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Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study. J Emerg Med 2020; 59:918-926. [PMID: 32978029 DOI: 10.1016/j.jemermed.2020.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 07/09/2020] [Accepted: 07/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Subclavian vein puncture is commonly used in the intensive care unit (ICU) but is associated with complications. OBJECTIVE Our aim was to compare the efficacy and safety of static ultrasound-guided subclavian vein puncture with traditional anatomical landmark-guided subclavian vein puncture in critically ill patients in the ICU. METHODS This pilot randomized controlled trial enrolled patients admitted to the ICU and requiring subclavian vein puncture between November 2017 and September 2018. The patients were randomized to ultrasound-guided puncture or anatomical landmark-guided puncture. The primary outcome measure was the puncture success rate. The secondary outcome measures included the number of punctures, rate of success at the first attempt, puncture time (i.e., procedure duration) and incidence of complications. RESULTS A total of 194 patients were included in the analyses. Compared with the anatomical landmarks group, the ultrasound group had a higher puncture success rate (91.7% vs. 77.6%; p = 0.007), lower rate of complications (7.3% vs. 20.4%; p = 0.008), and lower incidence of mispuncture of an artery (2.1% vs. 14.3%; p = 0.002). There were no significant differences in the number of punctures and puncture time between the two groups (both, p > 0.05). CONCLUSIONS Static ultrasound-guided subclavian vein puncture is superior to the traditional landmark-guided approach for critically ill patients in the ICU. It is suggested that static ultrasound-guided puncture techniques should be considered for subclavian vein puncture in the ICU. TRIAL REGISTRATION ChiCTR1900024051.
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Abstract
These practice guidelines update the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the American Society of Anesthesiologists in 2011 and published in 2012. These updated guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist and may also serve as a resource for other physicians, nurses, or healthcare providers who manage patients with central venous catheters.
Supplemental Digital Content is available in the text.
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Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, Rodgers SC, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E1-E22. [PMID: 31561287 DOI: 10.12788/jhm.3287] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
Abstract
PREPROCEDURE 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
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Affiliation(s)
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Benji K Mathews
- Department of Hospital Medicine, Regions Hospital, Health Partners, St. Paul, Minnesota
| | - Carolina Candotti
- Division of Hospital Medicine, University of California Davis, Davis, California
| | - Saaid Abdel-Ghani
- Department of Hospital Medicine, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Martin G Perez
- Department of Hospital Medicine, Memorial Hermann Northeast Hospital, Humble, Texas
| | - Sophia Chu Rodgers
- Division of Pulmonary Critical Care Medicine, Lovelace Health Systems, Albuquerque, New Mexico
| | - Michael J Mader
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Nilam J Soni
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
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Gallieni M. Central Vein Catheterization of Dialysis Patients with Real Time Ultrasound Guidance. J Vasc Access 2018; 1:10-4. [DOI: 10.1177/112972980000100104] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Internal jugular vein cannulation has become a routinary and clinically important aspect of medical care in critically ill patients. The landmark-guided technique usually affords rapid and easy vascular access, but it is not always successful and may be complicated by arterial puncture, hematoma, pneumothorax. A prospective, descriptive study is reported on the use and success of ultrasound-assisted central vein catheterization in dialysis patients who had an indication for internal jugular vein catheterization. Data were collected prospectively on number of punctures, needle passes, and success rates. Over a 6-year period, there were 220 attempts at internal jugular catheterization in 205 patients and ultrasound guidance was used in 210 of the 220 (95%) attempts. Incidences of successful puncture and cannulation using ultrasound were 100% (210 out of 210) and 99.5% (209 out of 210), respectively, compared with 80% (8 out of 10) and 80% (8 out of 10) in the landmark group. With the availability of the ultrasound device complication rates also improved markedly, suggesting that the ultrasound technique is an easily learned technique that rapidly produces an improvement over the external landmark method. First attempt success improved from 20% to 85%, carotid punctures decreased from 33% to 2.9% (6 out of 210). The patient population also included 32 patients with several high risk conditions, such as no visual or palpable landmarks, severe coagulopathies due to hepatic failure or excess of anticoagulation treatment. In these patients, cannulation was successful in 100% (32 out of 32) using ultrasound guidance. In 9 patients (9/195, 4.6%), preliminary ultrasound evaluation of the neck vessels failed to identify a right internal jugular vein suitable for cannulation, because of thrombosis or a small diameter of the vein. In all cases, the left internal jugular vein could be cannulated without difficulties. Our results confirm that ultrasound-guided cannulation of the internal jugular vein offers several advantages over the external landmarks technique: higher success rate in both vein puncture and catheter placement, lower complications, lower patient discomfort during the procedure because of a low number of needle passes. Ultrasound-assisted cannulation of the internal jugular vein may become the standard approach to dialysis catheter placement in the future.
