Comparison of two different approaches for internal jugular vein cannulation in surgical patients.LS Chudhari, US Karmarkar, RT Dixit, K Sonia
Department of Anaesthesiology, Seth G. S. Medical College, Mumbai, India., India
We compared the anterior approaches of internal jugular venous cannulation in 200 surgical patients, vis-Ă -vis the ease of cannulation and threading, number of attempts required and the incidence of complications following each route. The technique of posterior approach used in this study was found to have a higher rate of success in cannulation and lower rate of complication such as carotid puncture. The posterior approach was also a safe alternate route in obese or short necked patients.
Keywords: Adult, Cardiovascular Surgical Procedures, methods,Catheterization, methods,Comparative Study, Female, Human, Jugular Veins, surgery,Male, Perioperative Care,
Percutaneous cervical central venous cannulation is now common during perioperative care of major surgical patients, in intensive care monitoring, for long-term hyperalimentation and also for securing a central vein for rapid restoration of blood volume in a case of unexpected acute blood loss. Advantages of internal jugular vein cannulation relate to its consistent, predictable, anatomic location, its valve less course to the superior vena cava and right atrium, the possibility of repeated cannulation and low incidence of complications in experienced hands. We compared anterior and posterior approaches for internal jugular vein cannulation, to analyse the ease of insertion of cannulae, complications that arise and any other advantages of each route.
The internal jugular vein begins at the jugular foramen as a continuation of the sigmoid sinus and drains the skull, brain, superficial parts of face and much of the neck. After receiving tributaries, it joins the subclavian vein to form the brachiocephalic vein on both sides; which further unite to form the superior vena cava. The jugular vein forms a dilatation called the superior bulb at its upper end and the inferior bulb, just above its termination. Above the inferior bulb, the internal jugular vein contains a pair of valves.
Relation to Carotid: The internal jugular vein lies posterior to the internal carotid artery in the uppermost part of its course, but later lies lateral to it as it passes down. At the base of the neck, it becomes anterolateral to the common carotid artery and crosses in front of the sub-clavian artery to join the subclavian vein.
Surface anatomy: The internal jugular vein is represented in surface projection by a broad band from the ear lobule to the medial end of the clavicle.
Selection of patients
Two hundred patients undergoing open heart surgery were selected for the study. Ethics Committee’s sanction and patient’s informed consent were obtained for the procedure. Paediatric patients and those who were for closed heart surgery and other minor procedures were not included in the study. After examination of patients, those who had neck infection, history of neck surgery and gross pulmonary infection were excluded from the study. A note was made of short neck or gross pulmonary pathology. The selected 200 patients were divided into two random groups of 100 each and the anterior approach and posterior approach for cannulation of the internal jugular vein was tried out separately in these two groups.
16 G and 18 G cannulae made of radio-opaque teflon were used for puncture. The length of the cannulae used was 51 mm (Angiocath, Becton Dickinson Co., USA) and 44 mm (Jelco, Johnson and Johnson, Medi Calkk, Japan). Triple lumen catheters were used in 23 cases. The length of the catheter was 70 cm and the length of the introduction cannula was 55 mm, the vessel dilator was 10 cm long.
Techniques for cannulation
Anterior Approach: The patient was administered general anaesthesia and later given 15-20 degree Trendelenberg position. To distend the internal jugular vein the neck was fully turned to the left side. A rolled up towel or bolster was placed between the scapulae to extend the head and accentuate the landmarks. The right half of the neck was prepared with Povidone iodine and spirit from ear-lobe to nipple and then draped. The triangle formed by the two heads of the sternomastoid was identified by careful palpation [Figure - 1]. The carotid artery at the medial end of this triangle was also identified. At a point approximately two to three fingerbreadths above the clavicle, near the apex of this triangle, the skin puncture was made at 30? to the skin with a cannula (having a 5 or 10 ml syringe attached to it). The direction of the tip of the cannula was towards the ipsilateral nipple. With constant aspiration, the needle was slowly advanced till ‘2 tissue-pops’ at the prevertebral fascia and the vein-wall were felt and dark blood was aspirated when the vein was entered. The stylet was withdrawn slightly and the cannula was then freely advanced into the vein. The stylet was then fully withdrawn and an intravenous running drip, which was free of air, was attached to the cannula. Free return of blood was confirmed by lowering the fluid reservoir. The hub of the cannula was anchored with 2 sutures.
