Central venous catheterisation is a commonly used method of administering drugs and measuring central venous pressure (CVP) during major surgery. In 1969, English et al.1 were the first to describe the use of internal jugular vein catheterisation for this purpose. Since then, the right internal jugular vein (RIJV) has become a popular route because of easy access and frequent remoteness from the surgical field.2
Gordon et al.3 reported that the success rate for central vein catheterisation correlates with the cross-sectional area of the vein, and that an increase in the diameter of the vein would facilitate the catheterisation process and reduce potential side-effects. The Valsalva manoeuvre can increase the cross-sectional area of the internal jugular vein (IJV)4–6 and, in anaesthetised patients, a positive intrathoracic pressure or positive end-expiratory pressure could have the same effect.7,8 However, the practicality of this has not been adequately tested.
The purpose of this study was to determine the most suitable of four different positive airway pressures (PAPs) for RIJV catheterisation and to identify any complications that may arise.
This study was approved by the Ethical Committee of the Second Affiliated Hospital of Jiaxing College (Ethical Committee number CZJ 129; Chairperson Professor Liqin Jiang) on 4 March 2009. All patients provided prior written informed consent.
An arbitrary number of 240 American Society of Anesthesiologists’ (ASA) physical status class I–III patients from two medical centres, aged 19–81 years, scheduled between March 2009 and August 2010 inclusive for gastrointestinal tract surgery under general anaesthesia, were enrolled into this study. They were randomised by means of a random number table into four groups of 60 each to undergo RIJV catheterisation at four different PAPs: 0 (1 cmH2O = 0.098 kPa, group A); 15 (group B); 20 (group C); and 25 cmH2O (group D). Those with a history of haematological disease, external neck injury, previous RIJV catheterisation, severe cardiovascular disease, RIJV thrombosis, injection-site infection, pneumothorax or pulmonary bulla were excluded.
After induction of anaesthesia each patient was placed in a 15° Trendelenburg position without using pillows and with the head rotated 30° to the left. A two-dimensional ultrasound machine (Teratech, Burlington, Massachusetts, USA) with a 7.5-MHz ultrasound probe was used to visualise the RIJV during catheterisation. The ultrasound probe was applied perpendicularly to the skin at the level of cricoid cartilage and care was taken not to compress the RIJV. The RIJV and the right internal carotid artery (ICA) were identified according to their anatomical locations, compressibility and pulse patterns. In group A, in the absence of mechanical ventilation (0-cmH2O PAP), the cannulation needle was advanced slowly, with the simultaneous application of a constant negative pressure on the syringe and with a 35–45° angle between the needle and the skin. When blood flowed into the syringe, the cannulation needle was fixed and a guide wire was inserted. If the cannulation needle was advanced to a depth of 3 cm without aspiration of blood into the syringe, the needle was withdrawn slowly under negative pressure until aspiration occurred. At that point, a single-lumen catheter (16 G, 20 cm) was inserted. In group B, the cannulation needle was advanced slowly with a mechanically induced PAP of 15 cmH2O. This pressure was discontinued after the guide wire was inserted. In groups C and D with the airway pressure increased to 20 and 25 cmH2O, respectively, RIJV catheterisation was carried out in the same manner as group B. In each group, PAP was not maintained for longer than 30 s. If the right ICA was punctured, RIJV catheterisation was abandoned.
Heart rate (HR), mean arterial pressure (MAP) via a direct radial arterial cannula and oxygen saturation were monitored continuously. The cross-sectional area of the RIJV was measured before catheterisation and the CVP afterwards. The arterial blood pressure (BP) and CVP transducers were set to zero at the level of the right atrium while the patient was in the 15° Trendelenberg position. The cross-sectional area of the RIJV was measured in triplicate using electronic callipers on the ultrasound screen, and the mean value was used for analysis. All ultrasound procedures and measurements of the cross-sectional area were carried out by the same anaesthetist.