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Affiliation(s)
- M. Gallieni
- Nephrology and Dialysis Unit, San Paolo Hospital, University Department Milan - Italy
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Karaaslan P, Gokay BV, Karakaya MA, Darcin K, Karakaya AD, Ormeci T, Kose EA. Comparison of the Trendelenburg position versus upper-limb tourniquet on internal jugular vein diameter. Ann Saudi Med 2017; 37:308-312. [PMID: 28761030 PMCID: PMC6150587 DOI: 10.5144/0256-4947.2017.308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Central venous cannulation is a necessary invasive procedure for fluid management, haemodynamic monitoring and vasoactive drug therapy. The right internal jugular vein (RIJV) is the preferred site. Enlargement of the jugular vein area facilitates catheterization and reduces complication rates. Common methods to enlarge the RIJV cross-sectional area are the Trendelenburg position and the Valsalva maneuver. OBJECTIVE Compare the Trendelenburg position with upper-extremity venous return blockage using the tourniquet technique. DESIGN Prospective clinical study. SETTING University hospital. SUBJECTS AND METHODS Healthy adult volunteers (American Society of Anesthesiologists class I) aged 18-45 years were included in the study. The first measurement was made when the volunteers were in the supine position. The RIJV diameter and cross-sectional area were measured from the apex of the triangle formed by the clavicle and the two ends of the sternocleidomastoid muscle, which is used for the conventional approach. The second measurement was performed in a 20° Trendelenburg position. After the drainage of the veins using an Esbach bandage both arms were cuffed. The third measurement was made when tourniquets were inflated. MAIN OUTCOME MEASURE(S) Hemodynamic measurements and RIJV dimensions. RESULTS In 65 volunteers the diameter and cross-sectional area of the RIJV were significantly widened in both Trendelenburg and tourniquet measurements compared with the supine position (P < .001 for both measures). Measurements using the upper extremity tourniquet were significantly larger than Trendelenburg measurements (P=.002 and < .001 for cross-sectional area and diameter, respectively). CONCLUSION Channelling of the upper-extremity venous return to the jugular vein was significantly superior when compared with the Trendelenburg position and the supine position. LIMITATIONS No catheterization and study limited to healthy volunteers.
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Affiliation(s)
- Pelin Karaaslan
- Dr. Pelin Karaaslan, Department of Anesthesiology and Reanimation,, Istanbul Medipol University,, TEM Avrupa Otoyolu Goztepe, Cikisi No: 1,, Bagcilar, Istanbul 34078,, Turkey, T: +902127607831, , http://orcid.org/0000-0002-5273-1871
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Mahan AF, McEvoy MD, Gravenstein N. Long-axis view for ultrasound-guided central venous catheter placement via the internal jugular vein. Rom J Anaesth Intensive Care 2016; 23:27-31. [PMID: 28913474 DOI: 10.21454/rjaic.7518.231.axs] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In modern practice, real-time ultrasound guidance is commonly employed for the placement of internal jugular vein catheters. With a new tool, such as ultrasound, comes the opportunity to refine and further optimize the ultrasound view during jugular vein catheterization. We describe jugular vein access techniques and use the long-axis view as an alternative to the commonly employed short-axis cross-section view for internal jugular vein access and cannulation. CONCLUSION The long-axis ultrasound-guided internal jugular vein approach for internal jugular vein cannulation is a useful alternative technique that can provide better needle tip and guidewire visualization than the more traditional short-axis ultrasound view.
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Affiliation(s)
- Angel F Mahan
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Tennessee, USA
| | - Nikolaus Gravenstein
- Department of Anesthesiology and Critical Care, University of Florida College of Medicine, Gainesville, Florida, USA
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Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 2015; 1:CD006962. [PMID: 25575244 PMCID: PMC6517109 DOI: 10.1002/14651858.cd006962.pub2] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Central venous catheters (CVCs) can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed with as few attempts as possible. Traditionally, anatomical 'landmarks' on the body surface were used to find the correct place in which to insert catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain 'two-dimensional' ultrasound. OBJECTIVES The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional (imaging ultrasound (US) or ultrasound Doppler (USD)) guided puncture techniques for insertion of central venous catheters via the internal jugular vein in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.Our secondary objectives were to assess whether the effect differs between US and USD; whether the effect differs between ultrasound used throughout the puncture ('direct') and ultrasound used only to identify and mark the vein before the start of the puncture procedure (indirect'); and whether the effect differs between different groups of patients or between different levels of experience among those inserting the catheters. SEARCH METHODS We searched the Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013 ), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with identified studies of interest when we update the review. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound with an anatomical 'landmark' technique during insertion of internal jugular venous catheters in both adults and children. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. A priori, we aimed to perform subgroup analyses, when possible, for adults and children, and for experienced operators and inexperienced operators. MAIN RESULTS Of 735 identified citations, 35 studies enrolling 5108 participants fulfilled the inclusion criteria. The quality of evidence was very low for most of the outcomes and was moderate at best for four of the outcomes. Most trials had an unclear risk of bias across the six domains, and heterogeneity among the studies was significant.Use of two-dimensional ultrasound reduced the rate of total complications overall by 71% (14 trials, 2406 participants, risk ratio (RR) 0.29, 95% confidence interval (CI) 0.17 to 0.52; P value < 0.0001, I² = 57%), and the number of participants with an inadvertent arterial puncture by 72% (22 trials, 4388 participants, RR 0.28, 95% CI 0.18 to 0.44; P value < 0.00001, I² = 35%). Overall success rates were modestly increased in all groups combined at 12% (23 trials, 4340 participants, RR 1.12, 95% CI 1.08 to 1.17; P value < 0.00001, I² = 85%), and similar benefit was noted across all subgroups. The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I² = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.Use of Doppler ultrasound increased the chance of success at the first attempt by 58% (four trials, 199 participants, RR 1.58, 95% CI 1.02 to 2.43; P value 0.04, I² = 57%). No evidence showed a difference for the total numbers of perioperative and postoperative complications/adverse events (three trials, 93 participants, RR 0.52, 95% CI 0.16 to 1.71; P value 0.28), the overall success rate (seven trials, 289 participants, RR 1.09, 95% CI 0.95 to 1.25; P value 0.20), the total number of attempts until success (two trials, 69 participants, MD -0.63, 95% CI -1.92 to 0.66; P value 0.34), the overall number of participants with an arterial puncture (six trials, 213 participants, RR 0.61, 95% CI 0.21 to 1.73; P value 0.35) and time to successful cannulation (five trials, 214 participants, each using a different definition for this outcome; MD 62.04 seconds, 95% CI -13.47 to 137.55; P value 0.11) when Doppler ultrasound was used. It was not possible to perform analyses for the other outcomes because they were reported in only one trial. AUTHORS' CONCLUSIONS Based on available data, we conclude that two-dimensional ultrasound offers gains in safety and quality when compared with an anatomical landmark technique. Because of missing data, we did not compare effects with experienced versus inexperienced operators for all outcomes (arterial puncture, haematoma formation, other complications, success with attempt number one), and so the relative utility of ultrasound in these groups remains unclear and no data are available on use of this technique in patients at high risk of complications. The results for Doppler ultrasound techniques versus anatomical landmark techniques are also uncertain.
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Affiliation(s)
- Patrick Brass
- HELIOS Klinikum KrefeldDepartment of Anaesthesiology, Intensive Care Medicine, and Pain TherapyLutherplatz 40KrefeldGermany47805
- Witten/Herdecke UniversityIFOM ‐ The Institute for Research in Operative Medicine, Faculty of Health, Department of MedicineOstmerheimer Str. 200CologneGermany51109
| | - Martin Hellmich
- University of CologneInstitute of Medical Statistics, Informatics and EpidemiologyKerpener Str. 62CologneNRWGermany50937
| | - Laurentius Kolodziej
- Westdeutsches Lungenzentrum am Universitätsklinikum Essen, Klinik für Intensivmedizin und RespiratorentwöhnungRuhrlandklinikTüschener Weg 40EssenGermany
| | - Guido Schick
- Medizinisches Zentrum StädteRegion AachenKlinik für Anästhesie, Intensivmedizin und NotfallmedizinMauerfeldchen 25WürselenGermany
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Lee JG, Park HB, Shin HY, Kim JD, Yu SB, Kim DS, Ryu SJ, Kim GH. Effect of Trendelenburg position on right and left internal jugular vein cross-sectional area. Korean J Anesthesiol 2014; 67:305-9. [PMID: 25473458 PMCID: PMC4252341 DOI: 10.4097/kjae.2014.67.5.305] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/24/2014] [Accepted: 08/08/2014] [Indexed: 11/14/2022] Open
Abstract
Background Unlike the right internal jugular vein (RIJV), there is a paucity of data regarding the effect of the Trendelenburg position on the left internal jugular vein (LIJV). The purpose of this study is to investigate the cross-sectional area (CSA) of the LIJV and RIJV and their response to the Trendelenburg position using two-dimensional ultrasound in adult subjects. Methods This study enrolled fifty-eight patients with American Society of Anesthesiologists physical status class I-II who were undergoing general anesthesia. CSAs of both the RIJV and LIJV were measured with a two-dimensional ultrasound in the supine position and then in a 10° Trendelenburg position. Results In the supine position, the transverse diameter, anteroposterior diameter, and CSA of the RIJV were significantly larger than those of the LIJV (P < 0.001). Of 58 patients, the RIJV CSA was larger than the LIJV CSA in 43 patients (74.1%), and the LIJV CSA was larger than the RIJV CSA in 15 patients (25.9%). In the Trendelenburg position, CSAs of the RIJV and LIJV increased 39.4 and 25.5%, respectively, compared with the supine position. However, RIJV changed at a rate that was significantly greater than that of the LIJV (P < 0.05). Of 58 patients, the RIJV CSA was larger than the LIJV CSA in 48 patients (82.8%), and the LIJV CSA was larger than the RIJV CSA in 10 patients (17.2%). Conclusions In supine position, the RIJV CSA was larger than the LIJV CSA. The increased CSA in the Trendelenburg position was greater in the RIJV than the LIJV.
