|Year : 2015 | Volume
| Issue : 1 | Page : 20-24
Use of Transthoracic Echocardiography Probe for Locating the Internal Jugular Vein to Assist Cannulation In Children and Its Comparison With the Standard Landmark Technique
Deepak K Tempe, Suruchi Hasija, Indira Malik, Akashkeep Singh, Upendra Hansda, CS Joshi, AS Tomar, Saket Agarwal
Department of Anaesthesiology and Intensive Care, and Cardiothoracic Surgery, G. B. Pant Hospital, New Delhi, India
|Date of Web Publication||27-Jan-2015|
Deepak K Tempe
Dean, Maulana Azad Medical College and associated GB Pant, LN and GNEC Hospitals, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Objectives: The objective was to verify the validity of transthoracic echocardiography (TTE) probe for guiding the central venous catheter placement and to ascertain whether the ultrasound (US) guidance is superior to the landmark technique in terms of success rate, procedure time, and complication rate. Design: Prospective, randomized. Setting: Tertiary care, superspeciality hospital, single Institute. Participants: Pediatric cardiac surgical patients. Interventions: The study included 105 patients <12 years age, randomized into two groups. In the control group (Group A), internal jugular vein (IJV) cannulation was performed by the conventional landmark technique. In the US group (Group B), the course of the IJV was marked on the skin surface before cannulation using a 3-8 MHz TTE probe. The success rate, number of attempts, cannulation time, and complication rate were compared in the two groups. Results: Overall success rate (right IJV cannulation performed within five finder needle attempts) (95.9% vs. 82.1%, P < 0.05) and first-attempt success rate (right IJV cannulation performed within one finder needle attempt) (77.6% vs. 53.6%, P < 0.01) were higher in Group A. The number of attempts to locate the vein with finder needle (mean 2.8 ± 2.5 vs. 1.6 ± 1.6, median in both groups 1.0, P < 0.01) and puncture needle (mean 2.0 ± 1.5 vs. 1.5 ± 1.0, median in both groups 1.0, P < 0.05) were more in Group B. The cannulation time was more in Group B (413 ± 317 s vs. 233 ± 164 s, P = 0.001). A sub-group analysis of children weighing >10 kg did not reveal any differences in the above parameters. Conclusion: The success rate of IJV cannulation in infants and children is not improved with US guidance. Significantly better success rate was observed with the landmark technique as compared with the US guidance. On sub-group analysis, this difference was not observed in children weighing >10 kg.
Keywords: Central venous cannulation, internal jugular vein, pediatric cardiac surgery, ultrasound, vascular access
|How to cite this article:|
Tempe DK, Hasija S, Malik I, Singh A, Hansda U, Joshi C S, Tomar A S, Agarwal S. Use of Transthoracic Echocardiography Probe for Locating the Internal Jugular Vein to Assist Cannulation In Children and Its Comparison With the Standard Landmark Technique. MAMC J Med Sci 2015;1:20-4
|How to cite this URL:|
Tempe DK, Hasija S, Malik I, Singh A, Hansda U, Joshi C S, Tomar A S, Agarwal S. Use of Transthoracic Echocardiography Probe for Locating the Internal Jugular Vein to Assist Cannulation In Children and Its Comparison With the Standard Landmark Technique. MAMC J Med Sci [serial online] 2015 [cited 2020 Jun 4];1:20-4. Available from: http://www.mamcjms.in/text.asp?2015/1/1/20/150055
| Introduction|| |
Central venous access via the internal jugular vein (IJV) is a standard practice during cardiac surgery. Traditionally, the IJV is cannulated blindly using surface landmarks. However, one earlier report has shown that ultrasound (US) can be useful and increase the chances of a complication free IJV cannulation.  During the last decade, US has been used for vascular access and it is recommended during vascular cannulation.  However, it is not widely available in India. Nowadays, transesophageal echocardiography (TEE) machine is available in the cardiac operating room. The transthoracic probe (that is available with these machines) with a frequency of 3-8 MHz can be used for localizing the IJV.
