Article, Radiology

Short versus long axis ultrasound guided approach for internal jugular vein cannulations: A prospective randomized controlled trial

a b s t r a c t

Objectives: Ultrasound-guided internal jugular vein cannulation is a standard procedure performed in ICUs worldwide. According to the guidelines, the short-axis approach is recommended over the long-axis approach for IJV cannulation. Double-operator cannulation is more convenient for the said procedure. However, the guide- lines favor single-operator cannulation due to limited trials. We hypothesized that double-operator long-axis cannulation will be faster and have fewer complications than double-operator short-axis cannulation.

Methods: This was a prospective, randomized trial of patients who needed central venous catheterization in the intensive care unit. The eligible patients were randomized into two groups. In one group, the short-axis view by two operators was used for cannulation, and the long-axis view by 2 operators was used in the other group. The time elapsed from skin puncture to guide-wire insertion.

Results: The central venous catheter was placed by ultrasound guidance in all 100 patients. No significant differ- ences were observed in the patient characteristics between the two groups. The mean time of insertion was 74.2

+- 110.1 s with the short-axis approach compared with 70.3 +- 97.3 s with the long-axis approach. The frequency of complications was also significantly lower with the long-axis approach.

Discussion: The long-axis view for IJV cannulation has similar insertion and procedure timings to the short-axis

view. However, the complication rate and number of needle punctures required were less with the long-axis view than with those with the short-axis view.

(C) 2019

Introduction

central venous cannulation is a common procedure in Intensive care units . Prior to using bedside, Point-of-care ultrasound de- vices, the surface landmark-guided blind technique was used to insert central venous catheters . The latter approach was associated with many complications [1-3]. The US technique was first reported for internal jugular vein cannulation in the 1980s [4]. The development of portable lightweight US machines has practicalized its routine use in CVC insertion. The Society of Critical Care Medicine (SCCM) has

? Reprints may be ordered financial support used for the study, including any institutional departmental funds: None.

* Corresponding author at: Plot No. 521, Saheed Nagar, Bhubaneswar, 751007, India. Department of Anaesthesiology, IMS and SUM Hospital, Bhubaneswar, Odisha 751014, India.

E-mail address: [email protected] (S.B. Mishra).

proposed guidelines for the use of US in CVC insertion [5] that recom- mend the short-axis view over the long-axis view during visualization for IJV cannulation.

Two different real-time, two-dimensional US techniques can be employed for venous access–the long-axis and short-axis approaches [6]. Very few studies have comparison the long-axis versus short-axis approaches, and the evidence of the superiority of one method over the other is not yet established. The main differences between the tech- niques are that the former allows direct visualization of the needle and vein, whereas the latter allows visualization of the structures surround- ing the vein. The procedure of placing central venous catheters under US guidance is easier if performed by two operators, where one helps visu- alize the US image while the other inserts the line. Studies regarding the number of operators needed for better and quicker placement of CVCs has not properly elicited in the literature. IJV cannulation is faster in the short-axis view because it takes time to focus the vein in long axis and the target area is smaller. The advantage of the long-axis approach

https://doi.org/10.1016/j.ajem.2019.06.010

0735-6757/(C) 2019

732 A. Rath et al. / American Journal of Emergency Medicine 38 (2020) 731734

is that real-time visualization of the needle during cannulation may help to reduce complications [5].

We hypothesized that the two-operator long-axis approach will have faster cannulation and lower complication rates than the two- operator short-axis approach because of better visualization of the needle.

Materials and methods

Study population

This prospective randomized clinical trial was conducted at the Medicine Intensive Care Unit (MICU) (n = 9 beds) of the IMS and SUM Hospital, Bhubaneswar, Odisha, India. The study protocol was ap- proved by the Local Ethics Committee (Letter no. 16368 report n.5/13) and was registered in ClinicalTrials.gov (ID: NCT03130660) [7]. The study was conducted from January 1, 2017 until December 31, 2017. Patients who needed a CVC and gave consent for inclusion in the trial were randomized. Twenty-five patients were not included be- cause they required emergency CVC placement. A flow diagram of the study according to the CONSORT 2010 statement is shown in Fig. 1.

Methods

All CVC insertions were performed after admission to the intensive care unit (ICU). The decision to perform CVC insertion was made by the physician on duty and was not involved in the study. Patients were randomized to the short- or long-axis approach using a computer-generated random-numbers table. The randomization was centrally performed in the hospital pharmacy. Once the patient was in- cluded in the study, the allocation was communicated by phone call. Each cannulation was performed at the patient’s bedside by one of the two anesthesiologists, both of whom were not involved in this study and with 3-years of experience in US-guided central venous cannula- tion. They had similar experience in short- and long-axis cannulation (N150 procedures/year, 50% short- and 50% long-axis). We used non- tunneled triple-lumen 7F, 20-cm-long CVCs (CS-25802; Arrow Gard Blue(R); Teleflex Medical IDA, Business and Technology Park, Athlone, Ireland). The site of cannulation was the Right internal jugular vein. If the said site was not accessible, the patient was excluded from the trial.

