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Ultrasound Guidance Improves the Success Rate of Internal Jugular Vein Cannulation: Discussion (2)

The reported incidence of carotid artery puncture is 2 to 11 percent. Fatal exsanguination has been reported. Pneumothorax is a rare complication of internal jugular vein cannulation, but does occur. Such complications can be reduced by measures that reduce the number of needle passes required to cannulate the vein and by eliminating the practice of continued needle “probing” after multiple unsuccessful needle passes.
There is, however, no consensus on the number of needle passes appropriate at any site. Our data show that the chance of successful cannulation diminishes with each consecutive needle pass, making cannulation very unlikely after five unsuccessful needle passes. This is consistent with two prior reports in which these data are available, as well as a more recent study.
Johnson has suggested that three needle thrusts are sufficient to exhaust all acceptable variations in the technique. Three percent of the patients of Goldfarb and Lebrec, however, were cannulated only after six needle passes at the same site. An intermediate number of four to six passes is probably therefore a more reasonable maximum number of needle passes. Patients at unusually high risks for potential complications probably should receive a lower maximum number of passes.
It is not presently clear whether real-time twodimensional ultrasonography results in an overall increase or decrease in patient costs. However, ultrasound may reduce complications, patient discomfort, and save the physicians time, effects that promise improved quality of care and perhaps reduced overall costs. These results are promising and merit further investigation.

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