Is finder needle necessary for internal jugular

vein catheterization?

Eisa Bilehjani MD, Assistant Professor in Aesthesia, Fellowship in Cardiovascular

Anesthesia, Madani Heart Hospital, Tabriz – Iran. (Corresponding Author)

Amir Abbas Kianfar MD, Assistant Professor in Aesthesia, Fellowship in Cardiovascular

Anesthesia. Imamreza Heart Hospital, Tabriz - Iran.

Solmaz Fakhari MD, Resident in Anesthesiology. Madani Heart Hospital, Tabriz – Iran

Corresponding author: Dr. Eisa Bilehjani, Department of Cardiovascular Anesthesia,

Madani Heart Hospital, Tabriz University of Medical Sciences; Tabriz - Iran.

Tel: 0098 411 3360894, Fax:0098 411 3344021, E-mail: isa_bilehjani@yahoo.com

From: Department of Cardiovascular Anesthesia, Cardiovascular Research Center, Madani

Heart Hospital, Tabriz University of Medical Sciences: Tabriz – Iran

Implications Statement: we studied finder needle use and complications rate of internal

jugular vein catheterization in adult elective cardiac surgery in two university hospital. We

concluded that using finder needle increase procedure time without reducing risk of arterial

puncture and other complications.

Abstract:

Background: Internal jugular vein (IJV) is the most common vein used for

hemodynamic monitoring by anesthesiologists. Serious complications may be

associated with IJV catheterization such as carotid artery puncture, pneumothorax and

nerve injury. Finder needle is usually used for reducing its complications. We studied

finder needle use in IJV catheterization and complications rate in adult cardiac

surgery.

Methods: At a prospective study at about 3 month period from august to November

2007, all patients older than 18 years who were candidate for elective cardiac surgery

were studied. Data were collected about using finder needle, patient position, success

rate, intra and postoperative complications of IJV catheterization.

Results: Of totally 399 patients, 52 patients were excluded from study. Finally in

remaining 347 patients, in 92.5% (321) of patients, catheter was placed in right internal

jugular vein. Finder needle was used in 151(46.2%) of IJV catheterization (group one) versus

176 (53.8%) patients that IJV catheterization were done without finder needle (group two).

Anesthesiology residents significantly used finder needle more than attends (Pvalue= 0.001).

Using finder needle significantly increased catheterization time from 5.8 ± 2.2 to 8.8 ± 3.5

minutes (Pvalue= 0.002).There were not any significant differences in complications and

success rate between two groups.

Conclusions: To reduce complications or increase success rate, there is not any need for

finder needle use in internal jugular vein catheterization.

Key Words: internal jugular vein, Complications, Central venous catheterization, finder

needle, Seldinger technique

Word Count: 223

Introduction:

Central vein cannulation is the standard clinical method for monitoring central venous

pressure (CVP) in operating room and ICU. It is also performed for a few other

therapeutic interventions. Insertion of central venous catheters has become an

important skill for all hospital doctors to obtain. Internal jugular vein (IJV) is the most

common vein used by anesthesiologists. Serious complications may to be associated

with IJV catheterization such as carotid artery puncture, pneumothorax and nerve

injury. As with most medical procedures, the level of experience of the physician

reduces the risk of complications (1). Seldinger technique (catheter over guide-wire)

from 1956 could to provide an extremely useful and safe method of inserting all types

of central venous access lines. But, however, central venous catheterization continues

to be associated with significant complications (ex. carotid artery puncture, stroke,

death) approximately 10% of the time (1-3). Use of ultrasound during central venous

catheterization can reduce rate of complications, but it is not used routinely (4).

Finder needle is usually used for reducing its arterial complications, but its roll was

questioned. We studied finder needle use and complications rate in IJV catheterization

in elective adult cardiac surgery.

