Year :
2024
| Month :
June
| Volume :
18
| Issue :
6
| Page :
UC10 - UC14
Full Version
Comparison of Three Different Approaches to Ultrasound-guided Internal Jugular Vein Cannulation: A Randomised Clinical Study
Published: June 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/69660.19532
M Veneta Sandra, M Karthik Jain, Shilpa Jagadeesh, Vikram Shivappagoudar, Rashmi Rani
1. Resident, Department of Anesthesiology, SJMCH, Bengaluru, Karnataka, India.
2. Associate Professor, Department of Anesthesiology, SJMCH, Bengaluru, Karnataka, India.
3. Assistant Professor, Department of Anesthesiology, SJMCH, Bengaluru, Karnataka, India.
4. Associate Professor, Department of Anesthesiology, SJMCH, Bengaluru, Karnataka, India.
5. Associate Professor, Department of Anesthesiology, SJMCH, Bengaluru, Karnataka, India.
Correspondence Address :
Shilpa Jagadeesh,
Assistant Professor, Department of Anesthesiology, St. John’s Medical College Hospital, Koramangala, Sarjapura Road, Bengaluru-560034, Karnataka, India.
E-mail: shilpa.j.rao@gmail.com
Abstract 
Introduction: The standard approaches to ultrasound-guided central line insertion by Short Axis (SAX) and Long Axis (LAX) have limitations. The Medial Oblique Axis (M-OAX) approach allows visualisation of the length of the needle in real-time along with both the artery and vein.
Aim: To compare the three approaches for ultrasound-guided right Internal Jugular Vein (IJV) cannulation with respect to ease of access and complications.
Materials and Methods: A total of 171 patients scheduled to undergo right IJV cannulation were divided equally into three groups-SAX (Group-1), LAX (Group-2), and M-OAX (Group-3). They were compared with respect to first pass success, Venous Access Time (VAT), guide wire insertion time, catheterisation time, and complications. Continuous variables were compared with Analysis of Variance (ANOVA) test. Categorical variables were analysed using the Chi-square test. The p-value <0.05 was considered significant.
Results: First pass success was 55 (96.49%), 53(92.98%), and 54 (94.74%) in groups 1, 2, and 3, respectively. The VAT, guidewire insertion time, and catheterisation time were significantly lesser in Groups 1 and 3 compared to 2 (p<0.001). Two cases of carotid artery puncture were noted in Group-2, though statistically not significant (p>0.05).
Conclusion: The medial oblique approach to IJV cannulation combines the advantages of both LAX and SAX and is a safer alternative with easier and faster venous access.
Keywords
Carotid artery, Central venous catheterisation, Ultrasonography
Introduction
The IJV cannulation is an invasive procedure, often carried out in the Intensive Care Unit (ICU) and in the peri-operative period. Its suitable anatomical location and lower infection rate make IJV a very popular site for central venous access. Traditional approaches to IJV cannulation are based on anatomical landmarks, whereas the American Society of Anaesthesiologists’ practice guidelines for central venous access recommend using real-time Ultrasonography (USG) guidance for IJV access (1). Additionally, a study conducted by Karakitsos D et al., suggests that ultrasound-guided catheterisation of the IJV in intensive care patients is superior to the anatomical technique and is therefore recommended as the method of choice (2).
Two approaches commonly employed to view the IJV using ultrasound are LAX and SAX. The LAX approach guarantees visibility of the needle tip and the needle in its entirety. In the SAX approach, both the artery and vein are visualised simultaneously, but the entire length and tracking of the needle cannot be visualised and carries the risk of posterior wall puncture. A newer approach, M-OAX, combines the advantages of both, i.e., the ability to visualise the artery and vein in the same view as well as tracking the needle in real-time simultaneously, which can be useful for a novice anaesthesiologist (3). Limited studies are available regarding the use of this approach, and there is a need to prove its utility and safety (1),(3),(4). Thus, this study was conducted to compare three approaches, namely SAX, LAX, and M-OAX, for USG-guided IJV cannulation. The oblique view is obtained by first locating the vessel in the SAX, after which the probe is rotated to almost midway between the SAX and LAX views. With this technique, both the carotid artery and IJV are visualised in a slightly elongated view on the screen (5). It was hypothesised that the M-OAX approach is safer and faster when compared to LAX and SAX approaches for IJV catheterisation under USG guidance. The primary objective was to compare the three approaches for ultrasound-guided right IJV cannulation in terms of first needle pass success. The secondary objectives were to compare the number of needle passes, VAT, guide wire insertion time, catheterisation time as well as the complications pertaining to the procedure.
Material and Methods
A prospective single-blinded randomised clinical study was conducted in the Department of Anaesthesiology and Critical Care Unit at a tertiary care hospital in Bangalore from March 2021 to October 2022 after obtaining Institutional Ethical Committee clearance (IEC Study Ref No. 386/2020). The study was registered at CTRI/2022/03/041082.
