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A Descriptive Comparison of Ultrasound-guided Central Venous Cannulation of theInternal Jugular Vein to Landmark-based

Subclavian Vein CannulationDaniel Theodoro, MD, Brian Bausano, MD, Lawrence Lewis, MD, Bradley Evanoff, MD, MPH, andMarin Kollef, MD

Abstract

Objectives: The safest site for central venous cannulation (CVC) remains debated. Many emergency phy-

sicians (EPs) advocate the ultrasound-guided internal jugular (USIJ) approach because of data support-

ing its efficiency. However, a number of physicians prefer, and are most comfortable with, the

subclavian (SC) vein approach. The purpose of this study was to describe adverse event rates among

operators using the USIJ approach, and the landmark SC vein approach without US.

Methods: This was a prospective observational trial of patients undergoing CVC of the SC or internaljugular veins in the emergency department (ED). Physicians performing the procedures did not undergo

standardized training in either technique. The primary outcome was a composite of adverse events

defined as hematoma, arterial cannulation, pneumothorax, and failure to cannulate. Physicians recorded

the anatomical site of cannulation, US assistance, indications, and acute complications. Variables of

interest were collected from the pharmacy and ED record. Physician experience was based on a self-

reported survey. The authors followed outcomes of central line insertion until device removal or patient

discharge.

Results: Physicians attempted 236 USIJ and 132 SC cannulations on 333 patients. The overall adverse

event rate was 22% with failure to cannulate being the most common. Adverse events occurred in 19%

of USIJ attempts, compared to 29% of nonUS-guided SC attempts. Among highly experienced opera-

tors, CVCs placed at the SC site resulted in more adverse events than those performed using USIJ (rela-

tive risk [RR] = 1.89, 95% confidence interval [CI] = 1.05 to 3.39).

Conclusions: While limited by observational design, our results suggest that the USIJ technique may

result in fewer adverse events compared to the landmark SC approach.

ACADEMIC EMERGENCY MEDICINE 2010; 17:416422 2010 by the Society for Academic Emergency

Medicine

Keywords: catheterization, central venous; ultrasonography, interventional; emergency medicine

Physicians in the United States insert over 5 million

central venous catheters (CVC) annually.1,2 In

studies that examine acute mechanical complica-

tions, no anatomical site proves more advantageous than

the other.3,4 Two emergency department (ED) random-

ized clinical trials demonstrate that ultrasound (US) guid-

ance decreases the mean number of needle sticks

required to successfully cannulate the internal jugular

vein and modestly reduces adverse events.5,6 However,

these studies involved groups of physicians with an

interest or special expertise in US-guided procedures.

Moreover, hospital surveys indicate that physicians may

favor the subclavian (SC) approach over other sites.7,8

Therefore, in this study, we sought to compare adverse

events among patients who underwent US-guided

ISSN 1069-6563 2010 by the Society for Academic Emergency Medicine

416 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2010.00703.x

From the Division of Emergency Medicine (DT, BB, LL), the

Division of General Medical Sciences (BE), and the Medical

Intensive Care Unit (MK), Washington University School of

Medicine, St. Louis, MO.

Received August 20, 2009; revision received October 15, 2009;

accepted October 19, 2009.

Presented at the Society for Academic Emergency Medicine

Annual Meeting in Washington, DC, May 2008.

This study was supported by the Washington University School

of Medicine CTSA Grant (UL1 RR024992) and the Washington

University School of Medicines Clinical Research Training Cen-

ter (KL2 RR024994).

Address for correspondence and reprints: Daniel Theodoro,

MD; e-mail: [email protected].

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cannulation of the internal jugular vein (USIJ) to that in

patients undergoing the nonUS-guided SC approach in

a setting where physicians without focused training in

either technique performed the procedure.

METHODS

Study Design

We assembled a prospective cohort of adult patients

who underwent CVC in the ED. The institutional human

research protection office approved the study and

waived informed consent.

Study Setting and Population

We conducted the study in an academic, urban, 63-bed

ED with a volume of 79,000 visits per year. The emer-

gency medicine training program includes 48 residents

total (12 per year). During the year the study took place,

42 full-time emergency physicians (EPs) staffed the ED.