Methods:

In a 3 month period from august to November 2007 all adult patients underwent

cardiac surgery in two university hospitals, were studied prospectively about central

venous catheterization. Patient's anesthesia and surgical teams were blind about what

kinds of data are collecting. Patients of emergency or redo operations, same day

reoperation because of tamponade or hemorrhage, apparent preoperative

coagulupathy and renal failure were excluded from study. Demographic,

intraoperative and 48 hours ICU stay period data were collected. Totally 399 patients

were enrolled to study. Premeditation, anesthesia induction, arterial catheterization

performed as routine for all patients. Central venous catheterization performed after

anesthesia induction/tracheal intubation by an attend or resident of anesthesiology

who was blind about study and nature of what data are colleting. Site of central

venous cannulation, patient position, using finder needle, failure rate (more than two

tries), numbers of tries, arterial puncture, changing to other site, bleeding and

hematoma formation, anesthesia and operation times were recorded. In ICU sedation,

intubation and ICU stay times, objective and subjective complications were recorded.

Patients who need reoperation because of bleeding or post operation tamponade, long

mechanical ventilation (> 24houres) were excluded from study. From totally 399

patients, 42 patients were excluded from the study because of reoperation or

mechanical ventilation dependency more than 24 hours. In 10 of the patients, pulmonary

artery catheter were used, all of them simultaneously inserted via RIJV parallel to central

venous catheter, they were also excluded from the data analyzing. Finally in 347 patients,

data were analyzed with SPSS statistical software (version 14.0), using chi-square,

Fisher’s exact test, independed samples t-test.

Results:
After collecting data from totally 399 patients, 52 patients were excluded from study.

Initially data were analyzed in 347 patients. ASA class of physical status is shown in table 1.

In 4 patients, simultaneously, both right subclavian and internal jugular veins were used,

because of poor peripheral vascular access. Right internal jugular vein used in 92.5% of all

patients (table 1). In 4 patients initially attempts for internal jugular vein catheterization were

failed and changed to right subclavian vein.

Finally data analyzed in 327 patients, in whom right or left internal jugular veins were the

first preferred sites for catheterization, but were failed in 4 patients. Data were compared

between two groups: group one (finder needle used) and group two (finder needle not used).

Demographic data, risk factor, diagnosis and anesthesia, surgery, sedation, intubation and ICU

times are shown in tables 3 and 4.

In all patients head rotation about 30 degree was used but Trendelenburg (head down)

position was used in only 74 patients (22.6 %) during catheterization, there was not any

difference between anesthesiology attends and residents about using this position. Central

landmark approach was used in 99.3% of patients. Finder needle was used in 151(46.2 %)

of IJV catheterization. Total IJV catheterization procedures that performed by attends

and resident anesthesiologists were 246(75.2%) and 81(24.8%), respectively (table 5).

Resident anesthesiologists significantly preferred finder needle use (Pvalue= 0.001).

Attends significantly performed procedure faster than residents (Pvalue= 0.004). There were

not any significant differences in success rate or changing to subclavian vein between two

groups. There was not any difference about using finder needle, comparing male to

female patients (table 6), (Pvalue= 0.42).

There were not any differences about using finder needle related to risk factors or

diagnosis, except asthmatic patients in them usually finder needle was used (Pvalue=0.023).

At all there was any difference about complications rate between attends and

residents. Neck pain and Sore throat/dysphagia were seen as common as 19.3% and

7.9%, respectively (table 7).

Discussion:

Central venous cannulation has become an integral component of modern medical

care and has become an important skill for all hospital doctors and stuff, they must be

to obtain. This procedure is performed in a wide range of locations within the

hospital. Various sites are used for central venous access. An important factor in
choosing the best site is the operator's own knowledge and experiences, as the chance

of failure and complications increases if the operator is unfamiliar with the particular

technique (1,5). Right internal jugular vein (RIJV) is the most common vein used by

anesthesiologists, for hemodynamic monitoring in the operating room. Serious

complications may be associated with IJV catheterization such as carotid artery

puncture, pneumothorax and nerve injury. From the first recorded of placement a

central venous cannula in a human occurred in 1929, Seldinger technique (catheter

over guide-wire) in 1956 provided a safe and successful method for inserting all types

of central venous access lines. But still central venous catheterization continues to be

associated with significant complications approximately 10% of all the times. Carotid

artery puncture during internal jugular vein (IJV) catheterization is reported to occur

2%–17% of the time, in a wide range of studies (5). Rare but devastating

complications (e.g., stroke, death) resulting from arterial complications during

catheterization also continue to be reported (5-10).

