An Ultrasound Method for Safe and Rapid Central Venous Access

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Abstract
The standard method for gaining access to the internal jugular vein is by the external anatomical-landmark method.1 Although this method usually allows venous access, a failure rate of up to 19 percent and a complication rate of 5 to 10 percent, depending on the operator's experience, have been reported.2 Complications include puncture of the carotid artery, hematomas, pneumothorax, and injury to the brachial plexus, stellate ganglion, and the phrenic and recurrent laryngeal nerves. We have developed an ultrasound-guided method using portable equipment to improve access to the internal jugular vein. We prospectively evaluated 300 patients undergoing routine cannulation of the internal jugular vein. In 200 consecutive patients, the ultrasound-assisted approach was used, and the results were compared with those for 100 consecutive patients in whom the external landmark technique was used. Although the use of ultrasonography or Doppler methods for this purpose has been suggested in the past, 3 4 5 6 7 to our knowledge it has never been applied routinely or prospectively compared with the landmark method. Ultrasound assistance was provided by a 7.5-MHz mechanical sector-scanning transducer with a 5-cm standoff, focused at a depth of 6.5 cm and connected to a battery-powered, portable device (weight, 6 1b) with a 3-by-3-in. cathode-ray tube screen. The internal jugular vein and carotid artery were visualized by placing the transducer over the groove between the sternal and clavicular heads of the sternocleidomastoid muscle, so that it was parallel and superior to the clavicle. Performance of the Valsalva maneuver markedly enlarged the internal jugular vein and further facilitated access ( Fig. 1 ). The internal jugular vein was cannulated successfully in all patients with the use of ultrasonography and in 90 of the patients with the landmark technique (P<0.05). Access time (time from penetration of the skin to the aspiration of venous blood) was markedly shorter with ultrasonography (11 seconds; range, 2 to 62) than with the landmark technique (65 seconds; range, 3 to 1000) (P<0.001). With ultrasound assistance, more veins were entered on the first needle pass (95 percent vs. 33 percent; P<0.001) and fewer attempts were required (ultrasound-guided: average, 1; range, 1 to 3; landmark-guided: average, 3; range, 1 to 28; P<0.001). There were significantly fewer complications with ultrasonography than with the landmark technique (carotid puncture: 1 percent vs. 7 percent; P<0.05; brachial-plexus irritation: 0.5 percent vs. 8 percent; P<0.001; hematoma: 0 percent vs. 4 percent; P<0.005).