The Journal of Emergency Medicine, Vol. 57, No. 6, pp.

852–858, 2019
Ó 2019 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

https://doi.org/10.1016/j.jemermed.2019.08.029

Ultrasound in
Emergency Medicine

AN ALTERNATE IN-PLANE TECHNIQUE OF ULTRASOUND-GUIDED INTERNAL

JUGULAR VEIN CANNULATION

Ganapathi Aithal, MD, DNB, FCAI,* Ganapathy Muthuswamy, MD, DA, FCAI,*† Zulaidi Latif, FRCA,*
Vinod Bhaskaran, MD,* Haji Satry Haji Sani, FCAI,* Suresh Shindhe, MBBS,* Nurulhuda Binti A. Manap, MBBS,*
Kaivalya Sadashiv Vadaje, MD,* Wardina Shumaimah Dato Paduka Buntar, BMBS,* and
Rajendra Govindrao Daiwajna, FRCP*
*Department of Anaesthesiology, Raja Isteri Pengiran Anak Saleha Hospital, Jalan Putera Al-Muhtadee Billah, Bandar Seri, Begawan, Brunei
Darussalam and †Anesthetics Department, Hamad General Hospital, Doha, Qatar
Corresponding Address: Ganapathi Aithal, MD, DNB, FCAI, Bandar Seri Begawan BA1712, Brunei Darussalam

, Abstract—Background: Commonly used ultrasound- rior venous wall punctures and 2.66% misplacements and
guided internal jugular vein (IJV) cannulation techniques, no other complications. Conclusion: Anteroposterior short
short axis out of plane and long axis in-plane, have signifi- axis in-plane technique is relatively novel and could be alter-
cantly reduced complications but failed to eliminate them natively used safely and effectively in place of existing tech-
because of technical difficulties. Objective: This article de- niques for IJV cannulation. Ó 2019 Elsevier Inc. All rights
scribes a new anteroposterior short axis in-plane technique reserved.
that combines advantage of in-plane technique to track the
needle tip and short axis view of visualizing nearby anatom- , Keywords—APSAX; cannulation; in-plane; internal ju-
ical structures by placing the probe on the side of the neck, gular; ultrasonography
oriented anteroposteriorly, perpendicular to the long axis of
neck. This view visualizes IJV and its relationship to the ca-
rotid artery in short axis. The puncture needle is passed in- INTRODUCTION
plane anteroposteriorly from the anterior aspect of the neck.
Visualizing the needle, carotid artery, and IJV in single Internal jugular vein (IJV) cannulation is a common pro-
frame minimizes complications. Methods: A prospective
cedure to facilitate the care of critically ill patients. Two-
evaluative clinical trial was conducted in patients who
dimensional ultrasound (US) is used to guide IJV cannu-
require IJV cannulation for various reasons by performers
experienced in ultrasound-guided IJV cannulations. The ef- lation with improved success rates and significantly
ficacy of the technique is indicated by 3 primary outcome reduced complications (1–4). Various techniques of US
measures: access time, number of attempts and success probe position and the needle approach have been
rate, and safety by secondary outcome measure, which is described to improve the success rate and minimize
the incidence of mechanical complications. Results: Sev- complications (5–7). The long axis in-plane (LAX-IP)
enty-five patients were enrolled. The average number of at- technique provides a better needle path, tip visualization,
tempts was 1.17 (standard deviation 0.44), the access time and helps in reducing complication rate compared with
was 27.12 s (standard deviation 21.47), and the success the short axis out-of-plane (SAX-OOP) technique (4).
rate was 100%. This technique had 12% incidence of poste- SAX US view gives a better visualization of the IJV
and its relation to the carotid artery. The LAX-IP tech-
Reprints are not available from the authors. nique requires high skill to visualize both the carotid

RECEIVED: 3 June 2019; FINAL SUBMISSION RECEIVED: 29 July 2019;