Finder needle, a small 22-gauge 1 ½ inch, is usually used for reducing IJV

catheterization complications (5). When locating IJV with a small finder needle, using

surface anatomical landmarks, accidentally arterial puncture will result to a small

controllable hemorrhage or hematoma. Recently internal jugular vein cannulation

under two dimensional ultrasound guidance provided a quicker and safer method than

the landmark method in both adults and children (4,5). But its use is not popular

because needs sufficient ultrasound machines and staff training (4). That it is

important that “operators maintain their ability to use the landmark method and that

the method continues to be taught alongside the 2-D ultrasound guided

technique”(4,11).
Finder needle is not a permanent component of the IJV catheterization procedure.

Indeed in our study only in 46.2% of patients it was used. When catheterization is

performed by well trained, experienced clinicians, success rate and serious immediate

complications are infrequent, however, infectious complications remain common

(1,5,12). Anesthesiologists are the most experienced clinicians in this field, usually it

is their routine daily activity. In our study numbers of attempts were not differ

between attends and residents. The incidence of mechanical complications after three

or more insertion attempts is six times the rate after one attempt (1). In this study

resident anesthesiologists used finder needle in 91.4% versus 31.3% comparing to

more experience attends. Using finder needle not only did not change complication

and success rate, however increased procedure time.

Common immediate complications of procedure are: Vascular injury (Arterial,

Venous), cardiac tamponade, respiratory compromise (Airway compression from

hematoma, pneumothorax), nerve injury, arrhythmias, arterial thrombosis and

embolism, pulmonary embolism and catheter or guide-wire embolism, however, many

of these complications result from operator error (5,13).

In general, unintended arterial puncture is the most common immediate mechanical

complication. Shah and coauthors reported more than 6000 central venous

catheterizations over a 5-year period, with more than 95% performed through the

internal jugular vein. In this series, the most common complication was carotid artery

puncture, which occurred in 120 patients (1.9%) but did not result in any serious

morbidity. Authors of other large studies report a somewhat higher incidence of

arterial puncture during central venous catheterization ranging from approximately

3% to 15% (5). The frequency of arterial puncture with a small gauge finding needle

may be even higher than these estimates (5). Though usually benign, on rare
occasions, arterial puncture with even small-gauge needles may lead to serious

complications such as arterial thromboembolism (5). In our study arterial puncture

totally happened in 6.1%, but there was not any difference between two groups.

Pneumothorax incidence after IJV is very low. Shah and coauthors reported a 0.5%

incidence of pneumothorax in their series of nearly 6000 internal jugular

catheterizations. In our study there was not seen any case of pneumothorax, this is

probably may be due to that most of our cardiac surgeons usually place chest drain

tubes in pleural space, at the end of surgery.

Sore throat/dysphagia and neck pain were very common more than previous reports

(14), 7.9% and 19.3% respectively. There was not any difference between groups

considering finder needle use. Sore throat/dysphagia may be related to that all of our

patients underwent tracheal intubation. Neck pain, usually at epsilateral site, was the

most common symptom, which was usually relieved after catheter removal.

Nerve injury is a potential complication of central venous cannulation. Damage may

occur to the brachial plexus, satellite ganglion, phrenic, laryngeal nerves (15), or

vocal cords. Chronic pain syndromes have been attributed to this procedure as well

(16). It seems increasing operator skill is the best method for reducing these

complication. Anesthesia residents with low experiences used finder needle more than

attends, but complications rate was not differ significantly. Finder needle significantly

prolonged procedure time.

In summary it may be concluded when operator is a experienced clinician, finder

needle can be deleted from procedure without increasing risks.

References:

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Injuries and liability related to central vascular catheters: a closed claims

analysis. Anesthesiology 2004;100:1411–8.

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anesthesia, vol 1, 6th ed. Churchill Livingstone, Pennsylvania , 1286-1296.

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Inadvertent carotid artery cannulation during pulmonary artery catheter

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catheterization with a lethal complication. Intensive Care Med 1999;25:1180–2

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right vertebral artery. Anesth Analg 2006;103:1625-1626

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2005:112: 349–357
11. National Institute for Clinical Excellence. Guidance on the use of ultrasound

locating devices for placing central venous catheters. London: NICE, 2002.

[NICE Technology Appraisal No 49.]

