation using the landmark technique is a basic procedure and every anesthetist is expected to acquire it. It is very useful in emergency situations where availability of ultrasound machine, linear probes, and expert personnel for performing ultrasound may be limited.
The reported success rate of CV cannulation using landmark technique varies between 85% and 95% , with a complication rate of 6.3-11.8%. ,,,,,, Anomalies in the anatomy and the blind nature of the procedure may cause the operator to pass the needle in an inappropriate direction and each attempt increases the risk of complications; therefore, a successful IJV cannulation in first attempt is desirable. ,
| Aim and Objectives|| |
This prospective observational study was undertaken with the aim of finding out the success rate, complications and the time taken for IJV cannulation when using the anatomical landmark technique in adult patients undergoing cardiac surgery. The other objectives were-to study the incidence of successful first attempts at cannulation, the incidence of complications especially arterial puncture, and radiological evaluation of correct placement of the catheter.
| Materials and Methods|| |
With institutional ethics committee approval, this prospective observational study was carried out in patients ≥12 years of age, undergoing cardiothoracic surgery (n = 976), in whom IJV cannulation was performed. There were no specific exclusion criteria except those in whom pulmonary artery catheters were inserted.
The patients were anesthetized as per the standard institutional protocol, airway was secured and the right IJV cannulation was performed. For IJV cannulation, the patients were placed in 15-30° Trendelenburg position with the head of the patient turned to the left side. Taking aseptic precautions (the operator washed up for the procedure, wore sterile gown and gloves), the site of puncture was properly cleaned with betadine and spirit and draped with a sterile sheet. The cannulations were performed by a senior resident under supervision or by a consultant anesthesiologist. If the senior resident failed in five attempts, the consultant took over to complete the cannulation. The IJV was cannulated with a triple lumen catheter using the anatomical landmarks by the Seldinger technique. The preferred site for cannulation was right IJV via the central approach. This involves puncturing the vein at the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle. If the vein was not localized on the right side or carotid artery was punctured during vein localization, then left IJV and right or left external jugular vein (EJV) were cannulated in that order. The length of the catheter inserted was as per the discretion of the consultant anesthesiologist with the intention of placing the tip within 2.5 cm of the superior vena cava (SVC)-right atrium (RA) junction. The catheter was then sutured securely in place and sterile dressing applied. The time taken for cannulation was recorded by a separate resident doctor with the help of a stopwatch. It was calculated from the time of first insertion of locater needle till deairing of all three ports of the triple lumen catheter after insertion. Position of the catheter tip was determined by X-ray chest postoperatively. Position of the catheter tip within 2.5 cm of the cavo-atrial junction was taken as correct position, and the catheter tip lying in the RA or more than 2.5 cm away from the cavo-atrial junction was considered as incorrect position. The following data were recorded: Patient demographics, age, sex, body mass index (BMI), diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, EJV), number of attempts, duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray, and any complications.
Data are presented as mean ± SD. Categorical data are presented as number of patients per category (n). Student's t-test was used to compare independent means. A Chi-square test was used to compare categorical variables. P values <0.05 were considered statistically significant.
| Results|| |
A total of 976 patients over a period of 1 year were included. [Table 1] and [Table 2] show the patient characteristics and the types of procedures performed. A total of 792 patients underwent valvular heart surgery, 146 congenital heart surgery, and 38 underwent other procedures such as mediastinal mass excision and pericardiectomy. [Table 3] shows the details of IJV cannulation. The success rate of IJV cannulation was 100%. Right IJV was cannulated in 953 (97.6%) whereas left IJV cannulation was performed in the remaining 23 (2.4%) patients. In 809 (82.9%) patients, successful cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 (78.6%) patients the residents were successful in inserting the catheter. In 25 (2.6%) patients successful cannulation was performed by the consultant anesthesiologist due to failed five attempts by the resident. The mean length of catheter inserted was 10.31 ± 0.87 cm. In the postoperative chest X-ray the catheter was found in the RA in three patients and it was located within 2.5 cm of the cavo-atrial junction in all the other patients. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. [Table 4] shows the complications that occurred. No complication was seen in 96.6% cases. Carotid artery puncture (defined as the aspiration of arterial blood when inserting the locator needle or the puncture needle) was the most common complication, it occurred in 22 (2.3%) of patients. Difficulty in negotiating the guide wire, which required reinsertion of the puncture needle was seen in four patients. Hematoma formation (any swelling in or around the puncture site after IJV cannulation) occurred in three patients, right IJV could not be localized in three patients and difficulty in localizing right IJV occurred in one patient who had a thyroid swelling.
| Discussion|| |
In the present study, successful cannulation of the IJV using landmark technique was performed in all the 976 patients in 1.28 ± 0.76 attempts. In 82.9% of the patients the cannulation was accomplished in the first attempt, while ≥4 attempts were required in 2.7% of the patients. Carotid artery puncture was the most common complication seen in 2.3% patients.