ACCEPTED: 13 August 2019

852
In-Plane Technique of US-Guided IJV Cannulation 853

artery and the IJV at all times. Another pitfall of LAX-IP care unit with standard monitoring (noninvasive blood
is that the US probe occupies the anterior part of the neck pressure, electrocardiography, and pulse oximetry). The
and therefore hinders the process of cannulation and the anesthetic technique used was decided by each patient’s
needle manipulation in obese patients, children, and pa- circumstances and indication of IJV cannulation. Surgi-
tients with short necks. In addition, the side lobe artefacts cal patients were cannulated under general anesthesia
in LAX-IP give the impression that the needle is falsely with or without paralysis, intensive care patients were
inside the vein when the needle is slightly out of plane cannulated under local anesthesia/sedation, and other pa-
of the US beam (6). Finally, it is difficult to be sure that tients who required ward care were cannulated under
the needle is in the center of the vein in the LAX-IP tech- local anesthesia. The side of the cannulation was decided
nique. by the primary physician. The IJV is a superficial struc-
We describe a novel, anteroposterior SAX-IP (AP- ture, and therefore we selected the high-frequency wide
SAX-IP) technique that combines the advantages of the band linear array transducer from one of the following
in-plane technique and the SAX view. This technique US transducers: 12L–RS (5.0–13.0 MHz frequency)
overcomes some of the limitations of the standard from LOGIQ e (General Electric, Boston, MA) US ma-
LAX-IP technique. Limitation of space in patients with chine or HFL38 (13–6 MHz frequency) or L25 (13–
a short neck and hindrance to needle manipulation is 6 MHz frequency) from SonoSite S-Nerve US machine
overcome by placing the US probe on the lateral aspect (Bothell, WA).
of the neck anteroposteriorly. This probe orientation In each patient the IJV was scanned to evaluate the
gives the SAX image, which shows the relationship of suitability for cannulation before the actual procedure.
the IJV to the surrounding structures—especially the ca- Under sterile conditions the IJV was punctured and can-
rotid artery—and avoids the side lobe artefact. In addi- nulation was done with real-time US guidance using the
tion, the center of the vein can easily be identified in APSAX-IP technique. Catheters were sutured and dres-
the SAX view. The primary aim of this study is to pro- sing applied with transparent sterile adhesives according
spectively evaluate the APSAX-IP US-guided IJV cannu- to the standard protocols. Chest radiography was re-
lation with respect to ease of cannulation and quested in all patients to confirm the position of the cath-
complications. eter.
The primary outcome measures that together indicate
MATERIALS AND METHODS efficacy of the technique were access time, number of at-
tempts, and success rate. The incidence of mechanical
This study has been approved by the Medical and Health complications was considered as secondary outcome
Research and Ethics Committee, Ministry of Health, measure, which indicates safety of the technique. Access
Brunei Darussalam reference number MHREC/MOH/ time is the time (in seconds) from starting of the skin
2018/2(1) dated March 22, 2018, and registered with puncture to the successful aspiration of venous blood
Australian New Zealand Clinical Trials Registry through the needle. An attempt is considered as such if
(ACTRN12618000572268). the needle was advanced forward without any backward
All patients $18 years of age requiring IJV cannula- movement. Every successive needle withdrawal with sub-
tion and who were willing to join the study were enrolled. sequent advance was considered as an attempt, whether
The primary physician, using clinical judgement and or not a new skin puncture site was chosen. A maximum
departmental guidelines, identified patients who needed of 5 attempts were permitted, and after that it was consid-
IJV cannulation. Patients with previous surgery at the ered as a failure. Cannulation was considered successful
site of insertion, infection at the site of insertion, clotting once the guidewire was successfully advanced inside the
abnormalities, the presence of thrombus within the IJV, IJV and was considered a failure if the IJV could not be
abnormal IJV anatomy by US imaging (agenesis, stric- successfully punctured within 5 attempts or the physician
tures, or duplication), and patients with pre-existing cath- was unable to advance the guidewire after successful
eters in the IJV were excluded from the study. Written puncture in those 5 attempts. If the cannulation was un-
informed consent was obtained before the procedure. successful, the classical technique was used and cannula-
IJV cannulations were performed by a mixed cohort of tion was performed.
practitioners from consultant to medical officers who are
either intensivists or anesthesiologists with more than
Description of Technique
1 year of experience in US-guided IJV cannulation. The
operators were provided training in the APSAX-IP IJV Operator and US machine position. The operator’s dex-
cannulation technique using reading material, observa- terity determines his or her position with respect to the pa-
tion, and hands-on experience. All cannulations were per- tient to avoid the crossing of hands while holding the US
formed either in the operating room or in the intensive probe with the nondominant hand and the needle with the
854 G. Aithal et al.

dominant hand. For example, a right-handed person, for

right IJV cannulation, ideally, should stand on the left
side of the patient and hold the US probe with the left
hand while using the right hand for cannulation
(Figure 1), and for left IJV cannulation, should stand at
the head end of the patient (Figure 2). The US machine
is kept in front of the operator to view the screen directly
without straining the operator’s neck.

