SIMPLIFIED ECHO-GUIDED INTERNAL JUGULAR VEIN PUNCTURE

Abstract

Introduction. Echo-guided cannulation of the right internal jugular vein (RIJV) provides a higher success rate and fewer complications than traditional landmark-guided techniques. [1,2] However, the echo-guided puncture needs a dedicated echo scanner (Site Rite[registered sign]) and/or sterile scanner manipulation, both of which may reduce the advantage of the echo-guided technique. We describe the "simplified" echo-guided puncture, in which echo images are only used to determine the site and direction of needle insertion, and IJV cannulation is performed in a usual manner without echo-guidance after sterile draping. This prospective randomized study was undertaken to compare the access rate and the incidence of carotid artery (CA) puncture by the simplified echo-guided technique with the landmark-guided technique. Methods. After institutional approval, 160 adult patients aged 27 to 89 undergoing general anesthesia and RIJV cannulation were prospectively studied. After induction of anesthesia and endotracheal intubation, patients were placed in 15[degree sign] head-down position with the head rotated 30[degree sign] to the left. Patients were randomly assigned to one of 2 groups. In Landmark group, RIJV puncture was performed using the external anatomical landmarks. In Echo group, the site and direction of needle insertion was decided and marked on the neck before sterile draping, referring to 2-D echo images of the RIJV and CA. Patients in Echo group were subdivided into 7.5-MHz group and 3.75-MHz group, in which a 7.5-MHz probe (PLF-703NT, Toshiba) and a 3.75-MHz probe (PSH-37LT, Toshiba) were used, respectively. In all groups, seeking puncture was performed with a 23G needle to localize the RIJV and to guide the following cannulation puncture. The number of finder needle passes for RIJV access and the frequency of CA puncture were compared among groups. Results. There were no significant differences among groups regarding age, height and weight. Although the 7.5-MHz probe allowed better visualization of the RIJV and CA than the 3.75-MHz probe, no significant differences were seen between these 2 groups regarding the number of attempts for RIJV access and the incidence of CA puncture. (Table 1)Table 1Discussion. The use of the echo for determination of the site and direction of needle insertion significantly decreased the number of needle passes for the RIJV access, regardless of the echo probe frequency. Most impressively, RIJV access was achieved on the first attempt in 92.5% (74/80) of patients in Echo group, which is no worse than the results reported in echo-guided cannulation (74-78%). [1,2] The incidence of CA puncture was also reduced in Echo group, although statistical significance was not reached. Along with the increased use of TEE in cardiac surgery, availability of echo imaging devices has also increased in cardiac anesthesia. The simplified echo-guided puncture could be used to facilitate IJV cannulation as an alternative technique of echo-guided cannulation when a dedicated echo scanner is not available.