Percutaneous cannulation of the IJV using external landmarks was first described in 1966.  Out of the various routes available, IJV catheterization is most preferred in patients undergoing cardiac surgery because it is safe, convenient, and easily accessible and there is no risk of catheter kinking during sternal retraction.  Right IJV cannulation is preferred over the left IJV because it has a larger diameter, and a straighter course to the RA.  On the other hand, left IJV cannulation is more time consuming, requires more attempts and is associated with a higher rate of complications including the risk of thoracic duct injury. ,,
The landmark technique has been used traditionally with a success rate of 85-95%. , It is a blind procedure primarily based on the anatomical landmarks, but an experienced operator also locates the vein by balloting it by finger. , In patients undergoing cardiac surgery, identification and cannulation of IJV is facilitated by the raised CV pressure that exists in most of these patients. In the present study, the success rate was 100%. Of the 976 cannulations, 792 (81.1%) were performed by residents and 184 (18.9%) by the consultants. Out of the total cannulations performed by residents, 25 (2.6%) cannulations were assisted by the consultants. Troianos et al.,  Denys et al.,  and Turker et al., compared landmark technique with ultrasound-guided technique of IJV cannulation. Their success rate increased from 96%, 88.1%, and 97.36%, respectively (in the landmark technique) to 100% (99.47% in the study by Turker et al., ) in the ultrasound-guided group and the number of successful first attempt at cannulations also increased in the ultrasound group. The higher success rate in the present study when compared with the landmark technique of the studies by Troianos et al.,  Denys et al.,  and Turker et al., is difficult to explain, but it may be due to different level of experience and the fact that in the present study, the cannulations were performed in anesthetized and mechanically ventilated patients, whereas in all the above mentioned studies, the patients were spontaneously breathing. Our results are in accordance with the study by Sznajder et al.,  which shows higher success rate and lower complication rates by even inexperienced physicians in mechanically ventilated patients than in spontaneously breathing patients. Application of positive end expiratory pressure in mechanically ventilated patients also increases the cross sectional area of IJV and facilitates cannulation. , In spontaneously breathing patients, one must take the precaution of puncturing the IJV in the expiratory phase. Karakitsos et al., compared the real-time ultrasound-guided catheterization with the landmark technique in mechanically ventilated critically ill patients in intensive care unit (ICU). We observe that our results are comparable to the results of their real-time ultrasound group in percentage of successful cannulations (100%) and average number of attempts (1.20 ± 0.45); however, the rate of arterial puncture was higher in our study (2.3% vs. 1.1%). Grebenik et al., also showed that the success rate of IJV cannulation is more by the landmark technique than when using ultrasound (89.3% vs. 78%) and arterial puncture rates were significantly lower in the landmark group (6.2% vs. 11.9%) in children. 
Unfortunately, access time in studies by Troianaos et al.,  Denys et al.,  and Karakitsos et al., cannot be compared with the present study as in the above mentioned studies, it was measured till the aspiration of venous blood into the syringe, whereas in the present study, time was recorded from first puncture of locator needle till aspiration of blood from the last port of the catheter after insertion. In the present study, no complications occurred in 96.6% of patients. Carotid artery puncture was the most common complication and it occurred in 22 (2.3%) of patients, which is consistent with its incidence (2-16%) in literature. ,,,,,
In 2002, NICE recommended the use of ultrasound for CV cannulation as the preferred method for elective insertion of CV catheters in adults and children, based on studies that show a significant decrease in the rate of failed punctures (86%) and a reduction in complications (57%) and a shorter performance time (1.1 minutes vs. 2.6 minutes). ,, One important implication of the NICE guidelines is that when ultrasound has not been used, the event of a serious complication will be difficult to defend.  The 100% success rate obtained in the present study with minimal complications, indicate that ultrasound guidance is not necessary in adults undergoing cardiac surgery. It also suggests that using landmark technique should be considered an acceptable clinical practice in these patients. The widespread failure to implement and follow NICE guidelines has been documented.  One of the important reasons for this is that the acquisition of new equipment requires funding and the staff needs to be trained to use the new technique. Therefore, the transition to routine ultrasound guidance for CV cannulation has been slow and incomplete. , Implementing the guidelines into clinical practice is a significant challenge, especially those that require new equipment and training of staff. Arguably, in centers where ultrasound is not widely available, basic training of cannulating the IJV by using landmark technique should be imparted to all the trainees. However, a new technology such as ultrasound is likely to eventually find a place in clinical practice. Therefore, simultaneous training of utilizing ultrasound for cannulation of the IJV should be provided, wherever ultrasound is available. The authors believe that patients undergoing cardiothoracic surgery can form the substrate of patients where such training can be obtained. Thus, a smooth transition from limited ultrasound availability to wide spread availability can be achieved.
| Conclusion|| |
Right IJV cannulations with landmark technique is highly successful in the adult patients undergoing cardiothoracic surgery. We recommend that all anesthesiologists should be encouraged to teach, train, and practice the skill of CV cannulation by landmark technique. Although the ultrasound guidance does not appear to be imperative in these patients, it should be used as a part of training wherever the facility is available so that it can be used as a backup in difficult situations.
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Deepak K Tempe
Department of Anaesthesiology and Intensive Care, G. B. Pant Hospital, New Delhi - 110 002
[Table 1], [Table 2], [Table 3], [Table 4]