IJV scanning method. Traditionally, the US probe is

placed anteriorly over the neck to scan the IJV either in
the short axis by keeping the probe above and parallel
to the clavicle or in long axis by orienting the probe along
the long axis of the IJV. However, in the APSAX-IP tech-
nique, the US probe is placed by the side of the neck and
oriented anteroposteriorly on the side of cannulation
(Figures 1 and 3). It is important to hold the US probe
perpendicular to the long axis of neck without tilting or
angulation. The operator will have the same perspective
of the image by orienting the probe marker anteriorly
on both sides of the neck. This view shows the short
axis of the IJV and carotid artery, which is like the Figure 2. Position of a left-handed operator. CA = carotid ar-
tery; IJV = internal jugular vein; SCM = sternocleidomastoid.
classical short axis view rotated 90 counter-clockwise.
On the screen, the top part of the image is the lateral
aspect of the neck where the US probe is placed and the used as the approximate needle entry point away from,
left part of the image shows anterior the aspect of the in line with, and parallel to the US probe over the anterior
neck (Figures 1 and 3) where the needle can be seen. neck by visual assessment (Figures 1 and 3). The needle
can be seen entering at the left side of the screen toward
IJV cannulation technique using APSAX-IP. In the the center, which results in vertical puncture of the vein.
APSAX-IP technique, the standard Seldinger technique Depending on the thickness of the neck and because of
is used for IJV cannulation except the US probe position. the indentation caused by the needle, the transducer
To keep the needle as parallel to the US probe as possible footprint may lose contact with the skin. The needle
and to enter the center of the vein, the needle entry point can be redirected by moving the needle tip laterally or
on the anterior aspect of the neck is away from the probe medially for up and down movement on the screen and
at a distance approximate from the transducer footprint to not by tilting the needle in craniocaudal direction. As
the center of the vein. This distance is measured in the US the vein is punctured vertically, the guidewire is
image using the calipers from the transducer footprint to directed toward the heart by tilting the needle tip
the midpoint of the IJV (Figure 1). This measurement is caudally. US is used to confirm the direction of the

Figure 1. The anteroposterior short axis in-plane technique showing orientation of the ultrasound probe, needle direction, and
the entry point. A is the distance from the center of the internal jugular vein (IJV) to the transducer footprint used to identify
the needle entry point. CA = carotid artery; SCM = sternocleidomastoid.
In-Plane Technique of US-Guided IJV Cannulation 855

Figure 3. The anteroposterior short axis in-plane technique showing the needle within the internal jugular vein (IJV). CA = carotid
artery; SCM = sternocleidomastoid.

guidewire and its presence inside the IJV by locating it with their own advantages and disadvantages (1–4).
just above the clavicle. Previous studies have mentioned various techniques
for needle entry and catheter placement through the
RESULTS IJV (5–7). However, limitations and associated
complications persist while using real-time ultrasound.
Seventy-five patients were enrolled in the study from To overcome these complications, our study further
March to August 2018. Patient characteristics and simplified the technique in terms of visualizing the nee-
outcome measures data are presented using number and dle placement.
percentages for categorical variables and mean and stan- Traditional US-guided cannulation from the available
dard deviation for quantitative variables. There were 45 literature supports SAX-OOP being commonly used fol-
men and 30 women between 22 and 88 years of age. lowed by the LAX-IP approach and the oblique axis
The average weight was 74.68 kg (range 40–158 kg). (OAX) approach (6,7). The LAX-IP approach tracks the
There were 45 right-sided and 30 left-sided IJV cannula- needle as it enters the IJV and is considered the better
tions. Cannulation was successful in every patient, for a technique to avoid complications. However, it is difficult
success rate of 100%. The average number of attempts to practice because of the many inherent problems, such
was 1.17 (standard deviation 0.44) and the success rate as the need for a high level of skill, anatomical limita-
was 85.33% (64 patients), 12% (9 patients), and 2.66% tions, and the difficulty in viewing the artery and the
(2 patients) on the first, second and third attempts, respec- vein in the same view.
tively. The average access time was 27.12 s (standard de- This study on the APSAX-IP technique, in which the
viation 21.47). No major mechanical complications like US probe is placed laterally, addresses some of these lim-
arterial puncture, major hematoma, or pneumothorax itations. The average access time of 27.12 s (SD 21.47),
occurred because of the technique. There was, however, the average number of attempts of 1.17 (SD 0.44), and
a 12% (9 cannulations) incidence of posterior venous the 100% success rate means that APSAX-IP is not a
wall punctures (PVWPs) that did not result in any major difficult technique to practice. As an in-plane needling
complications. Although there was 100% success in nee- technique, it can potentially avoid major mechanical
dle placement, there were misplacements of catheters in 2 complications related to IJV cannulation because the im-
patients (2.66%), both left-sided IJV cannulations. One age shows clearly the relationship of the IJV with the sur-
catheter directly went toward the cranium immediately rounding structures, especially the carotid artery. In our
after entering the vein and the other catheter reflected study there is no incidence of carotid artery puncture.
back to the IJV from the junction with the subclavian The added advantage of a laterally placed US probe is
vein. that it will not interfere with cannulation procedure on
the anterior aspect of the neck and the needle can be in-
DISCUSSION serted parallel to the US probe (in-plane) and perpendic-
ular to the US beam, resulting in a bright image of the
The use of ultrasound has significantly reduced the me- entire needle (Figure 4). It is easier to align the needle
chanical complications of IJV cannulation. There are with the US beam because the distance from the skin to
many approaches to US-guided IJV cannulation, each the IJV is short.
856 G. Aithal et al.

