Small Ultrasounds Believed Affordable
To the Editor
Recently, after a patient developed a stroke following unintended carotid puncture during attempted internal jugular vein cannulation, I reviewed the (now extensive) literature documenting the greatly reduced incidence of carotid puncture when this procedure is performed under ultrasonic guidance. At the 1999 ASA meeting in Dallas, I saw that even portable, relatively inexpensive ultrasound machines permit easy visualization of the carotid artery and internal jugular vein at all levels of the neck.
For some time, it has been a source of pride to me that, among the members of the various physician specialties, anesthesiologists have consistently “set the curve” in the safety of the procedures we perform. It was not surprising to me, therefore, when my library work revealed that the initial description of ultrasound-guided internal jugular vein cannulation1 and many of the early studies demonstrating the superior safety of this procedure over traditional “blind” techniques2 were written by anesthesiologists. More recently, ultrasonic guidance of puncture of diverse arteries and veins has been promoted by physicians of many specialties.3 A recent editorial in the British Journal of Anaesthesia indicates, however, that if our intention is to eliminate all unnecessary patient injury associated with central venous cannulation, ultrasonic guidance remains underutilized.4
I write then, to ask that the APSF consider forming an ad hoc committee to define the proper use of ultrasound guidance during deep vein cannulation in clinical practice. Should such a committee determine that this new clinical method represents an important advance in patient safety, perhaps the APSF could also consider commending the anesthesiologists who were instrumental in its development.
James Riopelle, MD
New Orleans, LA
Notes and References
1. [First report of ultrasonically-guided internal jugular cannulation that I could find. When I phoned the first author—still an anesthesiologist—he stated that he remains unaware of any prior accounts.]
Bazaral M, Harlan S. Ultrasonographic anatomy of the internal jugular vein relevant to percutaneous cannulation. Crit Care Med 1981;9:307-310.
2. Other early (pre-1995) reports & studies by anesthesiologists* Metz S, Horrow JC, Balcar I. A controlled comparison of techniques for locating the internal jugular vein using ultrasonography. Anesth Analg 1984;7:673-9.
Yonei A, Nonoue T, Sari A. Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein. Anesthesiology 1986;64:830- 1.
Scherhag A, Klein A, Jantzen JP. Die Kaniffierung der Venajugularis interna mit Hilfe der Sonographie. Anasth Intensivther Notf Med. 1987; 153:321-3.
Scherhag A, Klein A, Jantzen JP. Die Venajugularis interna-KanCilierung mit Hilfe zweier Ultraschall Verfahren: eine vergleichende, kontrollierte Untersuchung. Anaesthesist 1989; 11:633-8.
Bond DM, Champion LK, Nolar R. Real-time ultrasound imaging aids jugular venipuncture. Anesth Analg 1989;68:700-1.
Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein: a prospective, randomized study. Anesth Analg 1991;72:823-6.
Alderson PJ, Burrows FA, Stemp LI, Holtby HM. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Brit J Anaesth 1993;70:145-8.
3. Many favorable reports of the benefits of ultrasound-guided jugular and subclavian vein cannulation have now been published by intensivists, obstetricians, radiologists, nephrologists and surgeons.*
4. Scott DHT. “In the country of the blind, the one-eyed man is king” (editorial). Brit J Anaesth 1999;82:820-1.
* A large portion of the published literature on ultrasound-guided central venous cannulation can be gleaned using the search engine at the National Library of Medicine’s home page (www.ncbi.nlm.nih.gov/pubmed) using such search term combinations as “ultrasound AND jugular.”