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Table of Contents
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 296-298
Use of optimized ultrasound axis along with marked introducer needle to prevent mechanical complications of internal jugular vein catheterization

Department of Critical Care Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India

Click here for correspondence address and email

Date of Submission03-May-2013
Date of Acceptance15-Jul-2013
Date of Web Publication1-Oct-2013


Internal jugular vein (IJV) catheterization is a routine technique in the intensive care unit. Ultrasound (US) guided central venous catheter (CVC) insertion is now the recommended standard. However, mechanical complications still occur due to non-visualization of the introducer needle tip during US guidance. This may result in arterial or posterior venous wall puncture or pneumothorax. We describe a new technique of (IJV) catheterization using US, initially the depth of the IJV from the skin is measured in short-axis and then using real time US long-axis view guidance a marked introducer needle is advanced towards the IJV to the defined depth measured earlier in the short axis and the IJV is identified, assessed and cannulated for the CVC insertion. Our technique is simple and may reduce mechanical complications of US guided CVC insertion.

Keywords: Internal jugular vein access; Introducer needle; Ultrasound; Ultrasound guided catheter insertion

How to cite this article:
Ghatak T, Singh RK, Baronia AK. Use of optimized ultrasound axis along with marked introducer needle to prevent mechanical complications of internal jugular vein catheterization. Ann Card Anaesth 2013;16:296-8

How to cite this URL:
Ghatak T, Singh RK, Baronia AK. Use of optimized ultrasound axis along with marked introducer needle to prevent mechanical complications of internal jugular vein catheterization. Ann Card Anaesth [serial online] 2013 [cited 2023 Feb 1];16:296-8. Available from:

   Introduction Top

Real time ultrasound (US) guided central venous catheter (CVC) insertion is now widely used in intensive care unit (ICU) because of better delineation of anatomy, safety and less mechanical complications. [1],[2] However, mechanical complication such as arterial puncture, arterial cannulation and pneumothorax occur in up to 4.6% cases even with static or real time US as compared with 5-19% complications reported with landmark techniques. [1],[3] When US was used for CVC placement in human simulators, the incidence of carotid puncture and posterior wall venous puncture was reported around 20% and 64% respectively. [4] The incidence of pneumothorax using real time US guided CVC insertion was reported to be around 0.7%. [5],[6] When real time US is used either in the short-axis (transverse) or long-axis (longitudinal) and the needle is advanced toward the anticipated vein, all the time the introducer needle tip may not be visualized. [7] This may lead to a number of complications. [4] To avoid complications, we describe a technique where initially the approximate depth of the anticipated vein is assessed in short-axis view, then during the real time US guidance using short-axis and then long-axis view, the marked introducer needle is advanced to the defined depth and the central vein is identified, assessed and cannulated. We describe the technique on a patient after written consent provided by the parents.

   Case Report Top

Assistance was sought for US guided CVC insertion in a 28-year-old male obese patient (body mass index 31.5) with grade 4 hepatic encephalopathy and coagulopathy (international normalized ratio = 1.98). Patient was hemodynamically stable, but had increased lactate levels and base deficit. He was intubated and mechanically ventilated with head up (20-30°) position. For inserting a CVC in the right internal jugular vein (IJV), the patient was put in Trendelenburg position with about 30° head rotation to left side. The 18G introducer needle from CVC set (Certofix Trio V 720; B Braun, Melsungen AG, Germany) was marked with the help of a sterile needle and scale [Figure 1]. Then, the right IJV was located in the triangle formed by the two heads of the sternocleidomastoid muscle and examined in short- and long-axis view with a 7.5-MHz linear/vascular probe of portable US machine (Sonosite MicroMaxx ® , Gurgaon, India) and approximate depths of anterior and posterior wall of vein, anterior wall of the artery and pleura were measured from the midpoint of probe in short-axis view [Figure 2]. The carotid artery and jugular vein were differentiated by obliteration of the vein with probe pressure and by color flow Doppler. Then, under real time US guidance, an experienced (2 years in US guided CVC insertion) interventionist inserted the marked introducer needle directing it toward the vein. After skin penetration, long-axis view was used to see the path of advancing needle [Figure 3]. While, carefully observing the markings over the needle and needle path using real time US long axis view, the needle was advanced toward IJV until the defined depth of vein was reached as assessed earlier during short-axis US examination. Successful insertion of the needle into the IJV was confirmed firstly by aspirating free flow of venous blood at the predicted distance (approximate 1.5 cm in our case). Successful insertion in our case was also confirmed by intravenous guide wire visualization in both short-axis and long-axis view prior to dilation of the vessel. The rest of the CVC insertion process is completed in a routine fashion.
Figure 1: Marked introducer needle. The markings on each centimeter is shown by arrow