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Affiliation(s)
- Jeong Gil Lee
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hee Bin Park
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hye Young Shin
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ju Deok Kim
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Soo Bong Yu
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Doo Sik Kim
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sie Jeong Ryu
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Gyeong Han Kim
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
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Ray BR, Mohan VK, Kashyap L, Shende D, Darlong VM, Pandey RK. Internal jugular vein cannulation: A comparison of three techniques. J Anaesthesiol Clin Pharmacol 2013; 29:367-71. [PMID: 24106363 PMCID: PMC3788237 DOI: 10.4103/0970-9185.117115] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Ultrasound-guided internal jugular vein (IJV) cannulation is known for increasing success rate and decreasing rate of complications. The ultrasound image can be used as a real time image during cannulation or to prelocate the IJV before attempting cannulation. AIMS This study compares both the ultrasound-guided technique with the classical anatomical landmark technique (central approach) for right IJV cannulation in terms of success rate, complications, and time for cannulation. SETTINGS AND DESIGN A prospective, randomized, observational study was conducted at a tertiary care hospital. MATERIAL AND METHODS One hundred twenty patients requiring IJV cannulation were included in this study and were randomly allocated in three groups. Number of attempts, success rate, venous access time, catheterization time, and complications were observed in each group. STATISTICAL ANALYSIS USED Statistical analysis was performed using STATA-9 software. Demographic data were compared using one-way analysis of variance (ANOVA). Nonparametric data were compared using the Kruskall-Wallis test, and multiple comparisons were done applying The Mann-Whitney test for individual pairs of groups. Nominal data were compared by applying the Chi-square test and Fisher exact test. RESULTS Successful cannulation (≤3 attempt) was achieved in 90.83% of patients without any statistical significant difference between the groups. Venous access time and catheterization time was found to be significantly less in both the ultrasound groups than the anatomical land mark group. Number of attempts and success in first attempt was similar between the groups. CONCLUSIONS Both the ultrasound techniques are found to be better than the anatomical landmark technique. Further, ultrasound-guided prelocation was found to be as effective as ultrasound guided real-time imaging technique for right IJV cannulation.
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Affiliation(s)
- Bikash R Ray
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Bailey PL, Glance LG, Eaton MP, Parshall B, McIntosh S. A Survey of the Use of Ultrasound During Central Venous Catheterization. Anesth Analg 2007; 104:491-7. [PMID: 17312193 DOI: 10.1213/01.ane.0000255289.78333.c2] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Complications during central venous catheterization (CVC) are not rare and can be serious. The use of ultrasound (US) during CVC has been recommended to improve patient safety. We performed a survey to evaluate the frequency of, and factors influencing, US use. METHODS We conducted an electronic survey of all members of the Society of Cardiovascular Anesthesiologists. Univariate and multivariate logistic regressions were used to assess the association between the frequency of US use and hospital and physician factors. All tests were two-sided, and a P value <0.05 was considered statistically significant. RESULTS Of the 4235 members, 1494 responded (response rate = 35.3%). Two-thirds of the respondents never, or almost never, use US, whereas only 15% always, or almost always, use US. Thirty-three percent of the respondents never, or almost never, have US available, whereas 41% stated that US is always, or almost always, available. Availability of US equipment was strongly associated with US use for CVC (adj OR = 18.9; P value <0.001). The most common reason cited for not using US was "no apparent need for the use of US" (46%). When US was used, rescue or screening approaches were more common (72%) than real-time use (26%). CONCLUSIONS The use of US during CVC remains limited and is most strongly associated with the availability of equipment. Screening and rescue use of US are more common than real-time guidance. Our survey suggests that current use of US during CVC differs from existing evidence-based recommendations.
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Affiliation(s)
- Peter L Bailey
- Department of Anesthesiology, University of Rochester, Rochester, New York, USA.
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Wu L, Cooper L. Potential of the Right Ventricular Endomyocardial Biopsy to Diagnose and Assist in the Management of Congestive Heart Failure: Insights From Recent Clinical Trials. ACTA ACUST UNITED AC 2007; 10:133-9. [PMID: 15184727 DOI: 10.1111/j.1527-5299.2004.03362.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the United States congestive heart failure is most commonly due to ischemic cardiomyopathy, but nonischemic causes of cardiomyopathy can also result in congestive heart failure. Indeed, nonischemic dilated cardiomyopathy affects approximately 100,000 persons in the United States and is responsible for 45% of heart transplants. Although these patients undergo thorough cardiovascular evaluation, a specific cause is usually not found. Endomyocardial biopsy may yield diagnostic and prognostic information in this setting, and there has been a renewed interest in the use of endomyocardial biopsy in the evaluation of specific subsets of patients with congestive heart failure to identify potentially treatable myocarditides. However, the role of endomyocardial biopsy in the evaluation of patients with nonischemic cardiomyopathy is ill defined. In this review, the authors discuss the latest data on the risks and the utility of endomyocardial biopsy in the management of heart failure in the setting of dilated cardiomyopathy and specific myocarditides. Gaps in present knowledge and the obstacles to research in this area are identified.
