Transpharyngeal Ultrasonography for Cannulation of the Internal Jugular Vein

Abstract

Complications due to internal jugular vein (IJV) cannulation are infrequent and rarely life threatening. However, inadvertent carotid artery puncture can lead to serious problems in patients who have atheromas or bleeding disorders or who are undergoing full anticoagulation therapy, as for cardiopulmonary bypass. An external vascular ultrasound technique, using a vascular probe positioned on the neck, has previously been described as an aid for IJV cannulation.1We have found useful in our practice an alternative method, using a transesophageal probe.During the past year, we selected 50 cardiac patients for whom jugular vein cannulation could present a risk. Patients who required monitoring with a transesophageal probe and who had carotid artery disease, previous carotid artery surgery, and difficult anatomy, such as unclear landmarks or no palpable venous pulse, were selected. The mean age of the patients was 72.3 ± 8.8 yr (median, 74 yr).Transesophageal echocardiographic monitoring is performed with use of a multiplane transducer and a Sonos 5500 imaging system (Hewlett Packard, Andover, MA). Induction of anesthesia and tracheal intubation are performed before insertion of the echo probe. A small towel is placed under the patient’s shoulders. The head is then extended and turned slightly to the side opposite the cannulation, and the patient’s arms are placed by his or her sides. The patient is positioned in a 25° head-down position. The ultrasound monitor is placed in front of the operator.The transesophageal echo probe is inserted 12–20 cm from the teeth. The tip is directed along the pharyngeal lateral wall, which is why we call this method transpharyngeal . The probe is then rotated laterally 15–20° until the cervical vascular bundle is seen. The view is a mirror image of that obtained from conventional vascular ultrasonography (fig. 1).A needle covered with a plastic hood is used to search the skin surface of the neck for the best site of cutaneous insertion to find the IJV, which is not pulsating and does not compress. The ultrasound probe is kept stable on a trolley. The operating field, the operator, and the devices are then prepared as usual under sterile conditions.The skin puncture site is that nearest the IJV, and the puncturing needle is directed away from the carotid artery. The needle is inserted at a 60° angle to the neck axis and directed to the middle of the vein while it is observed on the monitor. Insertion of the needle through the vein may be seen directly, or it may be seen indirectly as movement of the vein wall (fig. 1). Aspiration of blood in the syringe confirms the proper needle position. As the probe is left in place, no adjustment is needed to maintain the correct view.The IJV puncture was successful in 100% of the patients studied. No carotid punctures or other immediate complications occurred.Conventional ultrasound-guided cannulation of the IJV significantly improves the success rate, decreases the access time, and reduces the complication rate of cannulation.2–4Meta-analyses and a systematic review of control data from literature5–7were performed and suggested an advantage of ultrasonography in complicated cases and when access problems were anticipated.1,8At our institution, the widespread use of transesophageal echocardiography, with its ability to provide a view of the vascular bundle of the neck, offers the anesthesiologist a simple way to aid in central venous cannulation, without any additive cost.Potential advantages of transpharyngeal ultrasonography in comparison with conventional ultrasonography in intubated patients undergoing transesophageal echocardiographic monitoring are as follows: Direct compression on the IJV by the external probe is not needed; other professionals do not need to be involved in the procedure; the operator’s hands are free; and the ultrasound probe, still working in the patient, can be used for other purposes.Further studies are needed to assess the reliability of this procedure for IJV cannulation, to determine its proper indications, and to compare this technique with other methods.* Azienda Ospedaliera Universitaria Careggi, Firenze, Italy. sebevi@tin.it