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Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients
Resuscitation 80 (2009) 1361–1364
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients夽,夽夽 Pasi Lahtinen a,∗ , Tadeusz Musialowicz a , Harri Hyppölä b , Vesa Kiviniemi c , Jouni Kurola a a
Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland c IT Centre, Kuopio University, Finland b
a r t i c l e
i n f o
Article history: Received 30 June 2009 Accepted 24 August 2009 Keywords: Intravenous catheterisation Emergency care External jugular vein Cubital vein Catheterisation time
a b s t r a c t The optimal intravenous catheterisation site for emergencies is unknown. The external jugular vein might be preferable route compared to cubital veins in emergencies due to more rapid circulation time to heart and faster cardiac responses. However, the feasibility of the different venous catheterisation sites has not been compared in relation to catheterisation time and success rate. Methods: We examined the time differences and success rates of external jugular compared to antecubital vein catheterisations. 32 paramedics and 28 emergency department residents performed external jugular and antecubital venous catheterisations on anesthetized patients scheduled for elective cardiac surgery. The primary outcome was catheterisation time and the secondary outcomes the failure rate and catheterisation times needed to succeed. Results: Antecubital venous catheterisation was faster (113 ± 89 s) compared to external jugular vein catheterisation (156 ± 112 s), p = 0.008 and the success rate was higher (93% compared to 68%, respectively, p = 0.001). Less attempts were needed for antecubital vein catheterisations compared to external jugular vein catheterisations (p = 0.002). For the antecubital vein, subjects needed two attempts in 6 patients and three attempts in 6 patients. For the external jugular vein, subjects needed two attempts in 13 patients and three attempts in 20 patients. Two (6%) paramedics and two (7%) residents failed to catheterise the antecubital vein. Nine (28%) paramedics and 10 (36%) residents failed to catheterise the external jugular vein. Conclusions: Antecubital vein catheterisation was faster and had a superior success rate compared to external jugular vein catheterisation. © 2009 Elsevier Ireland Ltd. All rights reserved.
Peripheral veins are widely used as the primary route for fluid and drug administration during emergencies and resuscitations from cardiac arrest.1 During cardiac arrest and emergency trauma care, fast and reliable cannulation without interfering with other life-saving interventions, such as cardiopulmonary resuscitation (CPR) and defibrillation, is of outmost importance. Delays in patient care related to prolonged intravenous (i.v.) cannulation have been reported, especially with trauma patients.2
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.08.026. 夽夽 Trial registration: Study registered at www.ClinicalTrials.gov with the identifier number NCT00631098. ∗ Corresponding author at: Department of Anesthesiology and Intensive Care, Kuopio University Hospital, BO 1777, 70210 Kuopio, Finland. Tel.: +358 17 173311; fax: +358 17 173443. E-mail address: pasi.lahtinen@kuh.fi (P. Lahtinen). 0300-9572/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2009.08.026
The primary site of peripheral vein catheterisation is often chosen based on the previous experience of the performer, but preferred or recommended sites are poorly documented.3,4 The external jugular vein is often visible during cardiac arrest due to blood pooling and filling of the right ventricle causing elevated central venous pressure. Therefore, the external jugular vein might provide an alternative to the antecubital veins in the upper extremities that are normally used.5,6 Furthermore, the external jugular vein, which has rapid drainage through the internal jugular vein and upper vena cava into the heart, may have an advantage over antecubital veins due to rapid circulation time and faster onset of cardiac drug responses.7 Standard operating procedures (SOPs) with clearly defined, unambiguous instructions are preferred in emergencies. Therefore, the recommended approach to establish a rapid i.v. route for emergencies should be scrutinised. The aim of this study was to compare the feasibility of cannulation in the external jugular compared with that in the antecubital
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vein performed by medical residents and paramedics in the operating room (OR) on anaesthetised cardiac surgery patients.