vs. 1.24 6 0.56 in LAX), first-pass attempt success

rate (85.33% vs. 78% in LAX), and carotid puncture
rate (0% vs. 4% in LAX) (11). Tammam et al. prospec-
tively studied venous cannulations in patients who were
critically ill and patients undergoing hemodialysis with
SAX-OOP and LAX-IP techniques (12). All investigators
were well trained in US. APSAX-IP is comparable to
SAX-OOP and LAX-IP in terms of the success rate
(100%) and the number of attempts (1.17 6 0.44 vs.
1.13 6 0.35 in SAX vs. 1.17 6 0.38 in LAX) (12). How-
ever, the access time with our technique is shorter than
LAX-IP of above study (27.12 s vs. 52.7 6 11.74 s).
Carotid artery punctures are known, even with US-
guided IJV cannulations and may lead to serious compli-
cations (4,6,13). The carotid punctures reported with
SAX view in previous studies were 0.5%, 1.1%, and
1.5% (4,6,13). In our study, by virtue of APSAX-IP tech-
nique, both the carotid artery and the IJV are clearly visu-
alized in a single frame and the needle is advanced in-
Figure 4. Ultrasound (US) beam reflection and needle orien-
tation in the long axis (LAX) and anteroposterior short axis plane, which avoids carotid artery punctures. Therefore,
(APSAX) views. we did not have any incidence of arterial punctures. We
noticed a 12% incidence of PVWPs. The incidence of
PVWP is higher in SAX-OOP (11%) than LAX-IP
In a prospective, randomized comparative study of 3 (0%) or OAX-IP (1.4%) approaches according to Batllori
transducer approaches comparing SAX, LAX, and et al., and it is 21% in the study by Srinivasan et al. (7,14).
OAX approaches to IJV cannulation, Batllori et al. eval- US does not eliminate the incidence of PVWP. In the
uated the success rate and complications (7). They APSAX-IP technique, the operator can avoid carotid ar-
involved investigators who are well trained and proficient tery puncture by directing the needle away from the ca-
in using US and concluded that OAX and SAX have bet- rotid artery. This is not possible with SAX-OOP
ter cannulation quality outcomes than LAX, and inci- because of the inability to track the needle and LAX-IP
dence of PVWP is higher in SAX than OAX and LAX. because of the inability to visualize the carotid artery.
In our study using the APSAX-IP technique, we had an The published literature mentions a central venous
average number of attempts of 1.17 (SD 0.44), which is catheter misplacement rate between 5–7%, while in our
lower than SAX (1.51 [SD 0.97]), LAX (1.92 [SD study there were 2 (2.66%) misplacements, both in left-
1.26]), and OAX (1.37 [SD 0.84]), and the first-pass suc- sided IJV cannulations (15,16). In 1 patient, the
cess rate is higher (85.33% vs. 69.9% in SAX, 52% in catheter went up from the insertion site toward the
LAX, and 73.6% in OAX). Moreover, Phelan and Hag- cranium; in patient 2, the catheter reflected into the IJV
erty OAX as an alternate approach for US-guided cannu- from the junction with the subclavian vein.
lation (8). This view uses the superiority of the short axis Our approach is relatively novel and has not been
view by visualizing all of the important surrounding described in the literature. Therefore, novice operators
structures (artery and vein) in an oblong view while al- were provided with hands-on training.
lowing for continuous real-time visualization of the nee-
dle. However, 2 meta-analyses did not find any difference Limitations
between SAX, LAX, and OAX in the first-pass success
rate, mean time to success, puncture success rate, or num- In APSAX-IP, aligning the needle with the thin US beam
ber of attempts except for a reduced incidence of arterial can be challenging for novice operators using the in-plane
puncture (9,10). technique. This study was conducted in a single center
Chittoodan et al. conducted a randomized controlled without a control group, and the sample size is small.
trial of SAX and LAX performed by operators well expe- Also, because this study was done in an operating theater
rienced in using US in which they concluded that SAX is and intensive care unit, the applicability of this technique
the better technique in terms of a higher first-pass success in other settings such as emergency departments needs
rate and fewer needle passes (11). Our technique had a further consideration. We assessed only major complica-
better outcome compared with LAX of Chittoodan tions like arterial puncture and pneumothorax, while the
et al. in terms of the number of attempts (1.17 6 0.44 minor complications, such as temporary bleeding from
In-Plane Technique of US-Guided IJV Cannulation 857

