Does pre-procedure ultrasound increase the success and safety of right internal jugular venous catheterization? An intervention study

Abstract

Background

Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, ensuring real-time US into routine practice is impeded by its perceived expense and difficulty. This expertise requires hand–eye coordination and learning curve. Moreover, availability of multiple US machines and probes for multiple operation theatres may not be possible even at the tertiary level care set-up. Currently, pre-procedure US and landmark methods are most widely used. We investigated both the techniques with application of skin markings in the pre-procedure group to ascertain efficacy and safety with a view to incorporate pre-procedure US in our practice.

Methods

In this randomized study, we investigated 66 patients. Thirty-three patients in the pre-procedure ultrasound group and 33 patients in the landmark group were included for right internal jugular vein (RIJV) cannulation. We recorded the first needle pass success rate, cannulation time and complications.

Results

Pre-procedure US was associated with more successful attempts, shorter cannulation times and less complications. Under pre-procedure US, 75.76% of first attempts were successful with a cannulation time of 50 (25–180) seconds. Under landmark technique, 27.27% of first attempts were successful with a cannulation time of 85 (20–200) seconds. First puncture success rates were higher in pre-procedure US than landmark technique, 66.67% vs 27.27%, respectively.

Conclusion

Pre-procedure US for RIJV catheterization is safer, quicker and superior to landmark technique.

Introduction

Central venous catheterization (CVC) is one of the basic modalities of critical care medicine to provide vasoactive support, hypertonic drugs and total parenteral nutrition. The volume status of the patient can also be monitored and guided by central venous pressure. Anatomical landmark technique is traditionally used for CVC in most of the patients.

Internal jugular, subclavian and femoral veins are the usual sites of access. Anatomical landmark technique poses 12.3% risk of complications, even when performed by an experienced physician.¹ The availability of portable ultrasound (US) units has significantly helped in lowering the complications.²

The occurrence of complications or failure of catheterization could be explained by incidence of altered anatomy, which is observed in 18% of individuals.^{3, 4} The benefit of two-dimensional US machine for CVC is recognizing the patency of the vessel and visualization of the position of the needle in relation to the surrounding structures, which may help in faster access to central vein, lowering the complications.

Use of real-time US has shown to reduce the complications during central venous access by 35%.⁵ However, use of US for CVC needs expertise and hand–eye coordination. This at times may be difficult for a beginner.⁶ The limited number of USG machines becomes a restrictive factor to simultaneous use of real-time US for CVC in multiple theatres in one operation theatre complex. This study was intended to observe whether pre-procedure ultrasonogram (USG ) increases the efficacy and safety of routinely performed right internal jugular vein (RIJV) catheterization.

Material and methods

The aim of the study was to investigate the efficacy and safety of RIJV catheterization using pre-procedure US versus landmark technique.

The study design was prospective and interventional. Approval was obtained from the local ethical committee. The study was conducted in an operating room of a tertiary care hospital from November 2016 to December 2017. All the patients in the age group of 18 to 70 years, listed for elective surgery and requiring RIJV cannulation, were enrolled in the study. The patients were randomly assigned to one of the groups based on a computer-generated table of random numbers. The study was explained to the patients in the language they understood, and written informed consent was obtained. The inclusion criteria also encompassed patients with body mass index (BMI) more than 30 kg/m² or less than 20 kg/m², patients with a history of previous CVC on either side and patients with goitre. The criterion for goitre was a visibly enlarged thyroid gland. Patients in whom IJV catheter placement was contraindicated and patients not able to give consent were excluded from the study.