We collected a convenience sample of consecutive

CVC attempts in our ED. The study was conducted

from March 20, 2007, to March 17, 2008. We includedany patient who underwent cannulation of either the

internal jugular or SC vein, as determined by the treat-

ing EP caring for the patient. We excluded patients

with a concurrent indwelling CVC, suspected traumatic

injury of the vessels in the neck or thorax, or overlying

dermatologic process that precluded insertion at either

site and those who underwent CVC at another anatomi-

cal site.

Study Protocol

To capture consecutive central line attempts, we cre-

ated a standardized electronic procedure note for the

EDs electronic medical record system. Physiciansworking in the ED noted the indication for the proce-

dure, the anatomical site of the procedure, if US guid-

ance was employed, and any adverse event that may

have occurred during the procedure. Any patient who

required central venous access due to lack of peripheral

access was defined as poor access. Any patient who

required central venous access for resuscitation or he-

modynamic monitoring (as in cases of presumed sepsis)

was defined as septichypovolemic or hypotensive. If

the central line was inserted while the patient was in

cardiopulmonary arrest (from either traumatic or medi-

cal reasons) the indication for cannulation was consid-

ered as code line. USIJ was defined as the real-time

use of an US probe to direct the locator needle toward

the internal jugular vein. We excluded central lines

placed via the static approach (using the US probe to

site the vein but not actively cannulate it). SC vein cann-

ulation was defined as any infraclavicular attempt to

cannulate the SC vein, without US guidance to locate

the vessel or direct the needle. We specifically defined

an attempt as a single operators performance of the

procedure from beginning to completion at one ana-

tomic site. If a second operator attempted the proce-

dure at the same site, this was considered a new

attempt. Because the purpose of our study was to

examine adverse events and not efficiency outcomes,

we did not include the number of needle sticks ortime required for either procedure in this analysis. To

improve the precision of our data collection instrument,

we made two semiannual presentations regarding our

definitions of each variable. We did not modify the data

collection instrument during the study.

Demographic characteristics and vital signs were col-

lected from the patients ED charts. Body mass index

(BMI) was calculated according the patients self-

reported height and weight at the time of admission tothe hospital and categorized according to World Health

Organization BMI classifications. If no weight was

recorded, the weight in the ED chart recorded by the

ED nurse caring for the patient was noted. The height

at the nearest prior admission or from the patients

identification card copied into the chart was recorded if

no other record existed. The International Normalized

Ratio (INR) was obtained from the ED chart. Any

patient with systolic blood pressure (sBP) of

90 mm Hg at any time during the ED stay was consid-

ered hypotensive. Patients who required pressors

were identified by review of pharmacy records to deter-

mine whether the patient received vasopressors (epi-

nephrine, norepinephrine, or dopamine) or inotropes(dobutamine) at any time during the ED stay. We

defined mortality as those patients who did not sur-

vive the ED to hospital admission and those who

expired during their hospitalization.

All of the operators participating in the study were

physicians. The operators underwent training for each

technique under the apprenticeship model, meaning

they gained central line experience while simulta-

neously clinically caring for patients. There were two

additional lectures provided for US-guided techniques,

but there were no separate simulation or hands-on

sessions offered. All EPs were asked to fill out a survey

indicating their overall experience with CVC. The sur-vey asked the physicians how many central lines, irre-

spective of site or technique, they had placed in

increments of 10 to a maximum of 50 or above. We

identified no prior validated definition of experienced

operator, and all operators indicated they had placed

more than 20 central lines throughout their career, a

threshold used in prior studies.5 We defined experi-

enced operator as one who had performed more than

50 cannulations (not site specific) throughout their

career since our survey results indicated that a majority

of the operators had attained this level of experience.

Level of experience was missing for 16 attempts (5%).

All were from physicians with four or more years oftraining.

