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?

Design

• 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

Setting

• Single hospital in Spain
• April 2012 – March 2013

Population

• 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

Outcome

• 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

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

Strengths

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

Weaknesses

• 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

• [article] Randomized comparison of three transducer orientation approaches for ultrasound guided internal jugular venous cannulation
• [further reading] AAGBI Safer Vascular Access 2016
• [further reading] The oblique view: an alternative approach for ultrasound-guided central line placement

Metadata

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