Posterior approach: After administering general anesthesia in the 30-40 degree Trendelenberg position, head was turned to the left side and shifted slightly towards left so that the sternocleidomastoid was clearly visible as a straight muscle. The external jugular vein remains well distended and is seen to cross the sternocleidomastoid. The neck was prepared and draped as described earlier. The point where the external jugular vein crosses the posterolateral border of sternocleidomastoid was punctured with the cannula tip [Figure - 1]. Lifting up of the body of the sternocleidomastoid the cannula was then advanced flush with the skin under the posterolateral border of the sternocleidomastoid in a direction pointing towards the ipsilateral sternoclavicular joint. When dark blood was aspirated, the stylet was slightly withdrawn and the cannula was threaded in fully. Removal of stylet was then followed by connection to a free running fluid line. Upward shift of the fluid level with hepatic compression and back flow with lowering of the fluid reservoir confirm position of the cannula. The cannula was anchored with 2 sutures.
Monitoring during cannulation
By both techniques any swelling, pulsation, haematoma formation, extravasation of fluid were looked for. Accidental carotid puncture as evidence by bright red coloured pulsatile flow was looked for.
Post operative parameters
An X-ray chest was done in the recovery room (if ICD had not been put in) to look for evidence of pneumothorax.
Local swelling, redness, pain, infection, limitation of neck movements etc. were noted.
Catheter kinking, dislodging etc. were looked for.
Catheter tips were sent for bacteriological study once they were removed.
Duration of cannulation was noted.
Maximum age incidence of patients was between 20-40 years. There was no significant difference in the sex distribution of patients considered for each route of cannulation. Surgical procedures done on patients with each of the two routes of cannulation did not differ significantly in number with maximum number of cases in both groups falling in the category of valvular surgery. Other surgeries performed were coronary artery bypass surgery and congenital heart disease correction.
Incidence of successful cannulation
Successful cannulation was taken as those by 1) First or second attempt, 2) Threaded in with or without guide wire, 3) No arterial puncture. The incidence of successful cannulation increased as the number of cases done using the same technique increased. (Shown in [Table - 1]).
Analysis of ease of threading
In [Table - 2], it is seen that 90.5% cannulae were easily threaded by anterior approach and 95.8% by posterior approach, which is statistically significant.
Analysis of ease of cannulation in relation to weight
As seen in [Table - 3], there is significantly higher incidence of successful cannulation by posterior approach (97%) in the higher weight group and obese patients compared to anterior approach (75%) (i.e. 0.05 by Chi-square test). There is also a significant decrease in the number of carotid artery puncture using posterior approach (3.1%) compared to anterior approach (16.6%). There is no significant difference in complications or ease of cannulation in lower weight groups, using any of the two approaches. As seen in [Table - 4], the incidence of carotid puncture and haematoma formation is more by anterior approach. No evidence of local/focal infection was found in any of the 200 patients.
This study compared the widely popular technique of, anterior approach for cannulation of the internal jugular vein to the posterior approach; by studying 100 patients by each technique vis-ŕ-vis the successful cannulations, ease of cannulation and the complications of each. First widely described by Brinkman et al, the posterior approach moves the point of entry higher up in the neck thus providing a longer length of vein for cannulation and avoiding the dangers of haemothorax, pneumothorax and carotid puncture. Our method of cannulation was modified from the original Brinkman method by giving 40 degree head low and no bolster below the shoulders, so that a technique without disturbing the intraoperative position of the patient could be devised. Another modification was that the bulk of the sternomastoid muscle was also lifted before puncturing the vein so that this helps to go flush with the posterolateral border of the muscle.
[Table - 1] shows that success of cannulation improved with experience and expertise, whatever the technique used. The ease of threading [Table - 2] was significantly more in posterior approach (95.8%) compared to anterior approach (90.5%). Guide wire also had to be used in 7 cases by anterior approach as compared to 3 cases by posterior approach. Furthermore, it was found that in patients with low central venous pressure leading to poor back flow after cannulation; gentle hepatic compression succeeded in pushing the column into the intravenous line and was a reliable confirmation of successful cannulation.
Cannulation was difficult and carotid punctures were more (16.6%) in obese patients, [Table - 3]; by anterior approach. Rate of carotid puncture was overall higher by anterior approach (5.0%) as compared to posterior approach (2%). This is because by anterior approach, palpation of the landmarks i.e. the heads of the sternocleidomastoid is difficult in obese patients and if carotid pulsations are not gently palpated, the anatomy of the neck can be distorted and hence results in accidental carotid puncture by anterior approach.