Table 1 Demographic and preoperative data of patients (n = 60). Mean (SD)
1. Methods This study was approved by the Ethics Committee of the Kuopio University Hospital and registered in www.ClinicalTrials.gov with the identifier number NCT00631098. The study began in March 2004 and was conducted in accordance with the latest revision of the Declaration of Helsinki. Patients scheduled for elective primary cardiac surgery were eligible for inclusion. Patients with a body mass index (BMI) ≥ 35 and with severe cardiac insufficiency (ejection fraction ≤ 30%) were excluded. All participants were informed and they gave written consent. We initially studied eight pilot patients (and catheterisations) to estimate a reasonable sample size for calculating mean values and standard deviation (SD) for catheterisation times at both sites. We recruited eight intensive care unit (ICU), operative theatre or emergency department (ER) nurses, all with paramedic experience, from the Kuopio University hospital. The nurses completed catheterisations of the external jugular and antecubital veins of the pilot patients in a randomised order. The nurses worked as their own controls using their experience to establish venous access. Based on this pilot study, power analysis indicated a cohort of 60 patients was appropriate. The sample size for the main study was estimated using a two-sided p-level of 0.05 and a power of 0.80 to detect 60 s difference in catheterisation times between external jugular and antecubital veins. In the final study, emergency department residents and paramedics with advanced cardiac life-support skills and licensed by the Kuopio University Hospital performed cannulations. The order of the catheterisation site (which one first) was randomised to avoid bias in the setting and a possible learning effect. A computer-generated protocol with a block size of four was used for randomisation. The subjects catheterising the patients and the investigators were blinded to the order; however, the study nurse was not. Before the actual cannulation day, we informed residents and paramedics they were participating in a study involving a minor procedure in the OR that simulated a resuscitation situation. On the morning of the actual catheterisations, we gave detailed information on the study to avoid the learning effect and preoperative practice attempting to mimic the actual, sudden situation. All patients were pre-medicated with 0.15 mg kg−1 diazepam 1 h before anaesthesia, and they received their routine beta blockers and long-acting nitrates. In the operating theatre, patients were first monitored (12-lead electrocardiography (ECG) and peripheral oxygen saturation) and catheterised (invasive blood pressure from right radial artery and pulmonary artery catheter to the right subclavian vein). Before study cannulations, pulmonary capillary wedge pressures (PCWPs) were treated to ≥6 mmHg to avoid hypovolaemia. Anaesthesia was standardised and induced with sufentanil, midatsolam, propofol and pancuronium. Patients were intubated and connected to a ventilator for positive pressure ventilation. Before cannulations, PCWP was measured in a 30◦ Trendelenburg position. If the PCWP was below 6 mmHg, an i.v. fluid (Ringer’s acetate or gelatine) bolus was administered until the PCWP reached at least 6 mmHg. The aim of this moderate right heart filling pressure was to avoid hypovolaemia and to facilitate distension of the external jugular vein in actual catheterisation. An infusion set was prepared and kept ready before the start of the study. An 18-gauge i.v. catheter (VenflonTM Pro, Beckton Dickinson Infusion Therapy, Helsingborg, Sweden) was used in all patients. Study subjects stood beside the patient’s head with the anaesthesiologist. Patients were placed in a 30◦ Trendelenburg
Gender (M/F) (n) Age (years) Height (cm) Weight (kg) BMI (kg m−2 ) SAPS (mmHg) SAPD (mmHg) CVP (mmHg) PCWP (mmHg) Operations (n) 1/2/3/4a
43/17 64 (10) 170 (8) 80 (14) 27 (4) 116 (19) 59 (10) 9 (3) 12 (4) 39/12/12/3
Values are mean (SD) unless stated otherwise. BMI = body mass index; SAPS = systemic arterial pressure in systole; SAPD = systemic arterial pressure in diastole; CVP = central venous pressure; PCWP = pulmonary capillary wedge pressure. a 1 = coronary artery bypass graft (CABG); 2 = mitral valvuloplasty/replacement with or without CABG; 3 = aortic valve reconstruction with or without CABG; 4 = composite graft.