Measurements

Our primary outcome of interest was a composite of

acute adverse events. Borrowing from prior definitions,

we considered an adverse event to occur when a cann-

ulation attempt resulted in an accepted complication of,

or failure in, its technical performance.912 We there-

fore defined an acute adverse event as a composite of

the following outcomes: arterial puncture, pneumotho-

rax, hematoma, extravascular or misplacement, and

failed attempt at cannulation. An arterial puncture was

judged to have occurred when physicians aspirated pul-

satile arterial (bright red) blood into an 18-gauge loca-tor syringe. The presence of a pneumothorax was

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determined using plain films of the chest (either stan-

dard posteroanterior or portable anteroposterior) as

read by a radiologist blinded to the technique used for

central line cannulation. Any ipsilateral pneumothorax

identified within 24 hours of line placement was consid-

ered a complication of the procedure unless the patient

underwent another procedure that could also cause a

pneumothorax on the side in question. Physicians ornurses documented a hematoma if an area of bruising

or swelling greater than 3 cm was noted around the

insertion site. Placement of the central line outside of

the vascular lumen was defined by failure to aspirate

blood through any of the ports or a visible extravasa-

tion of intravenous fluid in the soft tissues (a blown

line appearance). A failed attempt at cannulation was

specifically defined as the inability to complete the

intended procedure by the primary operator for lack of

successfully cannulating the intended vessel. Any pur-

ported puncture of the vein that resulted in the inability

to pass a guide wire, and therefore complete the proce-

dure, was considered a failed attempt. We did not

attempt to determine the number of needle passes forthis analysis.

In the event that more than one adverse outcome

occurred, we recorded the complication that required a

therapeutic intervention as the primary adverse out-

come. We considered pneumothorax, failed cannula-

tion, and misplacement as primary adverse events if

they occurred simultaneously with arterial puncture

and hematoma. However, any occurrence of any com-

plication was considered an adverse event.

We followed subjects until there was radiologic or

medical record evidence that the ED central line was

removed or replaced, or to hospital discharge, to exam-

ine whether seemingly insignificant acute complicationsresulted in any therapeutic intervention or delayed

complications. A chart reviewer (SP and MP), blinded

to the site and technique of insertion, reviewed daily

nursing notes for the mention of hematoma or

transfusion. Patient discharge summaries were exam-

ined for evidence of a central line related adverse event.

Any mention of central line complication or cannu-

lation device complication triggered an audit of inpa-

tient nursing and operative records. Operative records

were reviewed for any mention of a vascular procedure

related to central line complications. In addition we

reviewed the annual records of our quality improve-

ment process for any cases referred to the committeethat involved an ED central line. For the purposes of

this study, catheter-related infections or thrombotic

events were not recorded.

Data Analysis

Results were inserted into an SAS (Version 9.2, SAS

Institute, Cary, NC) database. We performed bivariate

analysis for variables of interest using chi-square tests

and report the 95% confidence intervals (CI). Power cal-

culations were performed using an assumption of a

15% acute complication rate using the external land-

mark technique and a 5% acute complication rate using

the US-guided technique. Using these figures and

accounting for dropouts, we determined that it wouldrequire 128 patients in each group to have a power of

0.80 to detect this difference at the 0.05 level of signifi-

cance.

RESULTS

Physicians reported a total of 729 CVC attempts during

a 1-year period from March 20, 2007, to March 17, 2008

(Figure 1). Almost one-third (32.8%) were inserted into

the femoral vein. We excluded those central lines

inserted into the internal jugular vein without the use

of US, and those inserted into the SC vein under US

guidance, as well as all central lines inserted by physi-

cians who did not meet our minimum requirement of

20 central lines during their career (16.2%). Our final

sample consisted of 333 patients who underwent cann-

ulation by 63 physicians. Physicians indicated that 254

(69%) central lines were inserted for shock, 97 (26%)

were inserted for lack of peripheral access, and 17 (5%)

were inserted for cardiopulmonary resuscitation

(Advanced Cardiac Life Support or Advanced Trauma

Life Support protocols). A total of 32 physicians (51%)

contributed one attempt to each group, and 17 physi-cians (27%) contributed two or more attempts to each

group. Physicians indicating that they had placed more

than 50 central lines throughout their career made 275

attempts (76%). Physicians in their first, second, and

third years of training contributed 35 attempts (10%),

61 attempts (17%), and 104 attempts (28%), respectively.

Attending physicians and those in their fourth year of

training contributed 168 attempts (46%).