We compared pre-procedure USG with landmark technique. Data from 66 RIJV catheterizations were recorded. Initially, a scout scan of the supraclavicular region was conducted by an independent anaesthesiologist in a preoperative procedure room before any intervention in all patients to determine the presence of venous thrombosis, so as to avoid confounding observations in both the groups. The scan was performed using a portable ‘Sonosite Titan’ USG machine with a linear probe and a frequency of 6–13 MHz. Only one investigator from the department of anaesthesiology carried out RIJV catheterization in both the groups to avoid operator bias. This investigator had basic knowledge and experience of performing an US scan and CVC. However, the investigator's experience was not taken into account as the same investigator was performing all catheterization in both the groups. An independent observer, who was not one of the authors, supervised the conduct and recorded the data, thus avoiding interinvestigator differences. The number of cannulation attempts, the first needle pass success rate, cannulation time and early mechanical complications were recorded. The first needle pass success was designated by successful entry in the right IJV with a wide bore needle. A single skin puncture was the criterion for cannulation attempt. Cannulation time was recorded as interval between skin puncture by a needle to smooth advancement of the guide wire into the RIJV. Mechanical complications including haematoma and pnuemothorax were recorded based on clinical and chest roentgenogram findings. Inability to perform catheterisation for 10 min or more than three unsuccessful attempts was the criterion to define failure to cannulate the RIJV. All CV catheters were inserted by the Seldinger technique using a 7 French CVC (Arrow [Teleflex Medical, Ireland]).

Anatomical landmark technique group

The patients were placed in the Trendelenburg position (30°) with the head in neutral position under basic monitoring (Fig. 1). The area for procedure was prepared under all aseptic precautions. If the patient was conscious, 2% lidocaine was infiltrated into the skin. Cannulation was undertaken at the apex of the triangle formed by the union of two heads of the sternocleidomastoid muscle and the base formed by the clavicle. The RIJV was identified using a locator needle. 7French catheter was inserted by the Seldinger technique. The catheter was secured with 2-0 silk sutures, and a sterile dressing was applied.

Fig. 1.

Patient in the 30% Trendelenburg position with the head in neutral position.

Pre-procedure ultrasound group

The position for the procedure was Trendelenburg (30°) with the head in neutral position under basic monitoring in a preoperative procedure room. Two-dimensional US scans were carried out. Course, calibre, patency and relationship of the RIJV to the carotid artery were examined. Skin markings indicating the puncture site and direction were applied at the possible puncture site (Fig. 2). After shifting the patient to the operation room, the site for cannulation was prepared and draped under sterile precautions by placing the patient in the 30° Trendelenburg position with the head in neutral position. If the patient was conscious, 2% lidocaine was infiltrated into the skin; subsequently, the vein was accessed at the previously applied skin marking with 7French catheter without using locater needle or palpation of the neck vessels and muscles. After cannulation, the catheter was secured with 2-0 silk sutures, followed by application of a sterile adhesive dressing.

Fig. 2.

Skin markings applied after short-axis (upper) and long-axis (lower) view over the area of interest using the Titan Sonosite ultrasound machine.

Statistical analysis

To achieve the two-sided 95% significance level with a study power of 80% and for validity and reliability, the minimum sample size in each group was calculated to be a minimum of 31. However, we included 33 patients in each study group.

SPSS version 13.0 software was used for the analysis. Numbers and percentages were used to represent nominal data parameters including success rate and complications. The chi-square test was applied to analyze these data. The Mann–Whitney test was applied for analyzing ordinal data parameters including cannulation attempts and cannulation time, represented as the median and range. A P-value of <0.05 was considered statistically significant.

