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Is finder needle necessary for internal jugular vein catheterization?
Eisa Bilehjani MD, Assistant Professor in Aesthesia, Fellowship in Cardiovascular
Anesthesia, Madani Heart Hospital, Tabriz – Iran. (Corresponding Author)
Amir Abbas Kianfar MD, Assistant Professor in Aesthesia, Fellowship in Cardiovascular
Anesthesia. Imamreza Heart Hospital, Tabriz - Iran.
Solmaz Fakhari MD, Resident in Anesthesiology. Madani Heart Hospital, Tabriz – Iran
Corresponding author: Dr. Eisa Bilehjani, Department of Cardiovascular Anesthesia,
Madani Heart Hospital, Tabriz University of Medical Sciences; Tabriz - Iran.
Tel: 0098 411 3360894, Fax:0098 411 3344021, E-mail: [email protected]
From: Department of Cardiovascular Anesthesia, Cardiovascular Research Center, Madani
Heart Hospital, Tabriz University of Medical Sciences: Tabriz – Iran
Implications Statement: we studied finder needle use and complications rate of internal
jugular vein catheterization in adult elective cardiac surgery in two university hospital. We
concluded that using finder needle increase procedure time without reducing risk of arterial
puncture and other complications.
Abstract:
Background: Internal jugular vein (IJV) is the most common vein used for
hemodynamic monitoring by anesthesiologists. Serious complications may be
associated with IJV catheterization such as carotid artery puncture, pneumothorax and
nerve injury. Finder needle is usually used for reducing its complications. We studied
finder needle use in IJV catheterization and complications rate in adult cardiac
surgery.
Methods: At a prospective study at about 3 month period from august to November
2007, all patients older than 18 years who were candidate for elective cardiac surgery
were studied. Data were collected about using finder needle, patient position, success
rate, intra and postoperative complications of IJV catheterization.
Results: Of totally 399 patients, 52 patients were excluded from study. Finally in
remaining 347 patients, in 92.5% (321) of patients, catheter was placed in right internal
jugular vein. Finder needle was used in 151(46.2%) of IJV catheterization (group one) versus
176 (53.8%) patients that IJV catheterization were done without finder needle (group two).
Anesthesiology residents significantly used finder needle more than attends (Pvalue= 0.001).
Using finder needle significantly increased catheterization time from 5.8 ± 2.2 to 8.8 ± 3.5
minutes (Pvalue= 0.002).There were not any significant differences in complications and
success rate between two groups.
Conclusions: To reduce complications or increase success rate, there is not any need for
finder needle use in internal jugular vein catheterization.
Key Words: internal jugular vein, Complications, Central venous catheterization, finder
needle, Seldinger technique
Word Count: 223
Introduction:
Central vein cannulation is the standard clinical method for monitoring central venous
pressure (CVP) in operating room and ICU. It is also performed for a few other
therapeutic interventions. Insertion of central venous catheters has become an
important skill for all hospital doctors to obtain. Internal jugular vein (IJV) is the most
common vein used by anesthesiologists. Serious complications may to be associated
with IJV catheterization such as carotid artery puncture, pneumothorax and nerve
injury. As with most medical procedures, the level of experience of the physician
reduces the risk of complications (1). Seldinger technique (catheter over guide-wire)
from 1956 could to provide an extremely useful and safe method of inserting all types
of central venous access lines. But, however, central venous catheterization continues
to be associated with significant complications (ex. carotid artery puncture, stroke,
death) approximately 10% of the time (1-3). Use of ultrasound during central venous
catheterization can reduce rate of complications, but it is not used routinely (4).
Finder needle is usually used for reducing its arterial complications, but its roll was
questioned. We studied finder needle use and complications rate in IJV catheterization
in elective adult cardiac surgery.
Methods:
In a 3 month period from august to November 2007 all adult patients underwent
cardiac surgery in two university hospitals, were studied prospectively about central
venous catheterization. Patient's anesthesia and surgical teams were blind about what
kinds of data are collecting. Patients of emergency or redo operations, same day
reoperation because of tamponade or hemorrhage, apparent preoperative
coagulupathy and renal failure were excluded from study. Demographic,
intraoperative and 48 hours ICU stay period data were collected. Totally 399 patients
were enrolled to study. Premeditation, anesthesia induction, arterial catheterization
performed as routine for all patients. Central venous catheterization performed after
anesthesia induction/tracheal intubation by an attend or resident of anesthesiology
who was blind about study and nature of what data are colleting. Site of central
venous cannulation, patient position, using finder needle, failure rate (more than two
tries), numbers of tries, arterial puncture, changing to other site, bleeding and
hematoma formation, anesthesia and operation times were recorded. In ICU sedation,
intubation and ICU stay times, objective and subjective complications were recorded.