The age, sex, height, weight and ASA physical status were noted. The following variables were recorded during the catheterisation process: the cross-sectional area of RIJV, the CVP, the number of cannulations completed within 30 s, the number of first pass punctures, depth of needle insertion, the number with obvious loss of resistance and aspiration of blood into syringe during needle insertion, the degree to which the ICA overlapped the RIJV, the lowest HR and MAP in the course of catheterisation and puncture-related complications such as local haematoma, pneumothorax, haemopneumothorax and ICA puncture.
Statistical analysis was performed using SPSS 13.0 (SPSS Inc., Chicago, Illinois, USA). One-way analysis of variance was used to compare variables among groups. If a signiﬁcant difference was noted, a Bonferroni multiple comparison test was used to determine intergroup differences. Categorical variables were analysed using the χ2-test. Values of P less than 0.05 indicated signiﬁcance.
Of 261 potential participants, 12 failed to meet the inclusion criteria, seven declined to participate and for two the reason for exclusion was unknown. The remaining 240 were randomised into one of the four groups (Fig. 1). General patient characteristics were similar among the four groups (Table 1).
The changes of the right internal jugular vein cross-sectional area and central venous pressure
When compared to group A, the CVP and the cross-sectional area of the RIJV increased significantly as PAP increased from 15 cmH2O in group B to 20 cmH2O in group C (P < 0.05) and from 20 to 25 cmH2O in group D (P < 0.01) (Table 2 and Fig. 2).
Compared with group A or B, the number of catheterisations completed within 30 s and the number of first pass punctures increased significantly in groups C and D (P < 0.01) (Table 3).
Compared with group A, the depth of cannulation needle insertion was significantly decreased in the remaining groups (P < 0.01). Compared with group B, the depth of needle insertion was significantly less in groups C and D (P < 0.01) (Table 3).
Compared with group A, the number with obvious aspiration of blood into the syringe and loss of resistance during needle insertion were significantly increased in groups B, C and D (P < 0.01). Compared with group B, these rates were significantly increased in groups C and D (P < 0.01) (Table 4).
The extent to which the ICA was overlapped by the RIJV increased significantly as PAP increased from 15 (group B) to 25 cmH2O (group D). Differences between the four groups were significant (P < 0.01) (Table 3).
Hypotension and bradycardia
Compared with group A, hypotension and bradycardia were significantly increased in groups C (P < .05) and D (P < 0.01). Compared with group B or C, the occurrence of hypotension and bradycardia was significantly increased in group D (P < 0.01) (Table 5).
Compared with group A, B or C, the incidence of local haematoma was significantly increased in group D (P < 0.01) (Table 5). RIJV catheterisation was complicated in two individuals in group A because of ICA puncture. There were no other complications.
In this study, we found that the most suitable PAP for RIJV catheterisation in mechanically ventilated patients was 20 cmH2O. At this pressure, the cross-sectional area of the RIJV increased from 1.06 to 1.72 cm2, the CVP increased from 7.82 to 15.83 cmH2O and the rate of first pass puncture and catheterisation completed within 30 s increased significantly compared with lower pressures, and only slight changes in HR and BP were observed. At PAPs higher than this, the cross-sectional area of the RIJV remained almost unchanged, and more local haematomas were seen. PAPs above 20 cmH2O would appear to have no benefit in terms of facilitating RIJV catheterisation while increasing the risk of complications. Although bradycardia and hypotension disappear within 5 s of PAP removal, it is preferable to prevent their occurrence.
A number of studies9–13 have reported that when ultrasound guidance is used for internal jugular vein catheterisation, it can increase the success rate, shorten the time for puncture and decrease the occurrence of complications. Denys et al.13 found that the success rate for internal jugular vein catheterisation when guided by ultrasound was 100%, the average number of attempts was 1.3, the rate of venous access on a single attempt was 78% and the access time was 9.8 s. Similarly, Troianos et al.14 observed a success rate for ultrasound-guided internal jugular vein catheterisation of 100%, with an average of 1.4 attempts, a rate of access on a single attempt of 73% and a catheterisation time of 61 s. Our results compare favourably with these reports. We found that when the PAP was 20 cmH2O, the average number of attempts required for successful puncture was 1.05, the rate of puncture on one attempt was 96.7% and catheterisation time was reduced, although there was no difference in the success rate.