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advice. Anaesthesia 2005;60:1–4

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during Jugular catheter insertion. Nephron 1998;79:352-352

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Med 1999;92:386

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Table 1: ASA status classification of patients underwent cardiac surgery

ASA class* N (%)

I 5 (1.4%)

II 157(45.2%)

III 148(42.7%)

IV 37(10.7%)

Total 347

* ASA class; American society of anesthesiologist classification of clinical status

Table 2: Different successful sites used for central venous catheterization in total 347 patients underwent cardiac

surgery

Catheterization site N (%)

RIJV 321 (92.5%)
RSCV 23 (6.6%)
LSCV 5 (1.4%)
LIJV 2 (0.6%)
Total catheterization site number 351*
* In 4 patients, simultaneously, right subclavian and internal jugular veins were used, because of poor peripheral

vascular access
Table 3: demographic data of patients with central venous catheterization site in internal jugular vein

Mean ± SD

Age 55.5 ± 12.5

Height 163 ± 7.8

Weight 68.8 ± 10.4

Table 4: risk factors, diagnosis, anesthesia, surgery and ICU data of patients underwent cardiac surgery with

central venous catheterization site in internal jugular vein

N (%)

DM 72 ( 22.0%)

C/S 134 ( 41.0%)

HLP 135 ( 41.3%)

HTN 193 ( 59.0%)

Asthma 16 ( 4.9%)

COPD 23 (7.0%)

CAD 212 (64.8 %)

VHD 70 ( 21.4%)

CAD+VHD 22 ( 6.7%)

CHD 23 ( 7.1%)

Anesthesia time (minute)

337 ± 59
Operation time (minute)
287 ± 55
Sedation time (hour)
5.5 ± 5.0
MV time (hour)
9.4 ± 6.0
ICU stay time (hour)
57.3.0 ± 21.4
DM; diabetes mellitus, C/S; cigarette smoking, HLP; hyperlipidemia, HTN; hypertension, COPD; chronic

obstructive pulmonary disease, CAD; coronary artery disease, VHD; valvular heart disease, CAD+VHD;

coronary artery disease and valvular heart diseas,e CHD; congenital heart disease (ASD, VSD, TOF,PAPVC ),

MV time; mechanical ventilation time

Table 5: Using finder needle by attend and resident anesthesiologist and success rate

(success after 1-2 try) in internal jugular vein catheterization

catheterization Finder Finder One try* § Two try* More than Total Success

time(min) † needle needle not two try or First try rate ¥

used ‡ used Chang to on IJV

SCV
Resident 9.4 ± 3,6 74(91.4% 7(8.6%) 75 (92.6%) 4(4.9%) 2(2.5%)¶ 81 79

anesthesiologist ) (97.5%)
Attend 6.4 ± 2.6 77(31.3% 169(68.7%) 233(94.7%) 11(4.5%) 2(0.8%)¶ 246 244

anesthesiologist ) (99.2%)
total 7.1 ± 3.31 151 176 308(94.1%) 15(4.6) 4 (1.2%)¶ 327 323

(46.2%) (53.8%)
* numbers of try to IJV catheterizations

† Pvalue= 0.004 (difference between Residents and Attends)

‡ Pvalue= 0.001 (difference between Residents and Attends)

§ Pvalue= 0.52 (difference between Residents and Attends)

¶ changed to right subclavian vein

¥ success after 1-2 try

Table 6: using finder needle, catheterization time and comparing male to female patients in internal jugular vein

catheterization

Catheterization time (min)* male† Female†

Finder needle used 5.8 ± 2.2 91 (44.4%) 60 (49.2 %) 151

Finder needle not used 8.8 ± 3.5 114 (55.6%) 62(50.8%) 176
total 7.2 ± 3.27 205 122 327
* Pvalue= 0.002

† Pvalue= 0.42
Table 7: using finder needle and rate of complication for internal jugular vein catheterization

Arterial hematoma Sore Neck pain pneumothorax emphysem malposition

puncture throat/dysphagia a
Finder 12 1 10 32 - - -

needle used
Finder 8 1 16 31 - - -

needle not

used
total 20 (6.1%) 2 (0.6%) 26 (7.9%) 63 (19.3%)
Pvalue 0.06 0.71 0.27 0.21