Incidence of Posterior Vessel Wall Puncture During Ultrasound‐guided Vessel Cannulation in a Simulated Model

Abstract

Objectives: The incidence of posterior vessel wall puncture (PVWP) during central line placement with possible subsequent injury to structures lying behind the vein is unknown. At times the internal jugular vein lies immediately anterior to the carotid artery rather than lateral to it, leading to potential arterial puncture should the needle pass through the vein completely. The objective of this study is to evaluate the incidence of PVWP during simulated ultrasound (US)-guided vessel cannulation.Methods: Enrolled subjects were emergency medicine resident and attending physicians. Subjects performed US-guided venous access on simulated blood vessels within gelatin-based US phantoms. While blinded to the purpose of the study, each subject performed successful cannulation of the vessel on separate phantoms, with wire placement confirmed by expert review of a follow-up US. Each phantom was subsequently deconstructed to manually inspect for PVWP.Results: Thirty-five subjects with a range of experience in the technique participated, each performing both transverse and long-axis approaches for a total of 70 cannulations. The overall incidence of PVWP was 34% (95% confidence interval [CI] = 22.9% to 45.1%).Conclusions: This study found a high incidence of inadvertent PVWP during simulated US-guided vessel cannulation in this model. ACADEMIC EMERGENCY MEDICINE 2010; 17:1138-1141 ª 2010 by the Society for Academic Emergency MedicineKeywords: ultrasonography, shock, critical care, emergency medicine, patient simulation A rterial puncture during central venous catheter placement is a known complication of the procedure, with reported incidence up to 11%. 1,2While ultrasound (US) guidance has been shown in several studies to decrease arterial puncture, 1-3 the identification of this event is based on the presence of forceful, pulsatile blood flow from the needle after removal of the syringe. Occult arterial injuries occur when the artery is punctured during the course of the procedure without resultant pulsatile flow through the needle.4 Both recognized and occult arterial injuries may result in significant complications.When using a landmark technique for internal jugular venous access, many practitioners intentionally pass through-and-through the vessel and access the lumen when withdrawing the needle. The use of US allows for direct visualization of the internal jugular vein and internal carotid artery, but commonly demonstrates the vein superficial to the artery. 5 In this scenario, any posterior vessel wall puncture (PVWP) that occurs could result in arterial injury. The objective of this study was to measure the incidence of PVWP during US-guided vessel cannulation using a phantom model. METHODS Study DesignThis was an observational study to assess the incidence of PVWP in a simulated model. The study was approved by the institutional review board.

Randomized comparison of three transducer orientation approaches for ultrasound guided internal jugular venous cannulation

“…4 5 12 13 18 This can be explained by the fact that PVWP was considered as a complication, because under certain circumstances it can expose patients to an increased risk of developing mechanical complications. Previous clinical studies have not attempted to estimate the incidence of PVWP, although an experimental study using ultrasound phantoms suggested that it can be as high as 31% with SAX and 37% with LAX, and is not related to operator 19 The incidence of PVWP in our study was lower [eight patients (11%) with SAX and one patient (1.4%) with OAX] and not operator-related. All PVWP patients were detected after finding resistance to guidewire advance, even though the operator had initially identified the needle tip in the internal jugular lumen.…”

Incidence of posterior wall penetration during internal jugular vein cannulation: A comparison of two techniques using real-time ultrasound

“…[16] IJV cannulation by emergency physicians in a simulated model (by evaluating the path of needles that had been previously placed into vascular access tissue phantoms), the incidence of posterior vein wall penetration was found to be 34%. [17] Present study was performed on humans (previous published studies have been only on mannequins or vascular tissue phantoms).…”

Restricting resident work hours

“…One of the key update in the standards released by the Accredential Council for Graduate Medical Education is "strategic napping" (5). The applicability of this strategic napping seems less likely for intensive care unit residents than those in other fields.…”

“…Napping either before or during workshifts will improve performance and reduce fatigue, and has been studied in nonhealthcare and healthcare settings (though in non-ICU settings) (4,5). For example, napping was proposed as a potential solution by Drs.…”