Ultrasound-Guided Internal Jugular Catheter Insertion in Prone Position

OBTAINING vascular access is a vital component of patient care both in anesthesia and intensive care practice. Ultrasound-assisted vascular access can provide a safer and more efficient means of obtaining both peripheral and central venous access by reducing complications.^1, 2, 3

Several techniques have been used for the catheterization of the internal jugular vein (IJV). These include the oblique, central, anterior, and posterior approaches.⁴

In this technical note, the authors’ purpose is to describe the use of the oblique view for the direct visualization of the IJV and carotid artery (CA) during placement of an ultrasound-guided IJV catheter in 2 patients receiving anesthesia in the prone position.

Two male patients with no significant medical history (ages 66 and 71 with a body mass index of 34 kg/m² and 25 kg/m², respectively) underwent lumbar spine and spinal sacrum surgery. Induction of general anesthesia was uneventful, and they were placed in the prone position. However, during surgery the patients became hemodynamically unstable as a result of brisk bleeding. Although each patient had a 16- or 18-gauge intravenous peripheral catheter, we determined that placement of a central line was required for the provision of blood products and the need for infusion of vasoactive drugs.

While in the prone position, the patients were prepped and draped in sterile fashion and placed in a slight Trendelenburg position. The ultrasound transducer was placed at the anterior cervical triangle where both the IJV and CA were visualized in the short-axis view. The anterior cervical triangle had to be exposed in order to allow for proper transducer placement. Therefore, in each case, the patient’s head was turned laterally. The probe was rotated approximately 10 to 20 degrees clockwise thereby allowing for an oblique view. In this position, the IJV was visualized in the short-axis view (hypoechoic round to oval structure) and at the same time permitting visualization of an elongated, or expanded, view of the vein from a medial-lateral perspective. With the IJV visualized at the center of the screen, the needle was inserted laterally to the transducer at the posterior cervical triangle (Fig 1, A). The needle was directed medially to the anterior cervical triangle by using the long-axis technique (Fig 1, B). Once the needle tip was confirmed within the IJV lumen, the J-tip guide wire was inserted. The correct position was established by visualization of the J-tip guide wire in the long axis within the IJV lumen (short-axis view) and its direction toward the innominate vein (Fig 1, C) (Video 1).

Fig 1

(A) The lateral-medial oblique approach for ultrasound-guided internal jugular vein cannulation (mannequin). (B) Short-axis view (internal jugular vein), in-plane technique (needle). (C) The J-tip guide wire within the internal jugular vein. IJV, internal jugular vein; J-W, J-tip guide wire; N, needle.

We decided to cannulate the IJV with this technique for 2 reasons. First, the IJV was visualized in the short-axis view with the ultrasound probe placed at the anterior cervical triangle with a medial-to-lateral orientation, by allowing for enough space for the needle to be placed laterally to the ultrasound transducer. With a cephalad-to-caudad probe orientation, the mandible may have obstructed both proper needle placement and the required maneuvers in the anterior cervical region. We limited the challenges of maintaining the ultrasound beam, vessel, and needle in the same plane by using this approach. Second, by inserting the needle through the in-plane approach, we very precisely targeted the IJV. This approach also allowed for the ultrasound transducer to be rotated slightly caudal thereby facilitating the direction of the needle, and subsequently of the J-tip guide wire, toward the innominate vein. Caution and vigilance must be exercised because the CA is frequently situated medial to the IJV. Hence, a forced needle advancement without a clear visualization of the needle tip within the IJV lumen may entail certain risks to the CA.

In summary, the oblique view combines the superiority of the short-axis view by allowing for clear visualization of the IJV while allowing for continuous real-time visualization of the long axis of the needle. The authors are suggesting use of this novel approach to ultrasound-guided IJV cannulation because it provides unobstructed access to the IJV in patients lying in the prone position. Moreover, anesthesiologists also are encouraged to advance their procedural skills to ensure high competency in difficult cases that mandate urgent intervention and high precision.