Comparison of conventional needle holding technique and pen holding method of needle holding for real-time ultrasound-guided internal jugular venous cannulation – A randomised parallel-group study : Indian Journal of Anaesthesia

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Comparison of conventional needle holding technique and pen holding method of needle holding for real-time ultrasound-guided internal jugular venous cannulation – A randomised parallel-group study

Ramachandran, Srinivasan; Velayudhan, Savitri1,; Ramaraj, Krishna Prabu; Desingh, Dilip Chandar; Kuppusamy, Sureshkumar; Shanmugam, Balasubramanian

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Indian Journal of Anaesthesia 67(3):p 256-261, March 2023. | DOI: 10.4103/ija.ija_704_22
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Ultrasonography (USG)-guided cannulation is the procedure of choice for inserting central venous catheters in the internal jugular vein (IJV) because of the higher success rate and reduced complications.[1] Posterior vessel wall puncture (PVWP) and haematoma formation are not uncommon even with USG guidance. As IJV is mostly located anterior or anterolateral to the common carotid artery (CCA), any PVWP may translate into an increased risk of common carotid artery puncture and haematoma formation.[2] In clinical practice, the incidence of PVWP is 21%, and arterial puncture is 5.5% with the conventional needle holding technique.[3] Several techniques have been proposed to decrease the incidence of PVWP and arterial puncture. One of the techniques to avoid PVWP is the ‘proximal pen holding method’ of needle holding.[4] This study was aimed to compare the pen holding method of needle holding with the conventional needle holding technique for real-time USG-guided IJV catheterisation in short axis (SAX) view. The study’s primary objective was to compare the incidence of posterior vessel wall puncture between both the techniques. The secondary objectives were to compare the number of attempts needed to localise the vein, the time taken for successful guidewire insertion, the incidence of complications and the ease of the procedure between both the techniques.


After obtaining Institutional Ethics Committee approval and registration in Clinical Trials Registry of India (CTRI/2019/12/022349), participants were recruited for this, randomised parallel-group study. The study was conducted in 90 patients between December 2019 and November 2021 in a tertiary care teaching hospital. Patients of either sex aged between 18 and 70 years with American Society of Anaesthesiologists Physical Status I–III undergoing elective surgery under general anaesthesia requiring USG-guided IJV cannulation intraoperatively were included after written informed consent. Patients with coagulation abnormalities, cervical spine disorders and abnormal neck anatomy were excluded from the study.

Patients were divided into Group C (conventional needle holding technique) and Group P (pen holding method of needle holding) with the help of computer-generated random numbers and allocated using sealed envelope technique. Anaesthesia was administered to the patients at the discretion of the consultant anaesthesiologist of the operating room. The patients were then positioned for IJV cannulation in a supine Trendelenburg position of 15°, and the head was rotated to an angle of 30° towards the left side after administration of anaesthesia. The patients were blinded from group allocation.

All the operators (3 years of experience in the conventional method of USG-guided central venous cannulation) were trained in the pen holding method using a simulation model. Following sterile precautions, the cannulation was performed using one of the two techniques based on randomisation. A 7 French triple lumen central venous catheter (Arrow® multi-lumen central venous catheterisation set, Arrow international, Inc, Reading, PA, USA) was inserted into the IJV. The area of the neck was scanned by a high-frequency (6–13 MHz) probe (M-Turbo, Fujifilm Sonosite, Inc., Bothell, WA, USA) in the SAX view to identify the appropriate site of cannulation. The skin to the anterior wall of IJV distance and the relationship of IJV to CCA were noted. If the IJV overlapped more than 75% of CCA, it was considered anterior in position; if the overlap was less than 75%, it was anterolateral; if there was no overlap, it was considered lateral in position. Sterile preparation of the neck was done and draped.

In the conventional technique, ultrasound probe was held in non-dominant hand to get SAX view of vessels. A syringe attached to the introducer needle was held by the plunger in dominant hand. Under USG guidance, the skin was punctured with controlled pressure [Figure 1a]. The needle tip was used to make an indentation on the anterior wall of the vein, and the vein was pierced with the syringe held by the plunger with constant negative pressure applied on the plunger. Free flow of blood on aspiration, disappearance of the indentation on the vein wall and needle (echogenic dot) visualisation inside the lumen of the vein indicated successful entry of the needle into the vein. The guidewire was then inserted into the vein and over which a dilator was introduced to dilate the skin. The catheter was then railroaded over the guidewire and fixed.