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Affiliation(s)
- Lambert Wu
- Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Lim CL, Keshava SN, Lea M. Anatomical variations of the internal jugular veins and their relationship to the carotid arteries: A CT evaluation. ACTA ACUST UNITED AC 2006; 50:314-8. [PMID: 16884415 DOI: 10.1111/j.1440-1673.2006.01589.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The right internal jugular vein (IJV) is a common vessel to obtain venous access. It is important to have a clear understanding of the anatomy of the IJV and its relationship to the common carotid arteries (CCA) to avoid inadvertent arterial puncture. This study aims to objectively evaluate the variations in the anatomy of IJV and its relation to the CCA. A total of 176 right and left IJV were retrospectively evaluated using CT imaging with the CentraRad Diagnostic Viewer Version 4.09.0190 (CDN Telemedicine Solutions, Wollongong, Australia). The data were recorded and analysed. The right IJV (80.5%) was more often larger than the left IJV. With reference to the CCA, 85.2% of the IJV were found in the lateral position, 12.5% anteriorly, 1.1% medially and 1.1% posteriorly. Seven IJV were found to be hypoplastic, and in one case this was seen bilaterally in both the right and left IJV. The maximum depth of IJV from the skin was 27.9 mm. More than half (69.5%) of the IJV were less than 1 mm from the carotids. Computed tomography is an excellent method to delineate the anatomy of IJV. Variations in the anatomy of the IJV and their correlation to the CCA are common.
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Affiliation(s)
- C L Lim
- Department of Radiology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Augoustides JG, Horak J, Ochroch AE, Vernick WJ, Gambone AJ, Weiner J, Pinchasik D, Kowalchuk D, Savino JS, Jobes DR. A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth 2006; 19:310-5. [PMID: 16130056 DOI: 10.1053/j.jvca.2005.03.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department, to determine cumulative cannulation success by method, to determine first-pass cannulation success by method and operator, and to determine arterial puncture by method and operator. STUDY DESIGN Prospective, observational, and randomized. Blinding was not possible. Cohort size was calculated for 80% power to detect a technique difference, with significance defined as p < 0.05. SETTING Operating rooms of the Hospital of the University of Pennsylvania. PARTICIPANTS Elective surgical patients requiring internal jugular venous cannulation. INTERVENTIONS Cannulation of the internal jugular vein occurred by needle-guided ultrasound (NGU) or by ultrasound without a needle guide. MAIN RESULTS Four hundred thirty-four procedures were studied in 429 patients. NGU significantly enhances cannulation success after first (68.9%-80.9%, p = 0.0054) and second (80.0%-93.1%, p = 0.0001) needle passes. Cumulative cannulation success by the seventh needle pass is 100%, regardless of technique. The needle-guide specifically improves first-pass success in the junior operator (65.6%-79.8%, p = 0.0144). Arterial puncture averages 4.2%, regardless of technique (p > 0.05) or operator (p > 0.05). CONCLUSIONS Although the needle guide facilitates prompt cannulation with ultrasound in the novice operator, it offers no additional protection against arterial puncture. This may be because of a lack of control of needle depth rather than needle direction. A possible solution may be biplanar ultrasound for central venous cannulation.
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Affiliation(s)
- John G Augoustides
- Department of Anesthesia, Cardiothoracic Section, Hospital of the University of Pennsylvania, PA 19104, USA.
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Augoustides JG, Diaz D, Weiner J, Clarke C, Jobes DR. Current practice of internal jugular venous cannulation in a university anesthesia department: influence of operator experience on success of cannulation and arterial injury. J Cardiothorac Vasc Anesth 2002; 16:567-71. [PMID: 12407607 DOI: 10.1053/jcan.2002.126949] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe current cannulation of the internal jugular vein (CIJV) practice in a university anesthesia department. DESIGN Prospective, observational, and not randomized. SETTING Operating rooms of the Hospital of the University of Pennsylvania. PARTICIPANTS Elective surgical patients requiring CIJV (n = 426). INTERVENTIONS CIJV performed by real-time ultrasound visualization (U-CIJV) or by anatomic landmarks (AL-CIJV). MEASUREMENTS AND MAIN RESULTS A total of 462 procedures were studied in 426 patients. Overall cannulation failure was 2.1% with U-CIJV and 13.8% with AL-CIJV (p = 0.0001). Cumulative CIJV success by the sixth needle pass was 94.0%, regardless of technique. Junior operators performed 75.3% of CIJV, of which 86.8% was U-CIJV. First-pass success across operators was 60% to 70% for U-CIJV and 50% to 80% for AL-CIJV. Arterial puncture rates averaged 7.0%, regardless of technique (p = 0.45). The junior operator may be more at risk for arterial puncture during U-CIJV. CONCLUSION U-CIJV offers incomplete protection against arterial injury in this practice compared with the literature. A possible solution is the ultrasound needle guide, which may minimize arterial injury, especially with junior operators.
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Affiliation(s)
- John G Augoustides
- Department of Anesthesia, Cardiothoracic Section, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
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Mann T, Johnson F, Cokis C. Internal jugular vein patency following carotid endarterectomy. Anaesth Intensive Care 2002; 30:41-2. [PMID: 11939438 DOI: 10.1177/0310057x0203000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We performed ultrasound examinations on forty-five patients with a history of carotid endarterectomy to assess the patency and position of the internal jugular vein on the side of the endarterectomy. The study was performed in a tertiary referral centre. In the 55 internal jugular veins examined (ten bilateral procedures), the veins were patent and in a normal relationship to the carotid artery. We concluded that previous carotid surgery should not be a contraindication to cannulation of the internal jugular vein.