Overall there were 82 adverse events (22%, 95%

CI = 18.2% to 30.0%). Of the 236 central lines inserted

using the USIJ technique, 44 (19%) resulted in an

Central Line Attemptsn = 729

Chest or Neck Attemptsn = 490

Non Ultrasound GuidedInternal Jugular Attempts

n = 20

Ultrasound GuidedSubclavation Attempts

n = 1

Ultrasound Guided Internal JugularAttemptsn = 236

Performed byInexperienced Operator

n = 98

n = 470

n = 456

Femoral Siten = 239

Landmark Based Subclavation Attemptsn = 132

Figure 1. Study flow.

418 Theodoro et al. US-GUIDED CVC

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adverse event. Of the 132 attempts made at the SC, 38

(29%) resulted in an adverse event (Table 1). There was

no statistically significant difference between USIJ and

SC attempts among any clinical or demographic char-

acteristics, except age and mortality. Physicians who

met our definition of experienced operator used the

SC more often than the USIJ technique.

The most common adverse event across both sites

was failed attempt at cannulation. In total, 53 attempts

at initial cannulation failed. In the SC group, 30 (23%)

cannulation failures and two (2%) pneumothoraces

occurred. Both pneumothoraces required thoracosto-my. SC attempts resulted in two (2%) hematomas and

three (2%) arterial punctures, and one (1%) catheter

was misplaced in the soft tissues. The misplaced cathe-

ter resulted in no therapeutic intervention after

removal. The USIJ technique failed to result in cannula-

tion in 23 (10%) attempts and zero pneumothoraces

occurred. There were 17 (7%) hematomas noted, four

(2%) inadvertent arterial punctures, and zero misplace-

ments.

We found no instance where a delayed complication

occurred or where a seemingly insignificant complica-

tion in the ED required direct therapeutic intervention

upon follow-up in either group. One USIJ resulted in a

delayed hematoma 48 hours after the time of admis-

sion. The patient was on heparin therapy and did not

undergo any further therapeutic intervention, nor was

heparin therapy discontinued. The quality improvement

team reported no additional adverse events.

In general, more adverse events were noted amongthose patients undergoing attempted cannulation of the

SC compared to those undergoing USIJ cannulation,

regardless of operator experience. The adverse event

rate decreased with operator experience regardless of

approach used (Figure 2). Cannulations performed by

experienced operators were more likely to result in an

adverse event at the SC site than those performed

Table 1Baseline Characteristics of 368 Central Line Attempts

US-guided InternalJugular Approach

(n = 236), n (%)

Landmark SCApproach

(n = 132), n (%) % D 95% CI

Age 65 years 109 (46.1) 47 (35.6) 10.6 0.6 to 20.5Male sex 107 (45.3) 73 (55.3) 10.0 20.0 to 0.6African American 139 (58.9) 81 (61.3) 2.4 8.4 to 13.0COPDasthma 35 (14.8) 20 (15.1) 7.9 17.1 to 0.6Hypotensive in the ED 155 (65.6) 97 (73.4) 7.8 17.4 to 2.5Requiring pressor* 87 (36.8) 57 (43.1) 6.3 17.1 to 4.4BMI > 30 76 (32.2) 32 (24.2) 7.9 2.2 to 17.3INR > 2.0 41 (17.4) 15 (11.4) 6.0 2.3 to 13.3ACLSATLS 8 (3.4) 9 (6.8) 3.4 9.8 to 1.4Mortality 40 (16.9) 37 (28.0) 11.0 20.8 to 1.9Inserted by operator

with >50 CVCs in career162 (72.0) 113 (89.0) 17.0 25.8 to 7.9

Adverse event 44 (18.6) 38 (28.8) 10.2 19.5 to 1.2

ACLS = advanced cardiac life support; ATLS = advanced trauma life support; BMI = body mass index; COPD = chronic obstruc-tive pulmonary disease; CVC = central venous cannulation; INR = international normalized ratio;*Vasopressorinotrope administered.

Figure 2. The effect of experience as defined by 50 or more

cannulations (the absolute numbers of adverse events and

attempts are provided in the columns). USIJ = ultrasound-

guided internal jugular approach; SC = subclavian approach.

Figure 3. The effect of experience as defined by postgraduate

year level (the absolute numbers of adverse events and

attempts are provided in the columns). USIJ = ultrasound-

guided internal jugular approach; SC = subclavian approach.


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using USIJ (relative risk [RR] = 1.89, 95% CI = 1.05 to

3.39), but there was no difference among novice opera-

tors in adverse events when using the SC technique

(RR = 2.2, 95% CI = 0.66 to 7.3). There was no signifi-

cant difference in adverse events by postgraduate year

(v2 = 1.53, p = 0.68; Figure 3).