A few meta-analyses have concluded that for IJV cannulation in adults, using US guidance is more effective than the landmark technique. , Evidence for US guided central venous cannulations in children is limited. According to a document produced by the National Institute of Clinical Excellence (NICE) in 2002, US guidance is the preferred method of elective insertion of central venous catheters into the IJV of adults and children.  The results of few studies performed after these guidelines have been variable. ,,
In one study, TEE probe was used instead of a portable scanner to aid the IJV cannulation and shown to be beneficial in infants undergoing cardiac surgery.  However, there is no randomized controlled trial comparing the use of transthoracic echocardiography (TTE) probe for localization of IJV in pediatric patients with the standard landmark technique in the cardiac operating room. The authors used the TTE probe for localizing the IJV in order to assist its cannulation and compare it with the standard landmark technique.
| Materials and Methods|| |
After approval from the Institutional Ethical Committee, the study was carried out in 105 pediatric patients undergoing cardiac surgery. Written informed consent was obtained from the parents of the patients in the study. Patients with the following criteria were excluded from the study:
- Emergency surgery
- Previous cardiac surgery
- Local site infection
- Anatomical deformity, e.g., neck surgery, malignancy
- Burns at the site of insertion
- Bidirectional Glenn/Fontan surgery.
Using a computer-generated random number table, each patient was allocated to one of the two groups on the basis of the technique of IJV cannulation as follows:
Group A (Control group): Patients in whom IJV was cannulated by the landmark technique.
Group B (Study group): Patients in whom IJV was cannulated by US guidance, using a TTE probe.
All the cannulations were carried out using a 5 F triple lumen catheter after induction of anesthesia, endotracheal intubation, and initiation of mechanical ventilation with standard settings. The patient was placed in a 10-20° Trendelenburg position with the head turned to the left side. A rolled towel was placed under the shoulders. Standard aseptic precautions were followed in all patients.
Ultrasound examination was performed after induction of general anesthesia by the consultant anesthesiologist experienced in echocardiography. IJV cannulation was performed in the majority of cases by a consultant anesthesiologist in both the control and US group. Senior residents were allowed to perform the cannulation under supervision of consultants, in children >5-year-old or >10 kg weight. The intervention was taken over by the consultant in case of failure to locate the vein by the resident in the first three attempts.
The IJV was located at the apex of the triangle formed by the clavicle and the two heads of the sternocleidomastoid muscle. The fingers of the left hand were used to palpate the two heads of the sternocleidomastoid, the carotid pulse, and the IJV. The IJV was first located with a 22 G finder needle attached to a syringe held at an angle of 45° and directed toward the ipsilateral nipple. The finder needle was withdrawn, and the puncture repeated with an 18 gauge puncture needle. The catheterization was completed using the Seldinger technique.
A standard S8-3 TTE probe with a frequency of 3-8 MHz (HD11XE Philips; Philips Ultrasound, Bothell, WA, USA) was placed over the patient's right anterior triangle of the neck. US examination of the neck (probe set to 40-50 mm depth to optimize resolution) was performed with the use of acoustic gel. The IJV was visualized on both transverse and longitudinal sections [Figure 1]. IJV was identified as a thin walled and easily compressible structure by external pressure by the TTE probe lying anterolateral to the carotid artery (thick walled and non-compressible). In addition, pulse wave Doppler revealed a venous waveform. After identifying the vein, its projected course was marked on the overlying skin at two points, the upper point near the cricoid cartilage and the lower point close to the clavicle. The longitudinal section of the vein obtained at the center of the screen and the middle mark on the US probe was used for this purpose. By moving the probe along the line joining these two points, the entire course of the vein could be seen on the screen. These points served as a guide for cannulation, and the operator was advised to puncture the vein along this line. The vein was punctured at the upper point near the cricoid cartilage, and the catheterization was completed using the Seldinger technique.
|Figure 1: Ultrasound image showing longitudinal section (a) and transverse section (b) of the internal jugular vein (IJV: Internal jugular vein, CA: Carotid artery)|
Click here to view
Success was defined as the location of the IJV by the finder needle within five attempts. First attempt success was defined as the location of the IJV by the finder needle in the first attempt. Time to central venous catheter (CVC) cannulation was defined as the time taken from the insertion of finder needle till de-airing and flushing of all the three ports of the central line. The duration of US was defined as the time from placement of the probe on the neck till marking of the course of the vein on the skin. The number of attempts for the finder needle and the puncture needle, and complications (if any) were recorded.