Patients who need reoperation because of bleeding or post operation tamponade, long
mechanical ventilation (> 24houres) were excluded from study. From totally 399
patients, 42 patients were excluded from the study because of reoperation or
mechanical ventilation dependency more than 24 hours. In 10 of the patients, pulmonary
artery catheter were used, all of them simultaneously inserted via RIJV parallel to central
venous catheter, they were also excluded from the data analyzing. Finally in 347 patients,
data were analyzed with SPSS statistical software (version 14.0), using chi-square,
Fisher’s exact test, independed samples t-test.
Results:
After collecting data from totally 399 patients, 52 patients were excluded from study.
Initially data were analyzed in 347 patients. ASA class of physical status is shown in table 1.
In 4 patients, simultaneously, both right subclavian and internal jugular veins were used,
because of poor peripheral vascular access. Right internal jugular vein used in 92.5% of all
patients (table 1). In 4 patients initially attempts for internal jugular vein catheterization were
failed and changed to right subclavian vein.
Finally data analyzed in 327 patients, in whom right or left internal jugular veins were the
first preferred sites for catheterization, but were failed in 4 patients. Data were compared
between two groups: group one (finder needle used) and group two (finder needle not used).
Demographic data, risk factor, diagnosis and anesthesia, surgery, sedation, intubation and
ICU times are shown in tables 3 and 4.
In all patients head rotation about 30 degree was used but Trendelenburg (head down)
position was used in only 74 patients (22.6 %) during catheterization, there was not any
difference between anesthesiology attends and residents about using this position. Central
landmark approach was used in 99.3% of patients. Finder needle was used in 151(46.2 %)
of IJV catheterization. Total IJV catheterization procedures that performed by attends
and resident anesthesiologists were 246(75.2%) and 81(24.8%), respectively (table 5).
Resident anesthesiologists significantly preferred finder needle use (Pvalue= 0.001).
Attends significantly performed procedure faster than residents (Pvalue= 0.004). There were
not any significant differences in success rate or changing to subclavian vein between two
groups. There was not any difference about using finder needle, comparing male to
female patients (table 6), (Pvalue= 0.42).
There were not any differences about using finder needle related to risk factors or
diagnosis, except asthmatic patients in them usually finder needle was used (Pvalue=0.023).
At all there was any difference about complications rate between attends and
residents. Neck pain and Sore throat/dysphagia were seen as common as 19.3% and
7.9%, respectively (table 7).
Discussion:
Central venous cannulation has become an integral component of modern medical
care and has become an important skill for all hospital doctors and stuff, they must be
to obtain. This procedure is performed in a wide range of locations within the
hospital. Various sites are used for central venous access. An important factor in
choosing the best site is the operator's own knowledge and experiences, as the chance
of failure and complications increases if the operator is unfamiliar with the particular
technique (1,5). Right internal jugular vein (RIJV) is the most common vein used by
anesthesiologists, for hemodynamic monitoring in the operating room. Serious
complications may be associated with IJV catheterization such as carotid artery
puncture, pneumothorax and nerve injury. From the first recorded of placement a
central venous cannula in a human occurred in 1929, Seldinger technique (catheter
over guide-wire) in 1956 provided a safe and successful method for inserting all types
of central venous access lines. But still central venous catheterization continues to be
associated with significant complications approximately 10% of all the times. Carotid
artery puncture during internal jugular vein (IJV) catheterization is reported to occur
2%–17% of the time, in a wide range of studies (5). Rare but devastating
complications (e.g., stroke, death) resulting from arterial complications during
catheterization also continue to be reported (5-10).
Finder needle, a small 22-gauge 1 ½ inch, is usually used for reducing IJV
catheterization complications (5). When locating IJV with a small finder needle, using
surface anatomical landmarks, accidentally arterial puncture will result to a small
controllable hemorrhage or hematoma. Recently internal jugular vein cannulation
under two dimensional ultrasound guidance provided a quicker and safer method than
the landmark method in both adults and children (4,5). But its use is not popular
because needs sufficient ultrasound machines and staff training (4). That it is
important that “operators maintain their ability to use the landmark method and that
the method continues to be taught alongside the 2-D ultrasound guided
technique”(4,11).
Finder needle is not a permanent component of the IJV catheterization procedure.
Indeed in our study only in 46.2% of patients it was used. When catheterization is
performed by well trained, experienced clinicians, success rate and serious immediate
complications are infrequent, however, infectious complications remain common
(1,5,12). Anesthesiologists are the most experienced clinicians in this field, usually it
is their routine daily activity. In our study numbers of attempts were not differ
between attends and residents. The incidence of mechanical complications after three
or more insertion attempts is six times the rate after one attempt (1). In this study
resident anesthesiologists used finder needle in 91.4% versus 31.3% comparing to
more experience attends. Using finder needle not only did not change complication
and success rate, however increased procedure time.