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Figure 2: Two dimensional short-axis view - note the difference in the distances of jugular vein and carotid artery and pleura from the midpoint of the probe (needle entry point)

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Figure 3: Two dimensional long-axis view - note the difference in the distance of internal jugular vein from the pointer (needle entry point)

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   Discussion Top

The US beam is narrow (0.2-1.2 mm) and the operator sees the reflected view. [7] Even though, the operator believes that he is following the progress of the introducer needle tip towards the vessel in real time, in reality it's the cross sectional area near the needle tip that is actually visualized rather than the actual needle tip. [7] The short-axis view is specially confusing, but the partial visualization problem can occur with long-axis view also. [7] To solve this problem, an echogenic vascular cannula (Vascular-Sono, Pajunk, GmbH, Medizintechnologie, Geisingen, Germany) with "cornerstone" reflectors near the tip, is available in different parts of the developed world, but still at the trial level. [8]

Our technique has a potential to reduce the mechanical complication due to the poor visualization of the needle tip during real time US guided CVC insertion by utilizing a marked introducer needle. We first measure the depth and define the relative positions of artery, vein and pleural deflection and then proceed toward vein during real time US guided CVC cannulation. It should be noted that we took help of long-axis view during the needle insertion in the IJV to get maximum help with marked needle. [9],[10] An oblique approach with two dimensional (2D) and three/four dimensional US approaches have been also described in literature but not well-validated. [11],[12]

To summarize, our technique of 2D US guided IJV catheterization with the help of marked introducer needle is potentially safe, easy and helpful technique for CVC insertion in ICU patients. This technique may decrease mechanical complications, which are particularly important in patients with coagulopathy. However, further studies using our technique are required to prove ease and efficacy of this technique. The precision of the technique may be improved by marking the introducer needle at an interval of 0.5 cm.

   References Top

1.Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: A randomized, prospective study. Ann Emerg Med 2006;48:540-7.  Back to cited text no. 1
2.Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ 2003;327:361.  Back to cited text no. 2
3.McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 3
4.Blaivas M, Adhikari S. An unseen danger: Frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 2009;37:2345-9.  Back to cited text no. 4
5.Wilson TJ, Stetler WR Jr, Fletcher JJ. Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit. Clin Neurol Neurosurg 2013;115:879-82.  Back to cited text no. 5
6.Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access: A systematic review. Crit Care Med 2002;30:454-60.  Back to cited text no. 6
7.Levitov AB, Aziz S, Slonim AD. Before we go too far: Ultrasound-guided central catheter placement. Crit Care Med 2009;37:2473-4.  Back to cited text no. 7
8.Hebard S, Hocking G. Echogenic technology can improve needle visibility during ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2011;36:185-9.  Back to cited text no. 8
9.Sierzenski P, Baty G, Polan D, Nichols WL, Kochert E, Bollinger M, et al. Long-axis orientation of the ultrasound transducer is more accurate for the identification and determination of vascular access needle-tip location. Ann Emerg Med 2008;52:S170-1.  Back to cited text no. 9
10.Stone MB, Moon C, Sutijono D, Blaivas M. Needle tip visualization during ultrasound-guided vascular access: Short-axis vs long-axis approach. Am J Emerg Med 2010;28:343-7.  Back to cited text no. 10
11.Phelan M, Hagerty D. The oblique view: An alternative approach for ultrasound-guided central line placement. J Emerg Med 2009;37:403-8.  Back to cited text no. 11
12.French JL, Raine-Fenning NJ, Hardman JG, Bedforth NM. Pitfalls of ultrasound guided vascular access: The use of three/four-dimensional ultrasound. Anaesthesia 2008;63:806-13.  Back to cited text no. 12

Correspondence Address:
Tanmoy Ghatak
Rammohan Pally, Arambagh, Hooghly - 712 601, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.119185

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  [Figure 1], [Figure 2], [Figure 3]

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