Figure 1:
Needle holding techniques. a. Conventional technique and b. pen holding method

In pen-holding method of needle holding group, ultrasound probe was held in non-dominant hand to get optimal SAX view of vessels. The introducer needle was held at its hub in a pen holding fashion with a syringe attached [Figure 1b]. Under ultrasound guidance, after controlled puncture of the skin, gentle pressure was applied to create an indentation over the anterior vein wall and then the vein was pierced with controlled pressure. Needle entry into the vein was identified by disappearance of the indentation on the vein wall and needle (echogenic dot) visualisation inside the lumen of the vein. USG probe was kept aside, and the needle was held in the non-dominant hand and free flow of blood into the syringe on aspiration confirmed needle entry into the vein. Then the syringe was disconnected, and guidewire was introduced. The procedure was completed in the same manner as before.

In both the techniques, successful placement of the guidewire into the lumen of the vein was confirmed by USG imaging of the guidewire along the long axis (LAX) of IJV. The time taken from skin puncture to successful guidewire placement in the IJV was noted. Immediately after cannulation, central venous pressure (CVP) was measured using a transducer and noted. After IJV cannulation, the surgery proceeded as planned.

An unrelated observer recorded the incidence of PVWP (diagnosed if the needle pierced the posterior wall or lateral wall, blood was aspirated on withdrawal of the needle, arterial puncture after piercing the vein, posterior wall haematoma), number of attempts required to localise the vein (every time the needle was withdrawn and reinserted was considered an attempt), time taken for successful guidewire placement (time from skin puncture to placement of guidewire in IJV) and incidence of other complications (arterial puncture, haematoma formation and pneumothorax) were recorded. The observer was not blinded to the technique. Ease of the procedure (on a scale of 0 (denoting no ease and extreme difficulty) to 10 (denoting extreme ease and no difficulty)) in both the techniques was also noted.

The sample size was calculated to be 90 using OpenEpi software version 3.0, taking into consideration the occurrence of PVWP in conventional technique for real-time USG-guided internal jugular venous cannulation as 21%[3] and assuming occurrence of PVWP in pen holding technique as 3%, with 95% confidence interval and 80% power. Data were reported as mean and standard deviation or median and interquartile range according to the normality. Incidence of PVWP and distribution of IJV location with respect to CCA were compared using Chi-square test. Time to guidewire insertion was compared using Mann–Whitney U-test. The data were analysed using Statistical Package for the Social Sciences (SPSS version 24.0, Chicago, Illinois), and a P value less than 0.05 was considered statistically significant.


Patient flow is shown in Figure 2. The procedure was performed by six anaesthesia consultants with similar training in USG-guided CVC cannulation in 90 patients. There was no significant difference in baseline characteristics of patients, opening CVP and skin to IJV distance in both groups [Table 1]. The most common position of IJV in relation to CCA was anterolateral, which was similar in both groups [Table 2]. Guidewire insertion and cannula placement were achieved in a single attempt in all patients in both groups. There was no statistical significance in the incidence of PVWP (conventional technique 6.6% and pen holding method 4.4%) and time for cannulation in both the groups [Table 3]. No other complications were observed in both groups. Ease of procedure was found to be a median (interquartile range) of 10 (10) in both groups.

Figure 2:
Consolidated standards of reporting trials (CONSORT) diagram showing patient enrolment, allocation, follow-up and analysis
Table 1:
Baseline characteristics of the patients, skin to internal jugular vein distance and opening central venous pressure
Table 2:
Relationship of internal jugular vein to common artery
Table 3:
Incidence of posterior vessel wall puncture and time for successful guidewire insertion


In this study, we did not find any significant difference in incidence of PVWP between the conventional and pen holding method of needle holding. No other complications were noted in both groups.

With the advent of portable machines and the safety USG offers, USG-guided CVC has become the standard of care. USG-guided CVCs can still be associated with mechanical complications like PVWP, posterior haematoma, and arterial cannulation can still occur.[5]

The circumferential nature of the neck prevents scanning from anterior to posterior. Scanning from the lateral aspect of the neck depicts the IJV as overlapping over the CCA, and rotating the neck to the contralateral side for the cannulating position increases the overlap. This results in the anterior or anterolateral placement of IJV to the CCA. In this study, the anterolateral position was observed in most cases (80% in Group C and 75.6% in Group P). The lateral position with no overlap was seen in only 6.7% and 8.9% in groups C and P, respectively. These findings are similar to those observed by Srinivasan et al.[3] and Machanalli T et al.[2] Additionally, it is the propensity of IJV to get flattened during insertion of the needle, making the two walls to approximate. So, any PVWP can translate into an arterial puncture.