Inclusion criteria: Those patients aged between 18-70 years of either sex, posted for elective surgery or admitted to the critical care unit who required Central Venous Cannulation (CVC) were included in this study.
Exclusion criteria: Patients with an infection at the site of cannulation, subcutaneous haematoma at or close to the puncture site, recent cervical spine trauma, previous surgical procedures at the cannulation site, cervical spondylosis, coagulopathy (International Normalised Ratio (INR) >1.5, Platelet count <1 lac), and obese patients (BMI >30) were excluded from the study.
Sample size calculation: The sample size calculation was based on the study by Lal J et al., (4). They reported a 19.4% point difference in the first pass success rate between M-OAX and LAX view, where M-OAX had a success rate of 97.2%. To observe a similar difference with 80% power and a 2.5% level of significance (Bonferroni adjustment for three group comparisons), a sample size of 57 per group was required.
Procedure
After obtaining written informed consent, 171 patients were included in this study and were divided into three groups (Group-1, 2, 3) by computer-generated randomisation. The SAX approach was used in Group-1 (n=57), the LAX approach in Group-2 (n=57), and the M-OAX approach in Group-3 (n=57) (Table/Fig 1). In the operation theatre, standard monitors included Electrocardiography (ECG), SpO2, and Non-Invasive Blood Pressure (NIBP). Patients were intubated after the induction of general anaesthesia. Intubated patients from the ICU were also included in the study.
Subsequently, patients were placed in the Trendelenburg position with a 30° tilt. Ultrasound-guided IJV cannulations using the modified Seldinger technique were performed by an anaesthesiologist with experience of ≥20 procedures with a 7F (15 cm) triple-lumen catheter. The same operator handling the transducer also performed the vascular puncture while visualising the needle under ultrasound guidance. A high-frequency (6-13 MHz) linear array transducer vascular probe of the Turbo Sonosite USG machine was used.
In the SAX approach, the transducer was placed transversely over the neck, superior and parallel to the clavicle at the level of the cricoid cartilage. Once the vein was visualised, the needle attached with a syringe was introduced with gentle aspiration. The needle tip was visualised as a white dot on the screen (Table/Fig 2). In the LAX approach, the transducer was placed in a longitudinal axis over the neck, and once the vessels were identified, the needle was inserted in a cranio-caudad direction over the collapsible vein just underneath the footprint of the probe (Table/Fig 3).
In the M-OAX approach, after obtaining a SAX view of the vein, the transducer was rotated 30° counter-clockwise medial-cephalad to the lateral-caudal direction (Table/Fig 4) (6). The needle was inserted and advanced in the plane of the ultrasound probe after vein identification. When the needle entered the vein as visualised on the ultrasound screen, venous blood was aspirated, and a guidewire was passed into the vein. The venous placement confirmation of the guidewire was done by visualising the guidewire in the lumen of the vein using USG, thereafter the needle was retracted. Continuous ECG monitoring was done to look for any arrhythmias. The tract was dilated, and the catheter was threaded over the guidewire following which the guidewire was removed. Backflow in all three ports was confirmed, and the catheter was secured with sutures. The catheter tip position was confirmed on a chest X-ray, and complications pertaining to the procedure per se were documented.
The following parameters were observed in the study:
Primary outcome:
• First needle pass success (yes/no)-considered successful upon aspiration of venous blood.
Secondary outcomes:
1. Number of needle passes-up to four needle passes were allowed, after which it was considered a failure, and an alternate technique was adopted.
2. Venous Access Time (VAT)-the time from the start of the insertion of the introducer needle to the return of venous blood.
3. Guide wire insertion time-the time from the start of the insertion of the needle until crossing the second marker of the guide wire.
4. Catheterisation time-the time from the start of the insertion of the needle until the placement of the catheter and confirmation of blood aspiration in the ports were noted.
5. Complications-Carotid artery puncture, haematoma formation, arrhythmias, pneumothorax, and haemothorax, if any, were noted.
Statistical Analysis
The Statistical Package for Social Sciences (SPSS) program, windows version 23.0, was used for statistical analysis. Continuous variables are presented as mean±SD, and categorical variables are depicted as absolute numbers and percentages. Continuous variables such as VAT, guide wire time, and catheterisation time, which are normally distributed, were compared using Analysis of Variance (ANOVA) test. The Chi-square test was used for the analysis of categorical variables. A p-value <0.05 was considered statistically significant.
Results
The demographic data, including age, gender, and body mass index of the participants in all three groups, were comparable (Table/Fig 5). The average age of the participants in all groups was over 50 years.