DISCUSSION

Although our study was observational by design and

therefore limited, our findings suggest that physicians

who adopt US guidance when cannulating the internal

jugular in an apprenticeship model are less likely to

encounter an adverse event compared to the landmark

SC technique. Past studies that compared vascular

access sites to one another did not account for the

impact of US guidance. In these studies, adverse events

occurred with nearly equal proportion in both groups,

and no anatomic location was conclusively superior in

regard to acute mechanical complications.2,4,1320 While

a randomized clinical trial would be required to recom-

mend a change in practice, our observational studysuggests a benefit to using US-guided cannulation.

Our study also found that adverse events occurred

less frequently with the USIJ technique compared to

the SC technique among experienced operators. Past

studies suggest that US guidance conveys its greatest

benefit on operators with less experience, while more

experienced operators may realize less improvement in

their cannulation outcomes.21 Our findings suggest that

the US-guided technique confers benefit to experienced

operators in the absence of rigorous standardized train-

ing in either technique. Measuring expert operator per-

formance by strict counts may have limitations.

However, accreditation boards and prior research inthe area have focused on the number of procedures

performed to assess technical competence.5,2224 Our

study also relied on the number of performed proce-

dures, but it was self-reported and not site-specific.

Among our most experienced operators (those who

performed >50 CVC in their careers), USIJ resulted in

fewer adverse events, specifically fewer cannulation

failures. Although we caution the interpretation of an

individual component of our composite, our study sug-

gests that even operators with significant experience

can gain benefit from US-guided procedures. Overall

experience with cannulation may facilitate the acquisi-

tion of skills that pertain to US-assisted procedures.

With the exception of two pneumothoraces that

required chest tubes, none of our 333 patients sustained

an adverse event that required clinical interventions.

These findings echo past studies suggesting that the

majority of acute adverse events resulting from

attempted CVC in the ED are typically no harm

events. While this observation ignores the impact that

failed access may have on resource consumption and

timeliness of therapeutic interventions, it underscores

the modest extent to which CVC leads to adverse

events requiring intervention.

In prior studies comparing US-guided attempts to

non-US-guided attempts at a single site, the decrease in

adverse events that required a direct intervention wasmodest as well. In the study by Milling et al.,6 no

attempts resulted in a pneumothorax, and in the study

by Leung et al.,5 1 of 65 attempts resulted in a pneumo-

thorax in the non-US group. Both studies demonstrated

fewer hematomas and arterial punctures, but did not

report any therapeutic consequences.5,6

Hematomas were more common in our USIJ group

than in previous studies. This may be due to the fact

that our physicians were not selected for demonstratedexpertise in USIJ and may better reflect the true inci-

dence of this complication in a real-world experience.

Hematomas were reported significantly less often in the

SC group than in the USIJ group. This could be attrib-

uted to the difficulty in identifying hematomas in the

subclavicular location. The effect of this would be to

bias the study toward the SC approach. However, no

hematoma in either group resulted in a clinical inter-

vention in our cohort. Whether resource utilization,

timeliness of therapy, and a decrease in thoracostomies

becomes sufficiently significant across larger popula-

tions to justify solely using US-assisted techniques

remains a question for further investigation in larger

trials.Our cohort sustained a high failure rate utilizing US

compared to prior studies in similar settings.5,6,21,25 We

attributed this to a lack of hands-on training or simula-

tor-based learning opportunities. In prior ED studies,

US-guided cannulations (intervention arms) were per-

formed by small groups of physicians with targeted

training suggesting possible operator bias frequently

noted in US research. The study by Milling et al.6

involved nine physicians, and the study by Leung et al.5

involved 13 physicians, compared to the 63 physicians

involved in our cohort. The 63 physicians in our cohort

did not undergo intense targeted training in the use of

US assistance, but adopted the procedure in the classicapprenticeship model. Despite the lack of focused train-

ing, the intervention of US assistance resulted in some

benefit. Whether the impressive decrease in US-guided

central line complications noted in other studies is a

factor of directed educational sessions or a trend only

among physicians with highly specialized training in US

remains unexplored.