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Affiliation(s)
- T Mann
- Department of Anaesthesia, Royal Perth Hospital, Perth, Western Australia
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Cormio M, Robertson CS. Ultrasound is a reliable method for determining jugular bulb dominance. J Neurosurg Anesthesiol 2001; 13:250-4. [PMID: 11426103 DOI: 10.1097/00008506-200107000-00014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite widespread application of jugular oximetry devices, the optimal side to cannulate for monitoring cerebral oxygenation is controversial. For most monitoring strategies, the dominant or larger internal jugular vein gives the most representative values for venous oxygen saturation. However, there is little information on how to best determine the dominant side. The purpose of this study was to compare the results of an ultrasound examination to two other standard methods for determining the dominant internal jugular vein, the jugular vein compression test and the computed tomographic (CT) approach. Seventeen patients with severe head injury (GCS <8) were studied. The ultrasound examination showed the mean internal diameter of the right and the left internal jugular veins to be 1.27 cm (standard deviation [SD] 0.16 cm) and 1.21 cm (SD 0.36 cm), respectively. The right internal jugular vein was larger than the left in 11 (65%) of the patients. The diameter of the dominant or larger internal jugular veins were 1.44 cm (SD = 0.22), compared with 1.04 cm (SD = 0.18) on the opposite side (P < .05). The results of the ultrasound method were in agreement with the CT scan method in 94% of the comparisons and with the jugular vein compression test in 82% of comparisons. These studies demonstrate that the ultrasound method provides useful information about the side of the dominant cerebral venous drainage, comparable to other standard methods, without the need for a CT scan or manipulation of intracranial pressure.
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Affiliation(s)
- M Cormio
- Department of Anesthesia and Intensive Care, Ospedale San Gerardo, Milan, Italy
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Charney J, Hamid RK. Pediatric resuscitation outside the operating room. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2001; 19:391-8, viii. [PMID: 11469071 DOI: 10.1016/s0889-8537(05)70235-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Protocols regarding the treatment of cardiac arrest of the pediatric patient outside the operating room are continually being reviewed as knowledge regarding the pathophysiology of cardiac arrest and the pharmacologic properties of resuscitative drugs has progressed. The indications for treatment of cardiac arrest by the various resuscitative drugs, and techniques for obtaining access for the administration of these drugs are discussed.
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Affiliation(s)
- J Charney
- Department of Anesthesiology, Harbor UCLA Medical Center, Torrance, California, USA
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Shulman MS, Kaplan DB, Lee DL. An anteromedial internal jugular vein successfully cannulated using the assistance of ultrasonography. J Clin Anesth 2000; 12:83-6. [PMID: 10773517 DOI: 10.1016/s0952-8180(00)00118-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The internal jugular vein usually is found either lateral or anterolateral to the carotid artery when it is cannulated for central vein access using external anatomical landmarks. We report a case in which the carotid artery was inadvertently punctured, but the right internal jugular vein could not be found. We used ultrasonic guidance to determine that the right internal jugular vein was anteromedial to the carotid artery. A figure showing the ultrasound of this rare anatomical variation is provided. The advantages and utility of ultrasound when used for the placement of internal jugular central vein catheters are reviewed.
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Affiliation(s)
- M S Shulman
- Department of Anesthesiology, St. Elizabeth's Medical Center, Boston, MA 02135-2996, USA
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Abstract
The uses of the pulmonary artery catheter have been expanded from its original use, helping to assess the cardiac output and left ventricular filling pressure of patients with cardiac disease, to include the management of patients with trauma, septic shock, respiratory failure, and those undergoing high-risk surgeries. Although more than 1 million pulmonary artery catheters are inserted each year in the United States, clear evidence establishing that they improve outcome remains hard to find. This article discusses the complications of invasive hemodynamic monitoring.