First pass success was observed in 55 (96.49%), 53 (92.98%), and 54 (94.74%) patients in Groups 1, 2, and 3, respectively, with a p-value of 0.703, indicating no statistically significant difference. The distribution of the number of needle passes among the three groups was similar. Significant differences were observed between the groups for mean VAT, guidewire time, and catheterisation time (p=0.001) (Table/Fig 6). Both Group 1 and Group 3 had statistically significantly shorter VAT, guidewire insertion time, and catheterisation time compared to Group 2. There was no difference regarding guidewire insertion time and catheterisation time, but there was a significant difference in VAT between Group 1 and 3 (p<0.001). Pairwise comparisons of VAT, guidewire insertion time, and catheterisation time are shown in (Table/Fig 7).
There were two cases of carotid artery puncture (3.5%) seen in Group 2 and none in the other groups, which was not statistically significant (p-value=0.132). Other complications such as haematoma, haemothorax, and pneumothorax were not noted in any of the three groups (Table/Fig 8).
Discussion
The study was conducted to evaluate the safety profile and ease of Internal Jugular Vein (IJV) cannulation using the M-OAX view compared to traditional approaches. The M-OAX view had a higher first pass success rate compared to the other approaches. Intergroup comparison between M-OAX and LAX showed statistically significant differences in terms of Venous Access Time (VAT), guidewire insertion time, and catheterisation time. Guidewire insertion time and catheterisation in M-OAX were comparable to the SAX approach, but VAT was not comparable. Therefore, the M-OAX view allows for faster venous access, which can be attributed to the ideal imaging of the IJV and carotid artery alongside and following the needle path until vessel penetration in a medial cephalad to lateral caudal direction.
Although the catheterisation time in the LAX group was longer compared to other groups, the difference was only a few seconds and hence not clinically significant. Therefore, it was concluded that the ease of cannulation was similar between the three groups. The American Society of Echocardiography and the Society of Cardiovascular Anaesthesiologists published recommendations in 2011 emphasising the need for ultrasound guidance during vascular access as most effective when used in real-time during needle advancement. The needle is observed on the screen and concurrently directed toward the target vessel, advanced to an appropriate depth, away from important surrounding structures (7). Also, simultaneous visualisation of the artery and vein, along with real-time tracking of the needle, keeps a novice clinician more comfortable with the M-OAX approach compared to other approaches. The authors observed a higher first-pass success rate compared to similar studies (4),(8),(9),(10), as they routinely use USG for central line insertion and are familiar with these approaches. The faster and easier access probably depends on the frequency of USG usage, user habituation, and comfort, which in turn may depend upon institutional protocols.
The first-pass success rate was higher in similar studies conducted by Lal J et al., and Kamalipour H et al., but was lower in the study conducted by Batllori M et al., (4),(8),(9). The VAT, guidewire insertion time, and catheterisation time in the study conducted by Lal J et al., were similar to the present findings. Only the guidewire insertion time was compared between the three groups in the study conducted by Batllori M et al., and they found that it was longer in LAX compared to the other groups, which was similar to these findings. The catheterisation time was slightly lower in the SAX and M-OAX groups in the study conducted by Kamalipour H et al., compared to the present study. The guidewire insertion time in SAX and M-OAX in the study conducted by Balaban O et al., was comparable to this study (10). The differences in the VAT and catheterisation time among the different studies could be due to familiarity with the USG machine and the approaches used. Difficulties in catheter insertion were also taken into account in the present study, unlike some studies where only the guidewire insertion time was compared. The novel technique of the M-OAX approach could be extrapolated to other sites of central venous insertion for easier access. Kurien M et al., compared three approaches, namely, the high (HA), conventional (CA), and the medial oblique approach (MA), to identify the best approach and head position for IJV cannulation. They also established and recommended that the medial oblique probe position with a 30° head rotation provides ideal real-time sonographic parameters for US-guided IJV cannulation (11).
Vascular injury, carotid arterial puncture, pseudo-aneurysm, haematoma formation, and venous air embolism are some of the complications associated with CVC insertion. The incidence of various complications ranges from 5 to 19% (12). In the present study, two cases of carotid artery puncture were seen in the LAX group and none in the other groups. Haematoma, haemothorax, and pneumothorax were not encountered in any group. Carotid artery puncture was noted in two patients in the LAX group in the study conducted by Lal J et al., Haematoma and bleeding were noted in one patient in the M-OAX group and two patients in the SAX group in the study conducted by Balaban O et al., (4),(10). There was no increased incidence of complications in the M-OAX approach overall. Hence, the M-OAX view is a safe technique for IJV central venous catheter insertion. Similar studies from the literature have been compared in (Table/Fig 9) (4),(8),(9),(10),(13).
