Long Versus Short Axis Ultrasound Guided Approach for Internal Jugular Vein Cannulation: A Prospective Randomised Controlled Trial

INTRODUCTION: In 1940’s ultrasound was introduced in the clinical practice by Dr. Karl Dussik, an Austrian psychiatrist. He studied the brain for tumors and he termed the images hyper phonography. In 1978 first clinical use of ultrasound for anesthesia was used for peripheral nerve blocks by LaGrange et al. Internal jugular vein cannulation procedure is routinely performed by anaesthesiologists. Traditionally, anatomical surface landmark-guided technique has been used for IJV cannulation. This approach has many complications like bleeding, hematoma, arterial puncture, and pneumothorox. The use of the ultrasound in clinical practice enhances the quick, safe and reliable guidance for needle placement into the internal jugular vein, in elective routine and difficult cases. The level of evidence for ultrasound guided central venous cannulation is class A, level 1 Previous studies were comparing the blind landmark guided technique versus ultrasound guided cannulation of the internal jugular vein. The ultrasound image of the internal jugular vein may be orientated along either short axis (cross-sectional view) or long axis (longitudinal view). In this study we are comparing the two axes (short vs. long) of the ultrasound view for cannulation of the right internal jugular vein. AIM OF THE STUDY: The aim of the study is to compare the first pass success rate of ultrasound guided short axis versus long axis cannulation of the right internal jugular vein. MATERIALS AND METHODS: The materials needed for the study includes, 1. Ultrasound machine with high frequency probe (10 MHz), 2. Sterile gel, sterile transducer cover, 3. Central venous catheter, 4. Monitors – pulse oximeter, ECG, NIBP, 5. All emergency drugs. STUDY DESIGN: This study was a single blinded, randomized comparative study conducted in Government Stanley hospital, Chennai during the period of April 2012 to September 2012. After obtaining clearance from the Institutional Ethical Committee of the Stanley Medical College, Chennai-3, a pilot study was done to calculate the sample size. A pilot study with a sample size of 5patients in each group was done before the start of the study to decide on sample size. The sample size calculated based on the formula given in monographers on statistics and applied probability. Criteria for Selection: Inclusion Criteria: 1. Adult patients age more than 20 years, 2. Patients needed central vein cannulation. Exclusion Criteria: 1. Bleeding disorders and on anti-coagulant treatment, 2. Abnormal neck anatomy, 3. Morbid obesity, 4. Local infection. The selected patients were randomly assigned to two groups labeled as S and L. Each group was allotted 30 patients. Randomization was achieved by allotting lots with alphabets S and L. All our patients were prescaned in the premedication room on the day of surgery. The patients were brought to the operation room and intravenous access obtained with appropriate size venous cannula. Intravenous fluid Ringer’s lactate was started. Standard monitors like Pulse Oximeter, Noninvasive Blood pressure, ECG, Intubation was done under general anesthesia with appropriate size cuffed endotracheal tube by using direct laryngoscopy. The USG guided IJV cannulations were done by the author. The observations were noted by a theater staff nurse, who did not know about the aim and outcome of the study. The procedure was done using the 10MHZ ultrasound linear probe under sterile technique. First water based jelly was applied to the probe and a sterile cover placed over the probe. Care was taken to remove the air between the probe and the cover. For improving the quality of the images we used sterile water based jelly outside the cover for skin contact. After induction and intubation of the patient, head turned to opposite side up to 30°angle23. Head down position up to 10° was given for venous engorgement during the procedure24. The probe marker oriented to patients left side, corresponding marker on the screen. 2% chlorhexidine in alcohol was used for skin preparation. Methods of Statistical Analysis: The data were analysis using SPSS (Statistical Package for Social Science) Ver 16.01. The data collected were scored and analyzed, Continues variables were presented as means with Standard deviation (sd) and categorical variables were presented as frequency and percentages. Student t-test was used for testing the significance of all the variables (Mean & Sd) in both the group. Qualitative data was analyzed by using Chi square test. All the Statistical results were considered significant at P value < 0.05. SUMMARY: From our study we found that cannulation of right internal jugular vein using the ultrasound via short axis view is a better method compared to long axis view in terms of first pass success rate. During our study we also found the following data interesting, useful and statistically significant. The groups were comparable for age, sex, weight. Our observations were, • Number of needle attempts required for short axis view technique is lesser than the long axis view technique. It is a statistically significant result. • Time taken for guide wire placement was shorter in short axis view technique than the long axis view technique. It is a statistically significant result. • Time taken for catheter placement was increased in short axis view technique than the long axis view technique. It is not statistically significant result. • Carotid artery puncture is higher in long axis view technique than short axis view technique. It is not statistically significant result. Hence we felt that ultrasound guided short axis technique to be better than the ultrasound long axis technique for right internal jugular vein cannulation. CONCLUSION: In conclusion from our study we found that, the short axis view is better than the long axis view for the ultrasound guided central venous cannulation of right internal jugular venous in terms of first pass success rate. This technique also reduces the number of needle attempts required and time for guide wire placement in adult patients.