Ultrasound images obtained in the clinic suggested that in some patients the internal jugular vein collapses easily during catheterisation, making it difficult to puncture and cannulate successfully. Also Verghese et al.15 found that significant collapse could follow insertion of the cannulation needle and excessive finger compression during carotid artery palpation. Samy et al.16 reported that the diameter of the RIJV was less than 5 mm in 18% of patients and that successful catheterisation might be harder to achieve. We would expect that a raised PAP would facilitate RIJV catheterisation in these patients.
The principle underlying the ability of PAP to increase the cross-sectional area of the RIJV and raise the CVP during general anaesthesia is the associated increases in thoracic pressure and right atrial pressure, leading in turn to an increase in the volume of blood in the RIJV, resulting in its expansion. When PAP is maintained, the occurrence of hypotension will rise. In our study, a 15° Trendelenburg position was used to lessen the degree of hypotension caused by PAP.
The aspiration of blood into the syringe during needle insertion indicated that only the anterior vessel wall had been perforated. Michael and Srikar17 found that perforation of the posterior vessel wall could still occur even when venepuncture was guided by ultrasound. Koich et al.18 observed that only in 42.6% patients was blood aspirated into the syringe during the course of a 16-G needle insertion, whereas in our study at a PAP of 20 cmH2O, blood was aspirated in 95% of patients. We observed the sudden obvious loss of resistance in 86.7% patients during puncture which also suggests that only the anterior vascular wall was perforated. With a PAP of 20 cmH2O, the CVP increased, which made the RIJV less prone to indentation when the puncture needle was inserted, and as a result the puncture needle was more likely to break through the vessel wall without overshoot.
In several studies,19,20 investigators have found a partial overlap of the ICA by the internal jugular vein, increasing the risk of ICA puncture. In our study, we found that the extent to which the ICA was overlapped by the internal jugular vein increased with PAP, whereas the rate of accidental ICA punctured did not differ significantly among the four groups. It is possible that the posterior wall of the vein is less likely to be perforated under PAP and that this may help prevent accidental puncture of the ICA. When ICA puncture did occur, it was in two patients in group A, with PAP 0 cmH2O, and catheterisation was terminated. Local haematoma also developed in one patient in group B, three in group C and 11 patients in group D without evidence of a right ICA puncture. These hematomas were probably caused instead by blood leaking from the site of RIJV puncture because of the increased CVP during steel guidewire insertion.
In our preliminary experiments, we discovered that if PAP was removed before the guidewire insertion, the wire sometimes would not pass into the RIJV. We hypothesised that this was due to the very short distance that the needle was inserted; also, when the RIJV volume diminished after removal of PAP, the tip of the needle was no longer in the vein. To prevent this from occurring, we maintained PAP until the guidewire had been inserted into the RIJV.
Several studies have reported that the use of ultrasound guidance for central venous catheterisation remains limited for a number of reasons, such as availability of equipment and practitioners[Combining Acute Accent] attitude to its usefulness.21–24 Although this situation has gradually improved in developed countries in recent years, in others, many clinicians still locate the RIJV by external landmarks. While a PAP is maintained, however, the CVP and the cross-sectional area of the RIJV increase significantly, making the RIJV a bigger target, even without the guidance of ultrasound.
There are certain limitations to our study. Our patients were exclusively ethnic Chinese, and not all our findings might be applicable to other groups. In addition, the operator who took all the measurements and performed the venepunctures was not blinded to the protocol.
In conclusion, we found that, of four different PAPs for RIJV catheterisation in mechanically ventilated patients, 20 cmH2O proved to be the best. The CVP and the cross-sectional area of the RIJV increased significantly at this pressure, and this offered some advantages in RIJV catheterisation, resulting in fewer puncture-related complications. However, meticulous haemodynamic monitoring is needed to avoid hypotension and bradycardia.
This work was supported by the Second Affiliated Hospital of Jiaxing College, Jiaxing, China.
None of the authors has any conflicts of interest to report.
The authors would like to thank Allan Belinda and Yi Bao for their assistance with the study.
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