Limitation(s)
There is a likelihood of operator bias in the present study as it is not possible to blind the operator about the approach used for ultrasound-guided IJV insertion. This study cannot be extrapolated to the paediatric age group as there will be anatomical differences. The present study did not note the incidence of posterior wall puncture. Obese patients and those with cervical trauma were excluded from this study. Hence, challenges faced in these anatomical constraints need further investigation.
Conclusion
Within the limitations of this study, it can be concluded that the M-OAX approach to USG-guided IJV cannulation had a higher first-pass success and faster catheterisation time when compared to traditional SAX and LAX approaches. It is also a safe technique. The advantages of both SAX and LAX are combined in the medial oblique access, making venous access easier and faster. It can be routinely included in our clinical practice.
Reference
|
| | 1. | Baidya DK, Chandralekha, Darlong V, Pandey R, Goswami D, Maitra S. Comparative sonoanatomy of classic “short axis” probe position with a novel “medial-oblique” probe position for ultrasound-guided internal jugular vein cannulation: A crossover study. J Emerg Med. 2015;48(5):590-96.
[ CrossRef] [ PubMed] | | 2. | Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162.
[ CrossRef] [ PubMed] | | 3. | Tang JX, Wang L, Nian WQ, Tang WY, Tang XX, Xiao JY, et al. Compare the efficacy and safety of modified combined short and long axis method versus oblique axis method for right internal jugular vein catheterization in adult patients (The MCSLOA Trial): Study protocol of a randomized controlled trial. Front Surg. 2022;9:725357. doi: 10.3389/fsurg.2022.725357. eCollection 2022.
[ CrossRef] [ PubMed] | | 4. | Lal J, Bhardwaj M, Verma M, Bansal T. A prospective, randomised, comparative study to evaluate long axis, short axis and medial oblique axis approach for ultrasound-guided internal jugular vein cannulation. Indian J Anaesth. 2020;64(3):193-98.
[ CrossRef] [ PubMed] | | 5. | Phelan M, Hagerty D. The oblique view: An alternative approach for ultrasound-guided central line placement. J Emerg Med. 2009;37(4):403-08. Doi: 10.1016/j. jemermed.2008.02.061. Epub 2008 Oct 1. PMID: 18829208.
[ CrossRef] [ PubMed] | | 6. | Dilisio R, Mittnacht AJC. The “medial-oblique” approach to ultrasound-guided central venous cannulation--maximize the view, minimize the risk. J Cardiothorac Vasc Anesth. 2012;26(6):982-84. Doi: 10.1053/j.jvca.2012.04.013. Epub 2012 Jun 9. PMID: 22683157.
[ CrossRef] [ PubMed] | | 7. | Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, et al. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011;24(12):1291-318.
[ CrossRef] [ PubMed] | | 8. | Kamalipour H, Shahbazi S, Derakhshan MM, Moinvaziri MT, Allahyari E. Comparison of US-guided catheterization of the right internal jugular vein using medial-oblique and short axis techniques. Int Cardiovasc Res J. 2015;9(4):210-15.
[ CrossRef] | | 9. | Batllori M, Urra M, Uriarte E, Romero C, Pueyo J, López-Olaondo L, et al. Randomized comparison of three transducer orientation approaches for ultrasound guided internal jugular venous cannulation. Br J Anaesth. 2016;116(3):370-76.
[ CrossRef] [ PubMed] | | 10. | Balaban O, Aydin T, Musmul A. Lateral oblique approach for internal jugular vein catheterization: Randomized comparison of oblique and short-axis view of ultrasound-guided technique. North Clin Istanb. 2019;7(1):11-17.
[ CrossRef] [ PubMed] | | 11. | Kurien M, Teo R, Zainuddin K, Azidin AM, Izaham A, Budiman M, et al. Ultrasound probe positions for internal jugular vein cannulation: A prospective study of different techniques. Clin Ter. 2021;172(4):278-83.
| | 12. | Rossi UG, Rigamonti P, Tichà V, Zoffoli E, Giordano A, Gallieni M, et al. Percutaneous ultrasound-guided central venous catheters: The lateral in-plane technique for internal jugular vein access. J Vasc Access. 2014;15(1):56-60.
[ CrossRef] [ PubMed] | | 13. | Baidya DK, Arora MK, Ray BR, Mohan VK, Anand RK, Khanna P, et al. Comparison between classic short-axis out-of-plane approach and novel medial-oblique in-plane approach to ultrasound guided right internal jugular vein cannulation: A randomized controlled trial. Acta Anaesth Belg. 2018;69:107-12. |
DOI: 10.7860/JCDR/2024/69660.19532
Date of Submission: Jan 17, 2024
Date of Peer Review: Feb 26, 2024
Date of Acceptance: Apr 11, 2024
Date of Publishing: Jun 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 18, 2024
• Manual Googling: Feb 28, 2024
• iThenticate Software: Apr 10, 2024 (22%)
ETYMOLOGY: Author Origin
EMENDATIONS: 8
|