In contrast to this, the posterior approach needs identification of only the main bulk of the sternocleidomastoid muscle. The external jugular vein, which was the other landmark, could be identified easily by the Trendelenberg position. Therefore, there was no significant difference in the success of cannulation in non-obese and obese patients and incidence of carotid puncture was also drastically reduced in obese patients (3.1%). The overall incidence of carotid puncture was also lower (2.0%) by the posterior approach.
In all cases of carotid puncture, the cannula was withdrawn and firm compression was applied. By anterior approach, compression is difficult against the clavicle and the haematoma formed was larger. No problems were encountered for a subsequent second puncture.
Another complication we came across was haematoma, which could develop rapidly following carotid puncture or develop slowly following multiple punctures on the vein due to difficult cannulation or threading. By the anterior method, there were 6 cases of haematoma, 5 of which were due to carotid puncture; but only 3 cases of haematoma by the posterior method, which could be due to the smaller number of carotid punctures by this route. All haematomas resolved completely within 24 hours without causing any further complication.
Wisheart et al reported a case of injury to the ascending cervical artery by the lateral approach (described by Jernigan et al) which led to persistent bleeding, extrapleural haematoma and lateral hemothorax leading to death. Brown et al have reported a case of chronic haematoma following percutaneous internal jugular vein cannulation which required surgical removal two months later.
In our study, one case of mediastinal infiltration resulted by anterior approach. The cannulation had been difficult and guide-wire had to be used for threading. The presence of the catheter inside the vein was confirmed by free back flow and hepatic compression; however, the tip must have extruded out of the vessel wall later and was noticed by the surgeon after thoractomy. Immediate removal of the catheter was followed by a postoperative X-ray chest, which showed no evidence of fluid collection.
Similar cases of mediastinal infiltration from extruded catheter were reported by Daily et al and Jernigan et al.
Pneumothorax has been reported as a complication of internal jugular vein cannulation,. The incidence of pneumothorax could not be assessed in patients with ICD put in postoperatively, however no x-ray evidence of pneumothorax was found in any of the other cases.
Displacement of the cannula leading to decannulation, kinking, and inadequate CVP monitoring was noted in 6 cases in anterior group and 8 cases in posterior group. Most of these occurred in the first twenty-five cases and were due to imperfect suturing of the cannulae hub to the skin. In some cases, sutures became loose and cannulae slipped out and kinked at the junction between the hub and intravenous position. Proper precautions could be taken later to fix the cannulae thus resulting in reduction of these complications.
Mild thrombophlebitis was usually associated with cases where cannulation was for 48 hours or more and was noted in 8 cases in the anterior approach group and 7 cases in the posterior group. There were no cases of moderate or severe thrombophlebitis. There were no cases of local or focal infection at the cannulation site and no organisms were seen in the catheter tip cultures. The subjective discomfort on neck movement was less in patients cannulated by posterior approach, as the cannula was not anchored to the muscle.
Two hundred cases for open heart surgery were selected and randomly divided in to two groups of 100 each. In these patients, we compared the anterior approach with the posterior approach. We made two modifications from standard textbook descriptions in case of posterior approach.
Instead of 20 degree Trendelenberg position along with bolsters below the shoulders; we have given 30 to 40 degree Trendelenberg position and we have routinely lifted-up the sternocleidomastoid muscle before vene-puncture.
From our study, we found that for patients with average weight and build, both anterior and posterior approaches were equally feasible and useful; and experience and expertise in each of these routes improves the results. In obese, short necked patients and patients with thyroid swelling or scoliosis, posterior approach provides a safe alternate route. After venepuncture, threading was easier with posterior approach. When central venous pressure was low, the slow back flow, which resulted after cannulation, could be improved with hepatic compression.
After accidental carotid puncture, it was easier to apply pressure with posterior approach. Incidence of thrombophlebitis or injection rate did not differ with the approach used. The subjective discomfort on neck movement was less in patients cannulated by posterior approach, as the cannula was not anchored to the muscle.
We conclude that internal jugular vein cannulation is a simple and safe means of access to a central vein. The incidence of complications such as carotid puncture is less and cannulation is easier in obese, short-necked patients and in cases of pathology in lower part of neck with posterior approach as compared to anterior approach.
We thank the department of Cardiothoracic surgery for their co-operation in conducting this study.
[Figure - 1][Table - 1], [Table - 2], [Table - 3], [Table - 4]