US technique

The skin of the anterior and lateral neck was prepared using antisep- tic solution and was draped. The ultrasound probe used was a

Fig. 1. CONSORT flow diagram.

A. Rath et al. / American Journal of Emergency Medicine 38 (2020) 731734 733

6-10 L38 MHz linear transducer SonoSite Titan unit (SonoSite(R); Micromaxx, Bothwell, WA, USA). The probe was covered with a sterile sheet, and sterile ultrasound gel was applied to both the inside and out- side of the sheet.

Short-axis technique

An axial (cross-sectional), real-time image of the internal jugular vein was obtained by placing the transducer in a transverse orientation on the patient’s neck at the level of the cricoid cartilage. The needle was inserted at 30 degrees to the vertical, towards the vein with gentle aspi- ration on the attached syringe. US was performed by a resident in anes- thesiology who had training in US for at least 3 months, while the operating anesthesiologist used his dominant hand to advance the nee- dle. Once the venous blood was in the syringe and the guide-wire inserted, the US probe was removed.

Confirmation of guide-wire placement in the internal jugular was performed by rescanning the vein in both the long and short axes.

Long-axis technique

US was performed by a resident in anesthesiology who had training in US for at least 3 months. An axial (short-axis) view was initially ob- tained. The probe was centered on the internal jugular vein and rotated through 90 degrees clockwise, resulting in a long-axis image of the vein. The needle insertion point was directly underneath the most proximal end of the ultrasound probe. The needle was inserted at 30? to the ver- tical and towards the vein with gentle aspiration. Venous access was confirmed by visualizing the needle’s entry into the vein and by aspira- tion of venous blood in the syringe. Next, we performed guide-wire in- sertion, which was confirmed by rescanning the vein in both the long and short axes. An observer unskilled in ultrasound guidance who was unaware of the group allocation observed the procedure and recorded the following information:

insertion time–defined as the time in seconds from skin puncture to guide-wire insertion
  • procedure time–defined as the time in seconds between the start of US scanning to the fixing of the catheter on the skin
  • First puncture with a single-pass success rate–defined as the first puncture success rate without redirecting the needle
  • Number of skin punctures
  • Rate of complications–i.e., Arterial puncture, hematoma, catheter misplacement, pneumothorax and hemothorax.
  • The primary outcome was the difference in the insertion time, and the secondary outcome was the difference in the procedures, first punc- ture with a single-pass success rate, number of skin punctures and rate of complications.

    Statistical analysis

    Sample size was calculated assuming a mean insertion time of 40 s as per the Chittodan et al. study in the short-axis group and approxi- mately 35 s in the long-axis group [8]. Almost 49 patients per group

    Results

    We successfully performed central venous cannulation in all 100 pa- tients, with no switchovers between groups. No significant differences were observed in the patient characteristics between the groups (Table 1). The mean time of insertion (i.e., time from skin puncture to guide-wire insertion) was 74.2 +- 11.1 s in the short-axis approach com- pared with 70.3 +- 10.5 s in the long axis approach (Table 2).

    The total procedure time was longer in the short-axis approach (369

    +- 193.1 s) than in the long-axis approach (332 +- 111.8 s), but the dif- ference was not statistically significant (Table 2). The number of at- tempts/needle pricks needed to cannulate was significantly fewer in the long-axis approach (Table 2). The frequency of complications was also significantly smaller in the long-axis approach (Table 2). No statis- tically significant difference was found in the timing and complication rate between the two operators.

    Discussion

    This prospective randomized clinical study revealed that internal jugular vein cannulation using the long-axis ultrasound approach had similar insertion and procedure times to the short-axis ultrasound ap- proach. The complication rates were lower in long-axis view, especially posterior wall puncture and extravasation. The usefulness of ultrasound guidance for internal jugular line insertion is well established [9]. Ultra- sound significantly improves the rate of first-puncture success and re- duces the rate of complications [10-12]. Pre procedure scanning before sterile precautions can identify thrombi, occlusion or any unfa- vorable anatomy, prompting the choice of another site for insertion. However, the desirability of using dynamic ultrasound is not excluded. Dynamic ultrasound showed a success rate with an odds ratio 53.5 times (6.6-440) higher than that for landmarks, whereas static ultra- sound revealed a success rate with an odds ratio only 3 times (1.3-7) higher than that for landmarks [13,14].

    Anatomical relationships are best visualized in the short axis. The advantage of the long axis is that the whole course of the needle through the tissue is seen. The guide-wire entering the vein in real time can be visualized. Visualization of the posterior wall is also a major advantage of the long-axis view on US. The long-axis view seems to have many ad- vantages while performing the procedure at the bedside. However, var- ious trials that have compared it with the short-axis approach have failed to show any difference.

    The main problem with the long axis is the narrow window in which the slightest disturbance results in loss of the venous image. The pres- sure of the inserted needle also tends to displace the vein from view. The short-axis view allows full visualization of small target vessels (i.e., infant veins and arteries) and identification of vital structures close to the target vessels, thus avoiding inadvertent puncture/damage to surrounding structures during the vascular puncture. The long-axis view may prevent puncture of the post wall of the vein due to continu- ous visualization of the needle tip [15,16].

