Ultrasound Guided Internal Jugular Vein Cannulation Using Biplanar Imaging: A Pilot Study
Condition: Cardiac Disease
MeSH terms: Heart Diseases
Study type: Observational

Summary: 
      Central Venous access by real-time ultrasound guidance is considered as gold standard and a
      recommended clinical practice. Internal jugular vein cannulation is one of the central venous
      access commonly used for major cardiac surgeries for monitoring and administering life-saving
      medications. In daily practice internal jugular vein cannulation is done under the guidance
      of ultrasound imaging after general anesthesia before the surgery. Real time 2D ultrasound
      guidance (USG) during central venous cannulation (CVC) has shown to be superior to the
      traditional anatomical landmark guided CVC, but the incidence of carotid puncture is still
      4.2%. Any improvement that aids in the ease and safety of the procedures needs to be
      evaluated. Recently USG biplanar imaging can now successfully demonstrate real time imaging
      in two different views at the same time. Theoretically, this may help improve precision by
      improving real time needle tip visualization and thereby reduce potential complications as
      compared to a traditional 2D approach. This study aims to assess the feasibility of biplanar
      USG internal jugular venous cannulation.
    

Detailed description: 
      This is a single arm prospective observational pilot study conducted at Prince of Wales
      Hospital in Hong Kong SAR. 20 adult patients scheduled for elective cardiac surgeries under
      general anesthesia (GA) will be recruited. After GA, patients will be positioned in the head
      low position for the USG guided IJV access. The skin of the neck will be prepared in a
      standard aseptic fashion. After sterilization, the surrounding area will be covered with a
      full-body sterile drape. The footprint and the cable of the ultrasound transducer will also
      be covered with a sterile transparent cover. Sterile ultrasound gel will be used for acoustic
      coupling during the USG guided CVC placement, but care will be taken to avoid inserting the
      needle through the US gel.

      USG XL 14-3 transducer will be used to obtain the biplanar imaging of IJV. A 3 lumen CVC will
      be used to access the IJV. An experienced anesthesiologist shall perform the USG guided
      procedure using the Seldinger method. This special transducer can provide real-time short
      axis (out of the plane) and long axis (In-plane) view which can be used to identify, locate
      and choose the introducer needle entry site for IJV vascular access. IJV will be assessed for
      any anatomical variations, pre-existing pathologies and patency. Among the 'out of plane' and
      'in plane' view, the former will be used as a primary view to guide the CVC introducer
      needle. The reference mark/line in the primary 'out of the plane' image in the biplanar view
      can be adjusted sidewise to visualise the needle in the 'in plane' view. As the needle is
      visualised in the 'in plane' technique (figure 1), the relative position of the needle to the
      target IJV can be determined which will further help in redirecting the needle towards the
      IJV. Needle tip can be made visualised in the 'out of the plane' view by carefully moving the
      transducer initially towards the introducer needle. Once the needle tip is visualised, it is
      advanced further towards the target taking into consideration both the 'in plane' and 'out of
      plane' image guidance. When the needle is visualised (in both the views) inside the vein, the
      transducer will be kept aside, a 5 ml syringe will be used to aspirate blood and then the
      guidewire is inserted into the IJV. Presence of guidewire will be again confirmed using the
      same biplanar transducer before performing the dilatation of IJV and final passage of the
      CVC. Likewise, the final position of the CVC shall also be confirmed using biplanar imaging.
      After final confirmation, CVC will be secured safely to the neck using sutures and connected
      to the pressure transducers for central venous pressure (CVP) monitoring.
    

Intervention name(s): Biplanar Ultrasound guided Internal Jugular Vein Cannulation
Intervention type(s): Procedure
Intervention description(s): Using Philips EPIQ elite ultrasound system with a high-frequency 3D and 4D volume linear array transducer (USG XL 14-3) to obtain the biplanar imaging of Internal jugular vein cannulation.
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        All patients scheduled for elective cardiac surgeries that meet the inclusion criteria will
        be recruited.