336 A Comparison of Anatomical Landmark vs Ultrasound Static vs Ultrasound Real-Time Technique for Internal Jugular Vein Cannulation

Abstract

Ultrasound-guided real-time technique (US RT) for internal jugular vein (IJV) access is the gold standard recommendation for IJV cannulation. Ultrasound static technique (US ST) (prelocation of IJV with ultrasound and marking the venipuncture site on the neck and cannulating with guidance skin marking) can also be used to cannulate IJV in most of the patients requiring IJV assess in the emergency department (ED) and Intensive Care Unit (ICU) with equal success rate, reduced complication, better field sterility, better utilization of resources, and with an overall lower cost. However, there are limited studies that compare US RT vs US ST for IJV cannulation for emergency access in India. None of the previous studies have taken into account the depth of IJV from skin, diameter of IJV, respiratory change in diameter of IJV and have associated it with the difficulty of the cannulation and final success rate. The objective of this study was to compare the success rates, complications and mean cannulation time using 3 techniques: 1)Ultrasound real-time (US RT) 2) Ultrasound static (US ST) and 3) Anatomical landmark (ALM) techniques (without ultrasound) for IJV cannulation. We prospectively enrolled patients presenting to an emergency department or ICU setting at a single tertiary care hospital in Southern India. Patients were randomized by closed envelope method to receive IJV cannulation by US ST or US RT or ALM by emergency department residents over a 2 year period. We measure the rate of overall success, first pass success rates, and mean cannulation time in each group. In addition, among the ultrasound groups, we compared success rates in complicated cases (increased depth of the IJV from skin, degree of respiratory variation of IJV diameter and the diameter of IJV). Setting and Design: A prospective, randomized, observational study was conducted at a tertiary care hospital. Statistical Analysis: We used SPSS 16 software and Sigma stat 3.5 version to analyze data. Using ANOVA and chi-squared tests, we analyzed differences in the mean number of attempts and time until success between all the three groups in our study. A p value of less than 0.05 was taken as significant. We enrolled a total of 120 patients in our study, with 40 patients in each group. Success rates were 100% in US RT, 77.5% in US ST, and 70% in the ALM group. There were no difference between first pass success rates between US ST and US RT groups; however, first pass rate was better in both groups as compared to the ALM group.There was no statistical difference between the three groups with regards to final success. Venous cannulation time was lowest in the US ST group, followed by the US RT group and longest in the ALM group. In difficult cannulation with IJV depth from the skin 1.1cm and above or with inspiratory diameter of IJV 0.7cm or less, the US RT group had 100% success rate compared to a success rate of only 10% in the US ST group (p< 0.001). Both US RT and US ST are superior to the ALM technique. Although US RT has better overall success rate than US ST, US RT requires adequate training, more time, sterile scanner manipulation, and more resources, which translates into increased overall cost than US ST. US ST has statistically similar success rate, reduced complication, and better field sterility in most patients where the cannulation of IJV was not difficult.