Results

A total of 66 patients were studied, as shown in the consort diagram (Fig. 3). Patient characteristics pertaining to demography and study parameters were similar in both study groups (Table 1). In the efficacy outcome parameters, the first needle pass success rate was significantly higher in the ultrasound group (U group) (n = 22; 66.67%) than the landmark technique group (L group) (n = 9; 27.27%), as represented in Table 2 (p value, 0.003). The rate of successful first attempt of cannulation was higher in the U group (n = 25; 75.76%) and lower in the L group (n = 9; 27.27%), as shown in Table 2 (p value < 0.001). The median cannulation time in the U group was 50 s (with a range of 25–180), as compared with that in the L group 85 s (range of 20–200 s), was statistically significant (p value < 0.001), as shown in Table 3. In safety outcome parameters, the U group was associated with fewer arterial punctures (n = 1; 3.03%) than the L group (n = 3; 9.09%) (p value, 0.613). Haematoma formation during the procedure was lower (n = 2; 6.06%) in the U group, as compared with the L group (n = 5; 15.15%) (p value, 0.427). Occurrence of pnuemothorax was nil in the U group, however, occurred in two cases of the L group (6.06%) (p value, 0.492). Haemothorax occurrence was similar in both study groups (n = 1; 3.03%) (p value, 0.999). Catheterization failure was lower in the U’ group (n = 1; 3.03%) as compared with the L group (n = 3; 9.09%) (p value, 0.305). These parameters, although not statistically, were clinically significant (Table 4).

Fig. 3.

Consort diagram.

Table 1.

Demographic and study parameters.

Parameters	L group	U group
CVC [n (%)]	33	33
Patients
Females (n [%])	6 (18.18%)	10 (30.3%)
Age (yr) (median [range])	35 (18–50)	35 (18–50)
Height (cm) (median [range])	170 (148–191)	169 (149–189)
Body weight (kg) (median [range])	75 (37–130)	75 (44–128)
BMI (kg m −2) (median [range])	25.7 (15.4–52)	26.3 (17.5–58)
Cardiac surgery (n [%])	15 (45.4%)	10 (30.3%)
General surgery (n [%])	10	15
Neurosurgery (n [%])	4 (12.1%)	5 (15.1%)
Others (n [%])	4 (12.1%)	3 (9.09%)
Goitre (n [%])	5 (15.1%)	5 (15.1%)
Previous CVC (n [%])	5 (15.1%)	5 (15.1%)
BMI<20 kg m−2 (n [%])	3 (9.09%)	4 (12.1%)
BMI>30 kg m−2 (n [%])	7 (21.2%)	5 (15.1%)

BMI, body mass index; CVC, central venous catheterization; L group, landmark technique group; U group, ultrasound group.

Table 2.

Comparison of first needle pass success rate and cannulation attempts.

First needle pass success	Group		Total	P-value
	L group	U group
Yes	9	22	31	0.003
No	24	11	35
Total	33	33	66
Number of cannulation attempts
1	9	25	34	<0.001
2	19	7	26
3	4	1	5
Total	33	33	66

L group, landmark technique group; U group, ultrasound group.

Table 3.

Comparison of cannulation time.

	Cannulation time (sec)		p-value
	L group	U group
Minimum	20	25	<0.001
Maximum	285	180
Mean	98.06	54.55
SD	63.49	30.55
Median	85	50

L group, landmark technique group; U group, ultrasound group; SD, standard deviation.

Table 4.

Complications.

Complication		Group		Total	P- value
		L group	U group
Arterial	Present	3	1	4	0.613
	Absent	30	32	62
Haematoma	Present	5	2	7	0.427
	Absent	28	31	59
Pneumothorax	Present	2	0	22	0.492
	Absent	31	33	64
Haemothorax	Present	1	1	2	0.999
	Absent	32	32	64
Failure to catheterize	Present	3	1	4	0.305
	Absent	30	32	62

L group, landmark technique group; U group, ultrasound group.

The patients with goitre differed in some of the outcome parameters in the study. The mean cannulation time in the U group was less (50 s; n = 3) than in the L group (117 s; n = 4). Haematoma formation occurred in one case in the L group, whereas that was nil in the U group. These observations were clinically significant.

Discussion

Real-time US has been found to be more efficacious in central venous access in elective and emergency cases.^{7, 8} Real-time US technique requires training and additional help than pre-procedure US. However, in practice, use of real-time technique is limited by the number of USG machines available in the operation theatre complex. Patient turnover time is important in the routine operating schedule in clinical practice, thereby limiting the use of real-time US for central vein catheterization in multiple theatres at the same time.⁹ Jefferson et al. carried a survey in 288 critical care units with a response rate of 58%; 70 (53%) units did not use US because of lack of equipment, and 51 (38.9%) units did not find its use necessary. In this scenario, pre-procedure US offers support, but the benefits of pre-procedure techniques are not fully used in clinical practice.^{10, 11, 12} Our study has found that pre-procedure US is safe and offers faster placement of the CV catheter.

