A randomized trial of internal jugular vein cannulation: the ultrasound guided technique versus the landmark technique.

Placement of a central venous catheter (CVC) for surgery is used for
hemodynamic monitoring and venous access. Most often the right internal jugular
vein (RIJV) is used. The RIJV is preferred over the left-sided internal jugular
vein because cannulation of the left jugular vein is more difficult and
associated with a higher complication rate. The most common mechanical
complications during central venous cannulation are arterial puncture, hematoma
formation, hemothorax and pneumothorax. Since the late 60s many different
anatomic landsmark-guided techniques for internal jugular vein puncture have
been described but in spite of improvement of the landmark technique the
complication rate is still as high as 19%. The ultrasound-guided technique has
significantly decrease this complication rate. The reason why this technique
isn*t the *golden standard* for internal jugular vein cannulation is because
of the impracticality. The correct equipment is needed (eg ultrasound device,
sterile sheath for the transducer) and a well trained operator to perform the
procedure. Besides these features, scepticism say that there are studies which
prove that there isn*t any difference between ultrasound-guidance and the
landmark technique with respect to complications or success rate. Nevertheless,
the majority of the studies, whether it*s in a critical care setting or
elective surgery, say that ultrasound guidance is the safest way to perform
right internal jugular vein cannulation.
Studies suggest that one of the problems of the ultrasound technique is a lack
of experience. In this study we attempted to determine if there was any
difference between cannulation of the RIJV using the blind landmark technique
or the ultrasound technique performed by a trainee in (his/her second year of
education) with supervision of an anaesthesiologist.

In this study we attempt to determine if there is any difference between
cannulation of the RIJV using the blind landmark technique or the ultrasound
technique performed by a trainee in anesthesia (in his/her second year of
education) with supervision of an anaesthesiologist.

For this study we are randomly assign 216 patients to cannulation of the right
jugular vein by ultrasound guidance or by using the anatomic landmark method
followed by an ultrasound check after placement of the cannule. Only patients
who will undergo elective surgery are included. Exclusion criteria are <18
years of age, coagulopathy (with INR > 1.5, activated partial thromboplastine
time >1.5 and platelets < 50.000mm3), neck or head surgery in the past,
radiation therapy of the neck, local infection of the skin, known thyroid
pathology and skeletal deformities. All punctures are performed by a trainee in
anesthesia in his second year of training.

The blind technique
All procedures are performed using an aseptic technique: cleaning the skin with
chlorohexidine 0.5% in alcohol 70% and sterile drapes around around the
puncture place. The operator wear a sterile gown, cap, mask and sterile
handgloves. Patients are placed in a 15º-30º Trendelenburg position with the
head rotated to the left at a 30º angle. After correct positioning of the head,
the triangle which is formed by the sternocleidomastoid muscle, and the
clavicular and the sternal head are identified. The operator places the index
and middle finger of his left hand on the carotid artery and 1 centimeter
lateral to the carotis artery the needle will be advanced through the skin to
the ipsilateral nipple. An 18G-gauge needle is used connected to a 10 mL
syringe.(Arrow-Howes; Arrow international, Reading, USA). After the RIJV is
punctured a guidewire is placed into the RIJV. A triple lumen (8,5 Fr.)
indwelling catheter is placed using the Seldinger technique. After placing of
the cannule the correct positioning of the cannule is checked by ultrasound.

The ultrasound technique
All procedures are performed under the same conditions as described with the
blind technique. The ultrasound examinations are performed with a 12-3 mHz
broadband linear transducer (L12-3, Philips Ultrasound, Bothell, USA).With the
two dimensional ultrasound imaging we measure the depth of the jugular vein to
the skin, the diameter of the jugular vein and the carotid artery and the
distance between the puncture place of the needle to the jugular vein.
According to Cavanna et al. we will use *the three-handed method*. The jugular
vein is visualized using the *out of plane technique*. When the jugular vein is
in the middle of the monitor the operator starts the puncture while the
assistant facilitate the procedure by holding the probe to the skin. The needle
is passed through the skin perpendicular to the probe in a 30º angle in
relation to the skin. The procedure is performed under continuous vision until
the needle punctures the jugular vein and the syringe is filled with blood.
Then a guidewire is placed into the vein and confirmation of the correct place
of the guidewire is obtained by checking whether the guidewire is in the
correct lumen of the jugular vein by using the *in plane technique* in which
the probe was rotated in a parallel position with the jugular vein. The needle
is removed and the triple lumen catheter is placed over the guidewire into the
jugular vein.

A final verification of the correct CVC positioning is obtained after the
connection to a pressure transducer. In both groups following surgery, a
x-thorax is made to exclude a pneumo- or hematothorax and to confirm the
correct positioning of the CVC.

In both groups demographic characteristics are recorded including gender,
height, weight, BMI and type of surgery. We collect data about neck movement
and sternomental and thyromental distances. From the ultrasound images we
collect the measurements of the diameter of both carotid artery and the RIJV,
the surface area of both the carotid artery and the RIJV, the depth of the
anterior border of the jugular vein to the skin, the place where the needle
punctures the jugular vein (measured from the left side of the jugular vein)and
the position of the jugular vein in relation to the carotid artery. At the end
of the procedure the distance between the puncture and the clavicula is
measured.

None