Common immediate complications of procedure are: Vascular injury (Arterial,
Venous), cardiac tamponade, respiratory compromise (Airway compression from
hematoma, pneumothorax), nerve injury, arrhythmias, arterial thrombosis and
embolism, pulmonary embolism and catheter or guide-wire embolism, however, many
of these complications result from operator error (5,13).
In general, unintended arterial puncture is the most common immediate mechanical
complication. Shah and coauthors reported more than 6000 central venous
catheterizations over a 5-year period, with more than 95% performed through the
internal jugular vein. In this series, the most common complication was carotid artery
puncture, which occurred in 120 patients (1.9%) but did not result in any serious
morbidity. Authors of other large studies report a somewhat higher incidence of
arterial puncture during central venous catheterization ranging from approximately
3% to 15% (5). The frequency of arterial puncture with a small gauge finding needle
may be even higher than these estimates (5). Though usually benign, on rare
occasions, arterial puncture with even small-gauge needles may lead to serious
complications such as arterial thromboembolism (5). In our study arterial puncture
totally happened in 6.1%, but there was not any difference between two groups.
Pneumothorax incidence after IJV is very low. Shah and coauthors reported a 0.5%
incidence of pneumothorax in their series of nearly 6000 internal jugular
catheterizations. In our study there was not seen any case of pneumothorax, this is
probably may be due to that most of our cardiac surgeons usually place chest drain
tubes in pleural space, at the end of surgery.
Sore throat/dysphagia and neck pain were very common more than previous reports
(14), 7.9% and 19.3% respectively. There was not any difference between groups
considering finder needle use. Sore throat/dysphagia may be related to that all of our
patients underwent tracheal intubation. Neck pain, usually at epsilateral site, was the
most common symptom, which was usually relieved after catheter removal.
Nerve injury is a potential complication of central venous cannulation. Damage may
occur to the brachial plexus, satellite ganglion, phrenic, laryngeal nerves (15), or
vocal cords. Chronic pain syndromes have been attributed to this procedure as well
(16). It seems increasing operator skill is the best method for reducing these
complication. Anesthesia residents with low experiences used finder needle more than
attends, but complications rate was not differ significantly. Finder needle significantly
prolonged procedure time.
In summary it may be concluded when operator is a experienced clinician, finder
needle can be deleted from procedure without increasing risks.
References:
1. McGee DC and Gould MK. Preventing Complications of Central Venous
Catheterization. N Engl J Med 2003;348:1123-1133
2. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA and Cheney FW.
Injuries and liability related to central vascular catheters: a closed claims
analysis. Anesthesiology 2004;100:1411–8.
3. Bailey PL, Whitaker EE, Palmer LS and Glance LG. The accuracy of the central
landmark used for central venous catheterization of the internal jugular vein.
Anesth Analg 2006;102:1327-1332
4. Bailey PL, Glance LG, Eaton MP, Parshall B, McIntosh S. A survey of the use
of ultrasound during central venous catheterization. Anesth. Analg
2007;104(3):491 - 497
5. Mark JB and Slaughter TF. Cardiovascular monitoring. In: Miller RD: Miller
anesthesia, vol 1, 6th ed. Churchill Livingstone, Pennsylvania , 1286-1296.
6. Eckhardt WF, Iaconetti DJay, Kwon1JS, Brown Emery and Troianos CA.
Inadvertent carotid artery cannulation during pulmonary artery catheter
insertion. J Cardiothorac Vasc Anesth 1996;10:283–90.
7. Benter T, Teichgraber UK, Kluhs L, Dorken B. Percutaneous central venous
catheterization with a lethal complication. Intensive Care Med 1999;25:1180–2
8. Saxena N, Sharma M. Cerebral infarction following carotid arterial injection of
adrenaline. Can J Anaesth 2005;52:119.
9. Arthur ME, Castresana MR, Paschal JW and Patel VS. Acute cerebellar stroke
after inadvertent cannulation and pulmonary artery catheter placement in the
right vertebral artery. Anesth Analg 2006;103:1625-1626
10. Inamasu J, Guiot BH. Iatrogenic vertebral artery injury.. Acta Neurol Scand
2005:112: 349–357
11. National Institute for Clinical Excellence. Guidance on the use of ultrasound
locating devices for placing central venous catheters. London: NICE, 2002.
[NICE Technology Appraisal No 49.]