Statistical package SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. The values were expressed as mean ± 1 standard deviation or median with an interquartile range. Qualitative data were analyzed by Chi-square test. Quantitative data were analyzed by Mann-Whitney test. A P ≤ 0.05 was considered significant. The power of the study to see a mean difference of 1 with standard deviation of 1.4 in number of attempts gave a sample size of 43/group at a confidence interval (CI) of 95% and power of 80%.
| Results|| |
There were 49 children in Group A (mean age 4.1 ± 3.6 years) and 56 in Group B (mean age 4.3 ± 3.7 years). The mean weight, height, body surface area, and sex ratio were comparable in the two groups [Table 1]. The surgical procedures performed in the two groups were similar [Table 2]. The most common procedure performed was intracardiac repair for tetralogy of Fallot, 55.1% in Group A and 62.5% in Group B followed by ventricular septal defect closure, 12.2% in Group A and 12.5% in Group B. The success rate of IJV cannulation in Group A was 95.9% which was significantly more than Group B, 82.1% [Table 3], P < 0.05]. The likelihood of success in Group A was five times than that of Group B (Odds ratio [OR] 5.11 with CI of 1.06-24.6). The first attempt success rate in Group A was 77.6% which was significantly more than Group B, 53.6% (P < 0.05). The likelihood of first attempt success rate in Group A was three times than that of Group B (OR 2.99 with CI of 1.28-7.02). The complication (carotid artery puncture was the only complication observed) rate in Group A (6.12%) was less than that in Group B (10.7%), but this difference was not statistically significant. The number of attempts with the finder needle was significantly less in Group A mean, 1.63 ± 1.59 versus 2.75 ± 2.54, P < 0.01, median value in both the groups 1.00 (P < 0.005). Likewise, the number of attempts with the puncture needle was significantly less in Group A, mean 1.49 ± 1.04 versus 2.02 ± 1.48 (P < 0.05), median value 1.00 (P < 0.015) in both the groups. The mean time to CVC cannulation in Group A (233.16 ± 164.4 s) was significantly less than Group B (413.16 ± 317.68 s, P < 0.01). The IJV was easily localized by the US in all the patients in Group B, and the duration of US was 160.39 ± 82.52 s. The central venous access via right IJV was achieved in all the patients in the study; except three patients in Group B (left IJV in two and right external jugular vein in one).
In a subgroup analysis in >10 kg group, there were no significant differences in the two groups, although the success rate was higher in Group A [90% vs. 83%, [Table 4].
| Discussion|| |
The present study showed a significantly better success rate of IJV cannulation in the landmark group as compared with the US group. In addition, the first attempt success rate and the number of attempts were significantly better with the landmark technique. However, there was no difference in the complication rates in the two groups. Thus, according to the present study, conventional landmark method was better than the US method using TTE probe for IJV cannulation in children.
It is expected that the US would improve the success rate of IJV cannulation. It has been used in three different ways. ,, The real-time method involves wrapping the US probe in a sterile sheath so that it can be manipulated in a sterile field by the operator. The operator visualizes the vein holding the probe in the left hand while he guides the needle into the vein under vision with his right hand. Once the needle enters the vein, the probe is removed, and the cannulation is completed using the Seldinger technique. In the static method, the US scanner is used to visualize the IJV so that its projection can be marked on the overlying skin, which then serves as a guide to cannulation. The Doppler US guidance involves utilization of audible sound from the flowing venous blood. The real-time method involves a great degree of hand-eye co-ordination and manual dexterity, especially in pediatric patients. In the present study, the static method was used mainly due to nonavailability of the sterile sheath which involves extra expense. All the three methods have been used in clinical practice, although there is a general tendency to prefer the real-time technique. The literature has not clearly demonstrated the superiority of US, and conflicting data have been reported. One meta-analysis that included three studies in infants confirmed a higher success rate with US for IJV cannulation,  although this evidence came from only one study.  While another, more recent meta-analysis performed in children and infants has shown that US guidance has no effect on both success rate and complications. 