    Table 1

    Baseline characteristics of the study population.

    were required to detect a difference in the ‘mean time to insertion’ be-

    Characteristics

    Short axis

    Long axis

    p value

    tween the groups, with an alpha error of 0.05 and a power of 80%. We

    Age (yrs.)

    57.1 +- 15.4

    56.2 +- 17.7

    0.76

    enrolled 50 patients in each group to consider any loss of data. The

    Sex (F/M)

    20/30

    20/30

    0.99

    data were expressed as the means +- SD, median, ranges, interquartile

    BMI (kg/m2)

    23.5 +- 4.2

    22.8 +- 5.1

    0.66

    ranges (IQR), the count number, or percentages, as indicated. Unpaired

    Student’s test, the Mann-Whitney test, Chi-squared test, or Fischer’s exact test was used where appropriate to identify differences between the groups for continuous or categorical variables. Statistical signifi- cance was assumed with a p value b0.05. Statistical analyses were per- formed using SPSS (v.20.0; SPSS, Chicago, IL, USA).

    Operator (1/2) 33/17 25/25 0.15

    All values are expressed as means +- standard deviation. Sex and Operator characteristics are expressed as numbers. F: female, M: male, BMI: body mass index, INR: international normalized ratio, aPTT: activated partial thromboplastin time.

    INR

    1.21 +- 0.29

    1.26 +- 0.19

    0.46

    aPTT (sec)

    32.1 +- 5.1

    32.2 +- 4.1

    0.76

    Platelets (x103 ul)

    182 +- 82

    192 +- 78

    0.56

    734 A. Rath et al. / American Journal of Emergency Medicine 38 (2020) 731734

    Table 2

    Comparisons between the short-axis and long-axis groups for primary and secondary outcomes.

    Limitations

    Because ours was a single center study performed by experienced

    Characteristics Short axis

    (mean +- SD)

    Time from puncture to guide-wire insertion (s)

    74.2 +- 110.1

    70.3 +- 105.2

    0.71

    Time from scan to suture (s)

    369.2 +-

    332.7 +-

    0.35

    193.1

    111.8

    First-pass success rate n (%)

    40(80)

    48(96)

    0.02

    number of needle sticks

    2.0 +- 0.5

    1.1 +- 0.9

    0.04

    Complications Hematoma

    2(4)

    2(4)

    0.03

    Arterial puncture

    3(6)

    2(4)

    Extravasation

    5(10)

    0 (0)

    Posterior wall puncture

    3(6)

    0 (0)

    No complication

    37(74)

    46(92)

    Long axis (mean +- SD)

    p value

    operators, these findings may not be extrapolated to novice or first- time users. The study population was also not very large, and we ex- cluded obese patients who might have a higher chance of difficult can- nulation. Future trials may be designed with larger sample sizes to verify these findings.

    Conclusion

    The long-axis view showed similar insertion and procedure timings to the short-axis view. The complication rate and number of needle punctures required were fewer with the long-axis approach than with the short-axis approach.

    All values are expressed as means +- standard deviation unless specified. SD: standard deviation.

    Chittoodan et al. [8], in a clinical study of 99 patients undergoing car- diac surgery, compared the short- and long-axis approaches for ultrasound-guided right internal jugular vein cannulation with respect to different indicators of success. The first-pass success rate was signifi- cantly higher in the short-axis group than in the long-axis group [48:1 (98%) versus 39:11 (78%) p b 0.006]. The procedural time was similar in both the groups. Fewer needle redirections were required in the short-axis group, and carotid artery puncture occurred only in the long-axis group.

    Mahler et al. [17] randomized 40 patients to undergo emergency IJV cannulation with either the short-axis or long-axis approach. They found that the short-axis technique required less insertion time than the long-axis technique. The successful cannulation rate was higher in the short-axis group, but this difference was not statistically significant. However, all the failed cannulations in the long axis were rescued suc- cessfully in the short axis.

    Stone et al. [18] conducted a study on phantoms, in which senior medical students and first-year emergency medicine residents with lit- tle to no experience with ultrasound-guided vascular access were asked to place lines following a 20-minute didactic lecture. All the subjects underwent both the long-axis and short-axis techniques. The long- axis approach to ultrasound-guided vascular access was associated with improved visibility of the needle tip during vessel puncture. The authors proposed that using the long axis can result in fewer complica- tion rates. Blaivas et al. [19] performed a similar study with emergency medicine residents using phantoms. New users of ultrasound cannu- lated faster with a short axis than with a long axis. The ease of use was rated similar in both approaches. Vogel et al. [20], in an experimen- tal study with emergency residents placing a central line in manne- quins, showed that the long axis was better in preventing complications and posterior wall puncture.

    We found that the time required for cannulation was similar in both groups, in contrast to previous trials (show faster cannulation with a short axis). We believe the results showed a similar Cannulation time because we had two operators for the long-axis view who helped the person puncturing to complete the cannulation without worrying about focusing the vein’s image. The number of needle punctures in long axis group was fewer in our study, probably because of better visu- alization of the needle tip. The complication rates were lower in the long-axis view. These finding were similar to the study by Vogel [20].

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