12. Editorial. Toward safer central venous access: ultrasound guidance and sound
advice. Anaesthesia 2005;60:1–4
13. Cavatorta F, Campisi S, Fiorini F. Fatal pericardial tamponade by a guide wire
during Jugular catheter insertion. Nephron 1998;79:352-352
14. Strickland NH and Weir J. Sore throat after central venous cannulation. J R Soc
Med 1999;92:386
15. Salman M, Potter M, Ethel M, Myint F. Recurrent laryngeal nerve injury: A
complication of central venous catheterization. Angiology 2004;55(3):345-346
16. Dubey PK and Kumar. Pain in the ear resulting from misplaced subclavian
dialysis catheter into ipsilateral internal jugular vein. Anesth Analg
2002;94:1460-1
Table 1: ASA status classification of patients underwent cardiac surgery
ASA class* N (%)
I 5 (1.4%)
II 157(45.2%)
III 148(42.7%)
IV 37(10.7%)
Total 347
* ASA class; American society of anesthesiologist classification of clinical status
Table 2: Different successful sites used for central venous catheterization in total 347 patients underwent cardiac
surgery
Catheterization site N (%)
RIJV 321 (92.5%)
RSCV 23 (6.6%)
LSCV 5 (1.4%)
LIJV 2 (0.6%)
Total catheterization site number 351*
* In 4 patients, simultaneously, right subclavian and internal jugular veins were used, because of poor peripheral
vascular access
Table 3: demographic data of patients with central venous catheterization site in internal jugular vein
Mean ± SD
Age 55.5 ± 12.5
Height 163 ± 7.8
Weight 68.8 ± 10.4
Table 4: risk factors, diagnosis, anesthesia, surgery and ICU data of patients underwent cardiac surgery with
central venous catheterization site in internal jugular vein
N (%)
DM 72 ( 22.0%)
C/S 134 ( 41.0%)
HLP 135 ( 41.3%)
HTN 193 ( 59.0%)
Asthma 16 ( 4.9%)
COPD 23 (7.0%)
CAD 212 (64.8 %)
VHD 70 ( 21.4%)
CAD+VHD 22 ( 6.7%)
CHD 23 ( 7.1%)
Anesthesia time (minute) 337 ± 59
Operation time (minute) 287 ± 55
Sedation time (hour) 5.5 ± 5.0
MV time (hour) 9.4 ± 6.0
ICU stay time (hour) 57.3.0 ± 21.4
DM; diabetes mellitus, C/S; cigarette smoking, HLP; hyperlipidemia, HTN; hypertension, COPD; chronic
obstructive pulmonary disease, CAD; coronary artery disease, VHD; valvular heart disease, CAD+VHD;
coronary artery disease and valvular heart diseas,e CHD; congenital heart disease (ASD, VSD, TOF,PAPVC ),
MV time; mechanical ventilation time
Table 5: Using finder needle by attend and resident anesthesiologist and success rate
(success after 1-2 try) in internal jugular vein catheterization
catheterization
time(min) †
Finder
needle
used ‡
Finder
needle not
used
One try* § Two try* More than
two try or
Chang to
SCV
Total
First try
on IJV
Success
rate ¥
Resident
anesthesiologist
9.4 ± 3,6 74(91.4%) 7(8.6%) 75 (92.6%) 4(4.9%) 2(2.5%)¶ 81 79
(97.5%)
Attend
anesthesiologist
6.4 ± 2.6 77(31.3%) 169(68.7%) 233(94.7%) 11(4.5%) 2(0.8%)¶ 246 244
(99.2%)
total 7.1 ± 3.31 151
(46.2%)
176
(53.8%)
308(94.1%) 15(4.6) 4 (1.2%)¶ 327 323
* numbers of try to IJV catheterizations
† Pvalue= 0.004 (difference between Residents and Attends)
‡ Pvalue= 0.001 (difference between Residents and Attends)
§ Pvalue= 0.52 (difference between Residents and Attends)
¶ changed to right subclavian vein
¥ success after 1-2 try
Table 6: using finder needle, catheterization time and comparing male to female patients in internal jugular vein
catheterization
Catheterization time (min)* male† Female†
Finder needle used 5.8 ± 2.2 91 (44.4%) 60 (49.2 %) 151
Finder needle not used 8.8 ± 3.5 114 (55.6%) 62(50.8%) 176
total 7.2 ± 3.27 205 122 327
* Pvalue= 0.002
† Pvalue= 0.42
Table 7: using finder needle and rate of complication for internal jugular vein catheterization
Arterial
puncture
hematoma Sore
throat/dysphagia
Neck pain pneumothorax emphysema malposition
Finder
needle used
12 1 10 32 - - -
Finder
needle not
used
8 1 16 31 - - -
total 20 (6.1%) 2 (0.6%) 26 (7.9%) 63 (19.3%)
Pvalue 0.06 0.71 0.27 0.21