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Affiliation(s)
- T D Coulter
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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Pranikoff T, Hirschl RB, Remenapp R, Swaniker F, Bartlett RH. Venovenous extracorporeal life support via percutaneous cannulation in 94 patients. Chest 1999; 115:818-22. [PMID: 10084497 DOI: 10.1378/chest.115.3.818] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE The objective of this study was to demonstrate the safety and utility of a method of percutaneous access for cannulation of adult patients for venovenous extracorporeal life support (ECLS). DESIGN A retrospective review of a patient series. SETTING A surgical ICU at a university teaching hospital. PATIENTS The study group consisted of 94 adults > 17 years old with respiratory failure who were placed on venovenous ECLS by means of percutaneous cannulation. INTERVENTIONS The cannulation of the internal jugular and femoral veins (FVs) using the Seldinger technique for venovenous ECLS. MEASUREMENTS AND RESULTS Between May 1992 and November 1997, we performed percutaneous cannulation for venovenous ECLS in 94 adult patients with respiratory failure. The mean (+/- SD) age was 36.1+/-12.7 years old (range, 17 to 65 years). The mean (+/-SD) weight was 80.7+/-22.3 kg (range, 36 to 156 kg). The right internal jugular vein (RIJV) was used for venous drainage access in all but four cases. The right FV (n = 86), the left FV (n = 3), or the RIJV (n = 4) was utilized for venous reinfusion. The maximum blood flow (+/-SD) during ECLS was 57.6+/-17.5 mL/kg/min (range, 22.4 to 127.8 mL/kg/min), with a postmembrane outlet pressure (+/-SD) of 146+/-43 mm Hg (range, 56 to 258 mm Hg) at the maximum flow rate. There were 11 unsuccessful percutaneous cannulation attempts. In three patients (3%), the complications consisted of arterial injury requiring operative cutdown and repair. In six patients (6%), cannula-site bleeding required pursestring suture reinforcement of the cannula site. One patient died from the perforation of the superior vena cava during cannulation. CONCLUSIONS Based on these data, we conclude that percutaneous cannulation may be utilized to provide venovenous ECLS in adults.
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Affiliation(s)
- T Pranikoff
- Department of Surgery, The University of Michigan Medical School, Ann Arbor, USA
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Abstract
Inadvertent carotid artery puncture is a well-known complication of internal jugular vein cannulation. A case of cerebral infarct subsequent to carotid artery puncture during internal jugular vein cannulation is reported.
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Affiliation(s)
- N A Zaidi
- Department of Anaesthesiology, Aga Khan University Hospital, Karachi, Pakistan
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Maruyama K, Nakajima Y, Hayashi Y, Ohnishi Y, Kuro M. A guide to preventing deep insertion of the cannulation needle during catheterization of the internal jugular vein. J Cardiothorac Vasc Anesth 1997; 11:192-4. [PMID: 9105992 DOI: 10.1016/s1053-0770(97)90213-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Accidental puncture of the vertebral artery during the internal jugular vein cannulation produces lethal sequelae. To prevent this, the cannulation needle must not be inserted too deeply. However, there is no useful guide for the optimal length of insertion of the needle for accessing the internal jugular vein. The authors examined the length of the needle needed to reach the internal jugular vein with three different sizes of needle (16, 20, and 23 gauge). DESIGN Prospective study. SETTING An academic medical center. PARTICIPANTS Patients undergoing cardiovascular surgeries. INTERVENTIONS The cannulation of the internal jugular vein was performed through the right internal jugular vein by the high approach. The needle was slowly advanced, keeping constant negative pressure on the syringe at 45 degrees to the skin surface until blood was aspirated; if blood was not aspirated during insertion, the needle was slowly withdrawn until blood was aspirated. The distance to the internal jugular vein was assessed by calculating the entire length of needle minus the length of needle from the skin surface to the hub. MEASUREMENTS AND MAIN RESULTS The mean distance to the internal jugular vein ranged from 15.0 to 21.5 mm, and the larger needle required the longer distance to the internal jugular vein. CONCLUSIONS The results may be a useful guide to prevent too deep insertion of the needle during internal jugular vein catheterization, especially when teaching residents who have limited experience with internal jugular vein catheterization.
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Affiliation(s)
- K Maruyama
- Department of Anesthesiology, National Cardiovascular Center, Osaka, Japan
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Downie AC, Reidy JF, Adam AN. Short communication: tunnelled central venous catheter insertion via the internal jugular vein using a dedicated portable ultrasound device. Br J Radiol 1996; 69:178-81. [PMID: 8785648 DOI: 10.1259/0007-1285-69-818-178] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We describe the use of a purpose-built portable ultrasound device to assist puncture of the internal jugular vein during percutaneous insertion of tunnelled central venous catheters such as Hickman lines. In many situations the internal jugular route is safer, faster and less costly in comparison with the subclavian approach. The use of ultrasound allows an accurate initial venous puncture with fewer complications, in the hands of both experienced operators and those less familiar with the internal jugular vein approach.
