POCUS: Batllori



Randomized comparison of three transducer orientation approaches for ultrasound guided internal jugular venous cannulation

Batllori et al. BJA 2015 doi: 10.1093/BJA/aev399

Clinical Question

  • In patients undergoing internal jugular cannulation under ultrasound guidance, does the use of an oblique compared to short- and long-axis approach increase success rate and decrease complications?


  • Single centre, prospective, randomised study
  • Unblinded
  • Randomisation by computer-generated number list
  • Followed up until catheter removed with all tips sent for culture
  • Power calculation based on assumption of 60% first needle pass cannulation in Short Axis (SAX) group and to detect a 20% difference between the groups
    • alpha-level 0.05, 80% power
    • 70 patients per group required
  • Intention-to-treat analysis


  • Single hospital in Spain
  • April 2012 – March 2013


  • Inclusion:
    • 18 years and above
    • Indication for IJV cannulation
  • Exclusion:
    • <18 years
    • History of previous surgical intervention at the cannulation site
    • Presence of a CVC during the past 72 hours (in the same vein as the cannulation was planned)
    • Infection, haematoma or surgical emphysema close to the puncture site
    • Recent cervical trauma with present neck immobilisation
    • Altered haemostasis (INR >2, platelet count < 50,000)
    • Agitated or uncooperative patient
    • Cannulation planned to be performed outside of the surgical area
    • Urgent cannulation
  • 231 patients screened, 220 randomised

Common intervention

  • Performed by three anaesthetists
    • Structured training programme: 2 hour lecture, 1 hour beside teaching, 1 hour supervised practice using phantom
    • Previously had 10 successful cannulations in each of the three views
  • Linear array probe
  • Performed either in theatre or post-anaesthetic care unit
  • Full asepsis.
  • Real-time ultrasound guidance
  • Seldinger technique for CVC insertion
  • Chest radiograph performed to assess position of catheter and presence of complications

Short-axis (SAX)

  • Probe placed transversely over neck
  • Needle introduced in a plane perpendicular to long-axis of transducer

Long-axis (LAX)

  • Probe place longitudinally over neck
  • Needle introduced underneath footprint of probe following its long axis

Oblique-axis (OAX)

  • SAX first obtained
  • Probe rotated to a position midway between SAX and LAX view
  • Needle introduced underneath footprint of probe aiming from lateral to medial


  • Primary outcome:
    • First needle pass cannulation rate (needle pass was considered as any forward movement of needle without any backward movement, irrespective of skin puncture)
      • Higher 1st pass success rate in OAX vs LAX (OR 3.7, CI 1.71-8)
      • Higher 1st pass success rate in SAX vs LAX (OR 2.37, CI 1.16-4.86)
      • No difference between OAX and SAX
  • Secondary outcome:
    • Number of needle passes until successful cannulation
      • More needle passes required in LAX vs OAX
      • More needle passes required in LAX vs SAX
      • No difference between OAX and SAX
    • Cannulation time measured in seconds
      • Longer cannulation time in LAX vs SAX
    • Incidence of mechanical complications (including arterial puncture, posterior wall puncture, pneumothorax and haemothorax)
      • Higher complication rate in SAX compared to LAX and OAX
      • Commonest complication was puncture through the posterior wall
    • Incidence of catheter-related bloodstream infection
      • 2 in LAX group but not statistically significant

Screen Shot 2016-06-28 at 21.25.51

Authors’ Conclusions

  • OAX and SAX are better than LAX in terms of cannulation quality outcomes and that OAX is a safe and effective approach to performing IJV cannulation and should be encouraged


  • Comprehensive training programme for operator
  • Clear definition of what constitutes a needle pass
  • Analysis between operators


  • Small number of operators already experienced and accredited in ultrasound-guided IJV cannulation
  • Elective setting
  • Vast majority of insertions (87%) performed in anaesthetised patients

The Bottom Line

  • This study confirms the view that ultrasound-guided IJV cannulation is quicker and technically less demanding in SAX compared to LAX but is associated with greater risk of complication. OAX is a relatively less well-known approach which has the potential to combine the advantages of SAX and LAX but requires further evaluation and training.

External Links


Summary author: Adrian Wong
Summary date: 26 October 2016
Peer-review editor: Duncan Chambler

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