Avoid internal jugular vein transfixion

In a recent letter, it was shown that the internal jugular vein was transfixed in 50% of cases during venous cannulation [1]; other authors have found a similar incidence of venous transfixion [2]. In the first study, a ‘seeker’ needle was used initially to locate the vein. There was no comment on whether transfixion occurred with this needle. Subatmospheric pressure was maintained on the syringe attached to the main (Arrow) needle. This needle was advanced to a depth at which the vein had previously been located. If no blood appeared in the syringe, the needle was withdrawn. The authors recommended that the main needle be withdrawn slowly if the vein was not initially entered and had inadvertently been transfixed. This should maximise the chance of re-entering the lumen of the vein on removal of the needle. The position of the patient during the attempt at cannulation was not described. These findings are at variance with our experience in Cardiff, as illustrated by our incidence of venous transfixion in 20 consecutive patients presenting for cardiac surgery. The patients were placed in a horizontal position and a previously described method [3] was used to cannulate the internal jugular vein. A 21G, 40-mm ‘seeker’ needle was used initially and an 18G, 70-mm needle was then used for insertion of a Seldinger wire and triple-lumen catheter. Once the ‘seeker’ needle is in the vein, the operator can determine the depth of the vein from the skin surface. This allows more accurate control of depth of insertion of the main needle. In our practice, both the ‘seeker’ and the main needle are advanced slowly. The vein was not transfixed with the ‘seeker’ needle in any patient. The needles were advanced at ≈45° to the skin and, in the last 10 patients, with the bevel of the main needle pointed away from the operator. In many patients, a definite sense of ‘give’ was noted when the main needle entered the vein. In several cases this ‘give’ was obvious to an observer. The main needle was advanced to approximately the depth of the ‘seeker’ needle. The vein was transfixed with the main needle in only one patient (5% of the cases). In no case was the carotid artery punctured. There are a number of factors that can influence the incidence of venous transfixion. It is important to advance and, if necessary (on rare occasions in our experience), to withdraw the needle slowly. The size and sharpness of the needle are important. A fine, sharp needle is less likely to transfix the vein than a larger, blunt needle. Ideally, the bevel should face away from the operator to minimise downward force on the tissues. It is not clear whether the angle of approach is important in this respect; however, the angle of approach may be determined by the original description of the technique chosen. Initial use of a fine ‘seeker’ needle to locate the vein is an important part of an optimum technique and should minimise the incidence of serious complications [4]. Lastly, the size of the venous lumen and the ease of venous compression are important. The size of the vein can be influenced by posture, use of the Valsalva manoeuvre and venous filling. The larger the vein, the less the chance of transfixion. The potential for venous transfixion should therefore be reduced if the patient is placed in a head-down position. This was not done in this consecutive series of 20 patients because we have previously found that good results are obtained with patients placed in the horizontal position. We only employ the head-down position if there is any difficulty in venous cannulation. Transfixion is intrinsically undesirable. Firstly, because two holes are made in the vein. Second, the carotid artery can lie behind the vein and transfixion of the vein can lead to additional carotid artery puncture. In one study, the vein was shown to lie over the carotid artery in 54% of patients [5]. This information further supports the use of a technique that minimises the chance of transfixing the vein and also possibly entering the carotid artery. In another ultrasound study, the vein was first observed to be transfixed and the artery was then entered with the needle [6]. As the needle was withdrawn, bright red arterial blood was initially obtained and then dark blood was obtained as the needle re-entered the lumen of the vein. Naturally the choice of an appropriate technique and the choice of appropriate equipment and a sensible fall back plan if the first attempt is unsuccessful are all of paramount importance in successful internal jugular vein cannulation. The use of a ‘seeker’ needle should be an integral part of any technique that is imparted to staff-in-training. An important additional technical consideration is to advance the main needle slowly in order to minimise the risk of venous transfixion.