One study has demonstrated the benefit of US with a success rate of 100% and no/less complication rate using real-time method,  while in a retrospective study, Leyvi et al. have demonstrated a significant improvement in the success rate using US, especially in children above 1 year of age or 10 kg weight. 
Some studies have failed to demonstrate any significant improvement in success rate with US guidance, but they demonstrated an improvement in the number of attempts and safety of central venous cannulation. For instance, Alderson et al. using static US technique demonstrated a decrease in the time required, number of attempts, and complication rate in the US group.  Similarly, Verghese et al. using real-time US showed that the use of US decreased the number of attempts, and the number of complications was less (although not statistically significant) when compared with the landmark group. 
Some studies even showed that the use of US had worse success rates than the landmark techniques. Grebenik et al. had poor success rates with real-time US group.  The authors reported a significantly better success rate and a lower complication rate with the landmark technique which was attributed to the experienced operators. Their poor success rates and higher complication rate with the US group were attributed to inexperience with the use of the US probe.
In the pediatric critical care setting, on evaluation of the use of real-time US in central venous cannulations, Froehlich et al. found no significant difference in the success rate between the landmark group and the US group, with the US group having a significantly higher complication rate.  They suggested that some children were on vasoactive infusions, and some of the venous cannulations were performed in an emergency which might account for poor success rate and higher complication rate in the US group.
One of the difficulties in evaluating the results of other studies is that different definitions for success and failure have been used. Verghese et al. have defined failure as duration more than 45 min or more than seven attempts or serious complication or carotid artery puncture with hematoma.  Grebenik et al. have defined failure as the inability to cannulate the right IJV and alternate site chosen.  Many studies have not even defined success or failure rates.
There has been a marked variation in the types and frequency of probes used. Some studies used site rite scanner probe ,, or sonosite  or even TEE probes.  None of the studies used a TTE probe which was used in the present study. The frequency of the probes used in the various studies varied from 6 MHz to 15 MHz. Our probe had a frequency of 3-8 MHz, that is, its highest frequency was toward the lower end of the range which is recommended for US guided cannulation. Nonetheless, we still utilized this probe because higher frequency probes were not available.
In the present study, it was found that the landmark technique was more useful for locating the vein than the US technique. The visualization of the IJV was easily possible in all the patients, however, the transthoracic probe was bulkier (2.3 cm × 1.5 cm) in relation to the neck of the child. This may have been a limiting factor in accurate surface marking of the IJV, especially in smaller children leading to decreased success rate in the US group. Therefore, subgroup analysis of children >10 kg was performed. The group >10 kg demonstrated no significant difference for all the evaluated parameters between the two groups. Most of the studies have used a probe with a frequency >7.5 MHz for the location of the IJV. Moreover, this technique was practiced for the first time in our setting, which may have been an additional contributory factor for the failure of US guidance.
The NICE guidelines recommend the use of US for central venous cannulation. However, the widespread failure to implement and follow NICE guidelines has been documented.  One of the important reasons for this is that the acquisition of new equipment requires funding and the staff needs to be trained to use the new technique. Another important reason for reluctance may be that, the use of US does not completely eliminate complications and to use it successfully, there is a long-learning curve. , Nevertheless, a new technology like US is likely to eventually find a place in clinical practice. The results of the present study highlight the need to perform future studies focusing on the best way to use the technique to achieve optimum success rate of IJV cannulation. While this is going on, basic training of cannulating the IJV using landmark technique should be imparted to all the trainees.
Transthoracic echocardiography probe was used for performing US to locate the IJV which is a very superficial structure and is best visualized with probes having a frequency >7.5 MHz. However, due to unavailability of a higher frequency probe, we utilized the TTE probe with a frequency range of 3-8 MHz. The bulkiness of the probe as well as unfamiliarity of the operator to use this technique for cannutation may have been additional factors for inferior outcome in the US group.
| Conclusion|| |
The success rate of central venous cannulation of IJV in infants and children was not significantly improved with US guidance using the TTE probe. Significantly better success rate was observed with the landmark technique as compared with the US guidance with the TTE probe, using a static method. On subgroup analysis, this difference was less apparent in the >10 kg group.
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[Table 1], [Table 2], [Table 3], [Table 4]