Our study found pre-procedure US technique guides the operator to attempt cannulation at the previously marked site after studying the relation of the RIJV with the surrounding structures, the presence of thrombus or any anatomical variation. Successful first attempt and shorter cannulation time was observed in the U group. Pre-procedure US thus saves time and reduces complications. Anatomical landmark technique is based solely on premise of normal relations of the neck vessels, muscles and direction.¹³ Multiple attempts and repeated punctures can lead to injury to vital structures. Fatal consequences in critically ill patients are seen with repeated puncture attempts and in patients with coagulopathies.^{14, 15} Our study has revealed that pre-procedure US helps in reducing the number of unsuccessful attempts. We have kept the head in the neutral and 30^° Trendelenburg position in both the groups to increase the calibre of the RIJV by central venous filling. Neck rotation increases the degree of overlap of the carotid artery relative to the IJV from 20% to 30% to 50%, resulting in carotid artery injury.¹⁶ We had removed bias of head turning during cannulation. Schummer et al. compared pre-procedure US with landmark technique for IJV cannulation; they found favourable outcome with pre-procedure US technique, but they did not apply skin markings in their study.⁶ We applied skin markings in the U group so that the operator's area of interest is narrowed down, thus providing him a focused point of the puncture site and direction of vessel, further facilitating the catheterization.

Mansfield et al. studied 821 patients (411 in the U group and 410 in the control group) undergoing subclavian vein cannulation for chemotherapy. They found statistically significant association of failure rate and complications with previous cannulation and BMI <20 or >30 Kg/m² (14.2% vs BMI 20–30, 8.1%; P value < 0.001), but failed to show any clinical benefit with real-time US in their study.¹⁷

Silva¹⁸ reported neck haematoma and airway obstruction in a patient with goitre undergoing internal jugular catheterization by blind landmark technique. The author attributed this complication to changes in calibre and relationship of the neck vessels with goitre. In our study, the first puncture success rate was higher in patients with goitre in the U group. We found one case of haematoma with goitre in the L group that was clinically significant. In our study, we found that pre-procedure US resulted in fewer complications in patients having known risk factors, such as low BMI and goitre. Complications are increased with previous history of catheterization and are due to associated thrombosis, making subsequent attempt difficult.¹⁹ This factor was eliminated in our study as US assessment by a neutral anaesthesiologist was carried out before attempting actual catheterization in both the groups. First needle pass success was found to be higher in patients with previous central vein cannulation in the U group of our study. The overall number of complications, although not statistically significant, was less in the U group. We found pnuemothorax only in the L group.

Limitations

Our study is a prospective interventional study involving a small number of patients undergoing elective surgery. Neither the operator's level of experience nor the circumstances under which surgical procedures were carried out were taken into account. As only one observer was recording the variables, it is possible that operators were more careful during the procedure in the U group. The superiority of pre-procedure US over anatomical landmark technique in elective cases was demonstrated, despite these limitations. Further studies are required for emergency cases and critically ill patients.

Conclusions

In a busy operation theatre, where faster patient turnover time is desired and limited availability of USG prevents the conduct of real-time USG for every patient, use of pre-procedure US will be of benefit for the patients. Pre-procedure US ensures faster placement and reduces complications of RIJV catheterization when compared with anatomical landmark techniques. This holds true even for patients with risk factors. We have modified the technique by placing markings over the site of cannulation, thus facilitating the operator without any additional help. Based on these substantial differences, we are able to recommend the use of pre-procedure technique, with markings to be incorporated in clinical practice for elective cases.

Conflicts of interest

The authors have none to declare.