Central venous cannulation is commonly performed by anesthesiologists
to monitor cardiac filling pressures, to facilitate rapid fluid infusion,
to administer vasoactive drugs, and when peripheral intravenous access
is tenuous. The right internal jugular vein (IJV) is the site most frequently
chosen by anesthesiologists for percutaneous cannulation because it is
easily accessible during most operations and is associated with fewer
complications when compared to the subclavian approach. The most common
complication of IJV cannulation is carotid artery puncture with an incidence
ranging from 3-10% that is independent of the technique chosen or operator
experience. Although carotid artery puncture is usually a benign event,
it can be life-threatening when it results in inadvertent intraarterial
cannulation, stroke, hemothorax, carotid artery-IJV fistula, or airway
compromise due to a neck hematoma. In a recent analysis of central line
complications from the ASA Closed Claims Project, 16/26 cases (61%), including
7 fatalities, resulted from vascular injury, often from accidental cannulation
of the artery instead of the vein with an introducer sheath or large bore
Percutaneous cannulation of the IJV is routinely facilitated
by the use of landmark methods that are performed in blind fashion that
incorporates knowledge of the underlying anatomical relationship between
the artery and the vein. However, increasing data support the routine
application of Doppler and non-Doppler ultrasound during central venous
cannulation. Benefits of ultrasound guided cannulation include determination
of the vessel location and size; identification of aberrant anatomical
relationships between the artery and vein; visualization of needle puncture
of the vessel; and confirmation of guidewire and catheter placement within
the vessel. In a recent meta-analysis and report from the Agency for Healthcare
Research and Quality, surface ultrasound was associated with a reduced
incidence of complications and number of venipuncture attempts, thereby
improving the rate of successful catheter placement.2,3
Real-time ultrasound successfully identifies underlying
vessel relationships and is not dependent upon surface landmarks. This
characteristic is particularly beneficial in patients with distorted external
landmarks that include obesity, previous neck surgery or neck radiation;
previous IJV cannulation with thrombosis of the vessel; and carotid artery
stenosis. It is particularly useful in the presence of coagulopathy or
planned anticoagulation (ie, cardiopulmonary bypass). Aberrant anatomic
relationships between the IJV and carotid artery were observed in as many
as 3% of adult patients studied by ultrasound when their heads are rotated
30o from midline.4 In 2% the IJV was positioned
medial to the carotid artery. The carotid artery coursed posteriorly to
the IJV in 10% of pediatric cardiac patients who were studied by ultrasound,
thereby predisposing them to accidental carotid artery puncture.5
Anatomical variation in the size of the left and right
IJVs is well documented. The right IJV is slightly larger than the left
IJV in most patients.6 In 34% of healthy adults, the left
IJV is less than one-half the size of the right IJV, making cannulation
more difficult. Additionally, the left IJV is less responsive to Valsalva
and steep Trendelenburg maneuvers. Normal anatomical relationships between
the carotid artery and IJV are lost when the head is rotated away from
the midline, a technique commonly used to facilitate exposure of the IJV
prior to cannulation. As the head is rotated greater than 40o
from midline, the percent overlap of the carotid artery and IJV increases
significantly as does the risk of inadvertent puncture of the carotid
artery.7 At a head rotation of 80° the left IJV has a
greater overlap with the carotid artery than does the right IJV.
Real-time ultrasound determination of the anatomical
relationship of the vessels reduces the risks of carotid artery puncture,
neck hematoma and accidental cannulation. Cannulation of the carotid artery
with an introducer sheath often requires surgical repair of the vessel
and has been associated with stroke and death. In a meta-analysis of eight
randomized trials, the use of ultrasound resulted in a 78% relative risk
reduction for complications and a 68% relative risk reduction for catheter
placement failures.2,3 The reduction in complications is attributed
to visual determination of vessel location, recognition of anatomic variants
and identification of the guidewire within the vein prior to catheter
insertion. The number of venipuncture attempts also is significantly decreased
(relative risk reduction 40%), thus avoiding potential complications from
repeated punctures.3 Ultrasound-guided placement does not completely
eliminate the risk of complications, but lowers them significantly.
Routine use of real-time ultrasound for central venous
cannulation has been criticized because of equipment costs, reduced clinical
experience with placement by landmark methods (particularly by residents
in training), and the need for operator expertise. In my view, however,
ultrasound techniques are relatively simple to learn. The equipment is
portable, and it generally requires minimal training to gain expertise
in its use. Although equipment cost is a valid concern, the expense of
a major adverse event associated with central venous cannulation is potentially
much greater. In my view, ultrasonography for central venous cannulation
will soon be a standard of practice.
- Bowdle TA: Central line complications from the ASA Closed Claims Project:
An Update. ASA Newsletter 2002: 66.
- Randolph AG, Cook DJ, Gonzales CA, Pribble CG: Ultrasound guidance
for placement of central venous catheters: A meta-analysis of the literature.
Crit Care Med 1996; 24: 2053-2058.
- Rothschild JM: Ultrasound guidance of central vein catheterization.
Evidence Report/Technology Assessment, No. 43. Making Health Care Safer.
A Critical Analysis of Patient Safety Practices. Agency for Healthcare
Research and Quality Publication No. 01-E058. 2001; 245-253.
- Denys BG, Uretsky BF: Anatomical variations of internal jugular vein
location: impact on central venous access. Crit Care Med 1991; 19: 1516-1519.
- Alderson PJ, Burrows FA, Stemp LI , Holtby HM: Use of ultrasound to
evaluate internal jugular vein anatomy and to facilitate central venous
cannulation in paediatric patients. Br J Anaesth 1993; 70: 145-148.
- Lobato EB, Sulek CA, Moody RL, Morey TE: Cross-sectional area of the
right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999;
- Sulek CA, Gravenstein N, Blackshear RH, Weiss L: Head rotation during
internal jugular vein cannulation and the risk of carotid artery puncture.
Anesth Analg 1996; 82: 125-128.
Cheri A. Sulek, MD
University of Florida - Gainesville