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Affiliation(s)
- A C Downie
- Department of Radiology, Guy's and St Thomas' Hospitals Trust, London, UK
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Eckhardt WF, Iaconetti J, Kwon JS, Brown E, Troianos CA. Inadvertent carotid artery cannulation during pulmonary artery catheter insertion. J Cardiothorac Vasc Anesth 1996; 10:283-90. [PMID: 8850412 DOI: 10.1016/s1053-0770(96)80252-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Sulek CA, Gravenstein N, Blackshear RH, Weiss L. Head Rotation During Internal Jugular Vein Cannulation and the Risk of Carotid Artery Puncture. Anesth Analg 1996. [DOI: 10.1213/00000539-199601000-00022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sulek CA, Gravenstein N, Blackshear RH, Weiss L. Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996; 82:125-8. [PMID: 8712386 DOI: 10.1097/00000539-199601000-00022] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We undertook a prospective laboratory study to examine the effect of head position on the relative positions of the carotid artery and the internal jugular vein (IJV). Volunteers (n = 12) from departmental staff, 18-60 yr of age, who had never undergone cannulation of the IJV underwent imaging of their IJV and carotid artery. With the subject in a 15 degrees Trendelenburg position, two-dimensional ultrasound images of the IJV and the carotid artery were obtained on the left and right sides of the neck at 2 and 4 cm from the clavicle along the lateral border of the sternal head of the sternocleidomastoid muscle at 0 degrees, 40 degrees, and 80 degrees of head rotation from the midline. The percent overlap of the carotid artery and IJV increased significantly at 40 degrees and 80 degrees head rotation to both the right and left (P < 0.05). Data from 2 and 4 cm above the clavicle did not differ and were pooled. The percent overlap was larger on the left than the right only with 80 degrees of head rotation (P < 0.05). The increased overlap of carotid artery and IJV with head rotation > 40 degrees increases the risk of inadvertent puncture of the carotid artery associated with the common occurrence of transfixion of the IJV before it is identified during needle withdrawal. The IJV frequently collapses with needle insertion. This may result in puncture of the posterior wall of the vessel, and thus of the carotid artery when the two vessels overlap. To decrease this risk, the head should be kept in as neutral a position as possible, that is < 40 degrees rotation, during IJV cannulation.
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Affiliation(s)
- C A Sulek
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA
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Branger B, Dauzat M, Zabadani B, Vécina F, Lefranc JY. Pulsed Doppler sonography for the guidance of vein puncture: a prospective study. Artif Organs 1995; 19:933-8. [PMID: 8687301 DOI: 10.1111/j.1525-1594.1995.tb02454.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Blind deep venous puncture is an invasive procedure with risks of serious complications compromising the availability of veins for future punctures or endangering the patient's life. We designed a new hand-held pulsed Doppler probe for coaxial guidance of the puncture needle and a dedicated pulsed Doppler device displaying the depth of the measurement volume. We used this technique prospectively in two independent centers (the nephrology department and the intensive care unit) involving senior as well as junior staff members. Either the non-Doppler or the Doppler method were randomly selected for subclavian vein catheterization in 100 patients and for internal jugular vein catheterization in 30 patients. The success rate on the first attempt was 86.2% for the non-Doppler method versus 96.8% for the Doppler method (p = 0.03). The failure rate of the non-Doppler method used by junior staff members was 9.2%, reduced to 1.5% (p = 0.05) by secondary use of the Doppler method and/or help from a senior staff member (rescue procedure). Pulsed Doppler guidance reduced significantly the failure rate of venous punctures especially when used by seniors or by juniors after a training period.
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Affiliation(s)
- B Branger
- Department of Nephrology, Nimes University Hospital, France
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Vucevic M, Tehan B, Gamlin F, Berridge JC, Boylan M. The SMART needle. A new Doppler ultrasound-guided vascular access needle. Anaesthesia 1994; 49:889-91. [PMID: 7802189 DOI: 10.1111/j.1365-2044.1994.tb04268.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Central venous access is an essential part of patient management in many clinical settings. Traditionally this has been achieved by a blind, external landmark guided technique which may not correlate exactly with the location of the vessel. We have prospectively evaluated the SMART needle, a new Doppler ultrasound guided vascular access device, in 40 patients, to evaluate whether it can improve on the standard technique. The SMART needle was easy to use and reliably distinguished between arterial and venous signals. No advantage was demonstrated in 'easy' internal jugular vein cannulations. Although ease of cannulation in difficult cases was subjectively improved, the differences in time to cannulation and number of passes between the groups failed to reach statistical significance and the complication rates were similar. However, the use of the SMART needle on two occasions enabled avoidance of carotid artery puncture by correctly distinguishing the artery from the vein, so that it may have a rôle in patients in whom difficult internal jugular venous cannulation is anticipated.
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Affiliation(s)
- M Vucevic
- Academic Unit of Anaesthesia, General Infirmary at Leeds
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Armstrong PJ, Sutherland R, Scott DH. The effect of position and different manoeuvres on internal jugular vein diameter size. Acta Anaesthesiol Scand 1994; 38:229-31. [PMID: 8023661 DOI: 10.1111/j.1399-6576.1994.tb03879.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Internal jugular vein (IJV) cannulation is a popular approach for central venous access as it has few complications, of which failure to locate the vein and carotid artery puncture are the most common. A variety of manoeuvres and body positioning has been used to maximise IJV size and thereby increase cannulation success rate and decrease complications. Realtime 2D ultrasound can be used to view neck vascular anatomy in vivo and allow IJV size to be measured. Thirty-five volunteers had the lateral diameter of their IJV measured using the SiteRite ultrasound machine to discover the most effective methods of increasing its diameter. No correlation was found between the IJV lateral diameter and subject height, weight, age or neck circumference. Carotid artery palpation and full neck extension reduced its diameter considerably. Increasing Trendelenberg increased diameter. Abdominal binder and the Valsalva manoeuvre were the most efficient methods of increasing its size.
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Affiliation(s)
- P J Armstrong
- Department of Anaesthesia, Edinburgh University, Royal Infirmary of Edinburgh, Scotland, U.K
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