ISSN 0971-8561 | Volume 19 | Issues 4

Oct - Dec 2016

Annals of

Cardiac

Anaesthesia Special issue on TEE and Hemodynamic Monitoring

Original Article

Accidental arterial puncture during right internal jugular vein cannulation in cardiac surgical patients Madan Mohan Maddali, Venkitaramanan Arun, Al‑Ajmi Ahmed Wala1, Maher Jaffer Al‑Bahrani2, Cheskey Manoj Jayatilaka, Arora Ram Nishant Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, 2Department of Anesthesia and Adult Intensive Care, Royal Hospital, 1Department of Anesthesia Specialty, Oman Medical Specialty Board, Muscat, Sultanate of Oman

ABSTRACT

Received: 09‑03‑16 Accepted: 03‑08‑16

Background: The primary aim of this study was to compare the incidence of accidental arterial puncture during right internal jugular vein (RIJV) cannulation with and without ultrasound guidance (USG). The secondary end points were to assess if USG improves the chances of successful first pass cannulation and if BMI has an impact on incidence of arterial puncture and the number of attempts that are to be made for successful cannulation. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Material and methods: 255 consecutive adult and pediatric cardiac surgical patients were included. In Group I (n = 124) USG was used for the right internal jugular vein cannulation and in Group II (n = 81) it was not used. There were 135 adult patients and 70 pediatric patients. Statistical analysis: Demographic and categorical data were analyzed using Student ‘t’ test and chi- square test was used for qualitative variables. Results: The overall incidence of accidental arterial puncture in the entire study population was significantly higher when ultrasound guidance was not used (P < 0.001). In subgroup analysis, incidence of arterial puncture was significant in both adult (P = 0.03) and pediatric patients (P < 0.001) without USG. First attempt cannulation was more often possible in pediatric patients under USG (P = 0.03). In adult patients USG did not improve first attempt cannulation except in underweight patients. Conclusions: USG helped in the avoidance of inadvertent arterial puncture during RIJV cannulation and simultaneously improved the chances of first attempt cannulation in pediatric and in underweight adult cardiac surgical patients. Key words: Blood vessels/injuries; Blood vessels/ultrasonography; Catheterization; Central venous/adverse effects

INTRODUCTION

Access this article online

Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.191568 Quick Response Code:

594

Unintended arterial puncture can occur during central venous cannulation.[1] Data from the American Society of Anesthesiologists (ASA) Closed Claims Project database suggested that a majority of mechanical complications associated with central venous cannulation are vascular injuries and “accidental puncture or laceration.”[1] It is therefore important for anesthesia providers to be conversant with the tools and techniques that can help prevent arterial injuries. The current literature supports the use of ultrasound guidance  (USG) for central venous catheterizations to minimize complications.[2,3] This study was initiated with the hypothetical question whether USG

could avoid accidental arterial puncture during right internal jugular vein (RIJV) cannulation as compared to landmark technique. The Address for correspondence: Dr. Madan Mohan Maddali, Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, P. B. No: 1331, P. C: 111, Seeb, Muscat, Sultanate of Oman. E‑mail: [email protected]

This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] Cite this article as: Maddali MM, Arun V, Wala AAA, Al-Bahrani MJ, Jayatilaka CM, Nishant AR. Accidental arterial puncture during right internal jugular vein cannulation in cardiac surgical patients. Ann Card Anaesth 2016;19:594-8.

© 2016 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow

Maddali, et al.: Internal jugular vein cannulation: Adverse effects

primary aim of this study was to compare the incidence of carotid artery puncture during RIJV cannulation with and without USG. The secondary end‑points were to evaluate if the number of attempts for successful cannulation would be reduced under USG and if body mass index  (BMI) influences the incidence of the inadvertent arterial puncture as well as to determine the difficulty of RIJV access in terms of the number of attempts made. MATERIALS AND METHODS After obtaining approval from the Institutional Medical Ethics and Scientific Research Committee  (MESRC#50/2015), 205 consecutive patients undergoing cardiac surgery and who routinely need central venous access were prospectively included in this study. The patients in whom the RIJV cannulation was attempted were only included in the study. Of the 205  patients, there were 135 adult and 70 pediatric patients. In the adult patients, USG was used in 75 patients, and in pediatric patients, USG was used in 49 patients. The central venous access was performed in all patients under general anesthesia and strict aseptic precautions with standard ASA monitoring. The positioning of the patient in terms of head rotation, degree of head down tilt, support under the shoulders, etc., was similar in all patients. All cannulations were performed by experienced cardiac anesthesiologists with more than 10  years of experience in the field. The use of USG was based on the availability of the equipment. The patients in whom USG was used for RIJV cannulation were included into Group I (n = 124) and Group II (n = 81) included those patients who had jugular cannulation without USG. For USG during cannulation, out of plane imaging with a Philips L15‑7io linear probe that is compatible with iE33  xMATRIX echocardiography machine  (KPI Ultrasound, CA 92887, USA) was used. In the group without USG, a paracarotid approach was used with the site of skin puncture at the midpoint between the right mastoid process and sternal insertion of the sternocleidomastoid muscle. Successful internal jugular vein cannulation at the first attempt with a single skin puncture was considered the first‑pass cannulation. Further skin punctures beyond the first were considered multiple attempts. Demographic data including age, weight, height, BMI (in adults), body surface area (in pediatric patients) and procedure‑related data including the incidence of arterial puncture, and a number of attempts that were made were recorded. The arterial puncture was recognized either by pulsatile blood flow or by pressure Annals of Cardiac Anaesthesia |  Oct-Dec-2016 | Vol 19 | Issue 4

transduction. The patients were categorized based on their BMI into underweight (BMI