Reported incidence of PVWP during IJV cannulation has been very variable, with very few clinical trials. Most studies have been performed on phantom simulation models, and there is almost 34% increased incidence in patients compared to phantom models due to differences in the tissue texture and respiratory variations in the vessel diameter in actual patients.[3] In our study, the incidence of PVWP was 6.7% and 4.4% in groups C and P, respectively. This is relatively low compared to the published incidence ranging from 12% to 66%.[3–8] In the study by Gupta et al. where the pen holding method was evaluated, there were no instances of PVWP.[4]

This study had no instance of CA puncture or arterial cannulation. In a study done on phantom simulation model, the residents had a 64% incidence of PVWP, and there was an actual arterial puncture in five of those instances.[8] In the study by Srinivasan et al.,[3] the incidence of arterial puncture was 5.5% in US-guided IJV cannulation. This has resulted in lots of research identifying the optimal technique to reduce PVWP. These modified techniques attempt to do one of the following, namely better visualisation of the needle and the ability to follow the needle through the entire path, increase the IJV diameter and better control over the needle.

In this study, we chose the SAX view. Modification of the USG approach has been a well-studied method for reducing complications.[9–11] A study comparing LAX and SAX found that LAX required more expertise and probe dexterity despite the ability to follow the entire needle path.[9] In SAX, we cannot follow the needle path, and the needle is visible only in cross section, and this can result in increased PVWP. In terms of access time, ease of visualisation and incidence of complications, there is still a paucity of evidence to recommend one over the other. There are also modified approaches like oblique or anteroposterior SAX, which may be better but needs more complex orientation and expertise with USG to become the preferred approach.[12–14]

The bevel-down approach of needle insertion was studied by Lim et al. for the right IJV cannulation. Inserting the needle with the bevel facing down was found to decrease the incidence of PVWP and haematoma formation.[15] Wu T et al. described a novel puncture point-traction technique in which the skin just above the IJV is maintained in its position by the traction of surgical suture and found high success rate.[16] Gupta et al. described the novel technique of the pen holding method.[4] The authors suggested that holding the needle on the hub like a pen allows better control enabling precise movement, thereby avoiding overshooting of the needle and posterior wall puncture. Also, holding the needle like a pen is more familiar to the hand and helps estimate the skin thickness and texture and accurately estimate the pressure required for the puncture. Further, it allows the pressure to be applied to a very small point over the skin; hence, the distortion of the USG view is minimal. This technique only modifies how the needle is held and therefore involves minimal modification of the conventional technique. This helps with the learning curve. The access time, first attempt success and time to successful guidewire insertion were comparable between the two techniques.

In the current study, out of the total five instances of PVWP, three patients had less CVP. The skill level of the operator in performing the USG-guided cannulation influences the precision of the needle advancement, thereby determining the incidence of posterior vessel wall puncture.[17] Apart from operator skill, the diameter of the IJV (which depends on respiratory variation and hydration status of the patient) is one of the major contributing factors to the occurrence of PVWP.

We assessed the ease of the procedure on a Likert scale of 1 (very difficult, no ease) to 10 (no difficulty, very easy). The conventional technique was scored easier compared to the pen holding technique. Operators felt more confident with the conventional technique, probably because of the familiarity. And also, in the pen holding technique, the operator loses contact with the needle when they must change their hand position for aspirating blood to confirm the intravenous location of the needle tip. This momentary loss of contact could cause dislodgement of the needle, but it can be immediately rectified under US guidance.

Our study had the following limitations. The operators could not be blinded to the technique. More operators with different levels of experience in both the techniques will enable us to study the ease and comfort level of both the techniques. A large number of patients offering varying levels of difficulty like obesity and dehydration can genuinely assess the usefulness of this technique.


There was no significant difference in the incidence of PVWP in pen holding method of needle holding technique compared to the conventional technique. Further evaluation, including operators with varying levels of experience, is required to assess the true effectiveness of this novel technique in reducing mechanical complications during IJV cannulation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


We sincerely thank Epidemiology Unit of Community Medicine Department, for guiding us in designing the study and with statistical analysis.


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Cannulation; internal jugular vein; ultrasonography

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