the insertion site and minor hematomas, were not exam- ety of Cardiovascular Anesthesiologists. Anaesth Analg 2012;114:
46–72.
ined. We did not monitor the central venous catheter– 3. National Institute for Clinical Excellence. Guidance on the use of
related blood stream infection rate because we primarily ultrasound locating devices for placing central venous catheters.
wanted to study the safety of the technique in terms of Technology Appraisal Guidance No. 49. London: National Institute
for Clinical Excellence; 2002:1–34.
success of cannulation and immediate major complica-
4. Turker G, Kaya F, Gurbet A, et al. Internal jugular vein cannulation:
tions. We did not compare our technique with any other an ultrasound-guided technique versus a landmark-guided tech-
techniques presently in practice. We believe that further nique. Clinics (Sao Paulo) 2009;64:989–92.
5. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices
randomized prospective studies with a larger number of for central venous cannulation: meta-analysis. BMJ 2003;327:361.
patients and comparisons with other techniques are war- 6. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time
ranted. ultrasound-guided catheterisation of the internal jugular vein: a pro-
spective comparison with the landmark technique in critical care pa-
tients. Crit Care 2006;10:R162.
CONCLUSION 7. Batllori M, Urra M, Uriarte E, et al. Randomized comparison of
three transducer orientation approaches for ultrasound guided inter-
nal jugular venous cannulation. Br J Anaesth 2016;116:370–6.
APSAX-IP is a relatively novel technique and could be 8. Phelan M, Hagerty D. The oblique view: an alternative approach for
alternatively used safely and effectively in place of exist- ultrasound-guided central line placement. J Emerg Med 2009;37:
ing techniques for IJV cannulation. Additional study is 403–8.
9. Lv Y, Liu H, Yu P, et al. Evaluating the long-, short-, and oblique-
needed to compare its technical difficulties and advan- axis approaches for ultrasound-guided vascular access cannulation.
tages over other in-plane techniques and applicability to J Ultrasound Med 2019;38:347–55.
other practice settings. 10. Miao S, Wang X, Zou L, et al. Safety and efficacy of oblique-axis
plane in ultrasound-guided internal jugular vein puncture: a meta-
analysis. J Int Med Res 2018;46:2587–94.
Acknowledgments—We thank Dr. Manjunath Prabhu for his 11. Chittoodan S, Breen D, O’Donnell B, et al. Long versus short
advice in drafting the article. Our thanks to the Department of axis ultrasound guided approach for internal jugular vein cannula-
Anaesthesiology, Critical Care Medicine and Nephrology, Raja tion: a prospective randomised controlled trial. Med Ultrason
2011;13:21–5.
Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, 12. Tammam T, Shafey E, Tammam H. Ultrasound-guided internal ju-
Brunei Darussalam for their support in conducting the study. gular vein access: comparison between short axis and long axis
This research did not receive any specific grant from funding techniques. Saudi J Kidney Dis Transpl 2013;24:707–13.
agencies in the public, commercial, or not-for-profit sectors. 13. Leung L, Duffy M, Finckh A. Real-time ultrasonographically-
guided internal jugular vein catheterization in the emergency
department increases success rates and reduces complications: a
randomized, prospective study. Ann Emerg Med 2006;48:540–7.
14. Srinivasan S, Govil D, Gupta S, et al. Incidence of posterior wall
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ARTICLE SUMMARY
1. Why is this topic important?
Standard techniques of ultrasound (US)-guided internal
jugular vein (IJV) cannulations have inherent difficulties,
and complications still persist.
2. What does this study attempt to show?
This study introduces an alternative in-plane US-
guided IJV cannulation technique to improve both safety
and efficacy by combining the advantages of both a short
axis view and an in-plane technique.
3. What are the key findings?
This study shows that anteroposterior short axis in-
plane US-guided IJV cannulation may be reasonably
easily practiced with a high success rate and the major
complications may be further reduced.
4. How is patient care impacted?
Anteroposterior short axis in-plane US-guided IJV can-
nulation has the potential to improve patient safety.