The adoption of the US-guided technique came at the

expense of performing fewer nonUS-guided central

lines. This may be partly explained by the suggestion

from prior studies that physicians in training may bene-

fit the most from US guidance.21,26 This may represent

a concerning practice shift, since failed US-guidedattempts may require rescue by nonUS-guided tech-

niques. Given that a majority of community EDs have

limited access to US technology, training programs

should be wary of overemphasizing US-guided tech-

niques so as to not impede the development of non

US-guided techniques among their graduates.27

Our SC adverse event rate was higher than in studies

conducted by experienced operators, yet lower than in

some studies of inexperienced operators, a fact likely

explained by the nature of emergent central lines and

the acutely ill ED patient population.16,26,28,29 The

mortality rate of patients undergoing the SC technique

was higher than those undergoing USIJ. Our data sug-

gested that this was due to physician preference forlandmark-based approaches during code situations.


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The poor prognosis of these patients likely explains the

baseline difference in mortality rates between the two

central line approaches. Whether US guidance can

assist placement of SC vein catheters in the ED requires

further investigation.

LIMITATIONS

Due to the observational design, central line attempts

were not randomly assigned, increasing the likelihood

that selection bias was introduced. We hypothesized

that physicians would preferentially use the technique

with which they were most comfortable, possibly bias-

ing our results toward the null. Despite this, we still

found a difference in adverse events, even among those

considered experienced with CVC. Although we

accounted for patient factors that might make venous

cannulation difficult (e.g., BMI), it is possible that sev-

eral unrecorded patient variables could result in a

selection bias toward one technique or the other.

We relied on the apprenticeship model to teach

both techniques. It is possible that an institutional trenddeveloped whereby USIJ became the preferred method.

This may have biased the results in favor of USIJ in that

less time was devoted to acquiring skills of non-US

techniques. However, a survey during the study indi-

cated that 80% of all physicians were initially taught

solely nonUS-guided techniques, and 68% did not use

US in almost half their central line attempts.30 However,

as the study proceeded, more physicians opted for US

guidance than the landmark technique.

As in prior studies, our measure of physician experi-

ence was based on survey data. The results of our sur-

vey are subject to recall bias. Furthermore, we asked

physicians to indicate their general experience withCVC, not their experience with each procedure and not

their experience with US. This may bias operator expe-

rience results because physicians may have reported

experience solely with one technique and at one site,

not both. In this case, adverse events may be explained

more by experience than technique. Although we

restricted our analysis to exclude beginner-level

physicians, we were not able to confirm the level of

experience of operators for each technique. However,

current studies and accreditation standards currently

do not define experience other than by the total

number of cannulations performed during training or

career.

It is likely that physician and nurse self-report led to

measurement bias. Other than pneumothorax, unsuc-

cessful cannulation, and misplacement, the outcomes

studied do not have gold standards and rely on report-

ing by the physician or the nurse. In addition, some

adverse events may be more obvious in certain ana-

tomic areas. Furthermore, our results would be greatly

biased if physicians reported their successes less com-

monly with their preferred technique while they

reported their failures more commonly with their least

preferred technique or vice versa. However, the rates

of our adverse events were similar to those found in

other studies, and our quality assurance committee

found no instance of an unreported adverse event thattook place in the ED during this study.

CONCLUSIONS

Our observational trial suggests that physicians without

rigorous standardized training can adopt the ultra-

sound-guided internal jugular technique and decrease

the number of acute adverse events, compared to using

the landmark subclavian approach. However, our study

was limited by its design, and a randomized control

trial would be necessary to recommend a change inpractice. Very few adverse events from central venous

cannulation attempts require direct clinical intervention.

Whether the benefit of ultrasound guidance translates

to other outcomes, such as timeliness of therapy,

resource utilization, or thrombotic or infectious compli-

cations, remains unstudied and will likely require large

coordinated efforts to gain statistical power. Physicians

who solely perform the landmark subclavian approach

may expose their patients to a modestly increased risk

of an acute adverse event, mainly the risk of failing to

complete the intended procedure.

The authors acknowledge Sarah Boslaugh, PhD, and Missy Krauss,MPH, for their statistical advice for this work. We also acknowl-

edge Max Palatnik, Connor Deal, and Shruti Patil for their contri-

butions to this project.

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