position to avoid risk of air embolism and to establish rigorous venous filling. A venous tourniquet (same model for all patients) was employed in all antecubital cannulations for adequate venous filling. The study nurse started the study time which included finding the jugular or cubital vein, actual cannulation, connecting the infusion set and detecting the free backflow of blood confirmed by the anaesthesiologist. The study nurse recorded time spent for cannulation and the number of attempts, failures and adverse events (e.g., perforation of vein, arterial puncture and others). One of the study authors (an anaesthesiologist) attended each cannulation and observed if the antecubital or external jugular veins were visible and distended. The paramedics and residents provided self-information including age, experience in years, theoretical guidance of cannulation (self-estimated/h), practical guidance of cannulation (self-estimated/h) and experience in cannulation of the external jugular vein (self-estimated/times). 2. Statistical analysis The primary endpoint in this study was catheterisation time of the two sites (external jugular vein and antecubital vein). The secondary end points were failure/success of catheterisation and reliability of venous access as defined above. We compared the catheterisation times between the two sites using paired-samples t-test. Success of catheterisation was compared using McNemar’s test appropriate for comparing with related proportions. The difference in the number of catheterisation attempts needed was compared using the Wilcoxon signed-rank test. The catheterisation times and success rates in both sites were compared between paramedics and residents using two independent-samples t-test and Chi-squared test, respectively. Finally, univariate logistic regression was applied to explain the success of catheterisation with working experience, theoretical guidance for catheterisation, number of performed catheterisations, central venous pressure or PCWP. p-Values less than 0.05 is considered statistically significant. Results are given as mean (standard deviation (SD)) or number of patients and percentages. All statistical analyses were performed with SPSS version 14 software (SPSS Inc., Chicago, IL, USA). 3. Results Demographic and preoperative data of patients are presented in Table 1 and data on the paramedics and the residents are presented in Table 2. Antecubital venous catheterisation was faster (113 ± 89 s) compared with external jugular vein catheterisation
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Table 2 Paramedic (n = 32) and medical resident (n = 28) work and cannulation experience.
Age (years) Work experience (years) Theoretical guidance for cannulation (h) Practical experience of central cannulation (n) Number of peripheral cannulations n (% of performers) 1/2/3/4a
Paramedics
Residents
33 (4) 4 (3) 7 (5) 7 (6) 1 (3%)/17 (53)/10 (31)/4 (13)
33 (4) 6 (4) 2 (3) 0 (1) 12 (43%)/11 (39)/4 (14)/1 (4)
Values are mean (SD) unless stated otherwise. a 1 = less than 100; 2 = 100–500; 3 = 500–1000; 4 = more than 1000. Table 3 Results for antecubital and external jugular vein cannulations.
Cannulation time (s) Failure rate (%) Attempts needed (n) 1/2/3/4a Vein not visible (n) Cannulation time in succeeded cannulations (s)
Antecubital vein
External jugular vein
p-Value
113 (89) 7 48/6/6/0 0 92 (57)
156 (112) 32 24/13/20/3 3 108 (69)
0.008 0.001 0.002 0.293
Values are mean (SD). a Number of successful cannulations in the first attempt (1), second attempt (2), third attempt (3), or not attempted at all (4).
(156 ± 112 s), p = 0.008 (mean difference 43 s; 95% confidence interval (CI): 12–74 s). In addition, the success rate of antecubital venous catheterisation was higher than that of external jugular vein catheterisation (93% compared with 68%, respectively, p = 0.001) and required fewer attempts (p = 0.002). For the antecubital vein, two attempts were needed in 6 and three attempts in 6 patients. For the external jugular vein two attempts were needed in 13 patients and three attempts in 20 patients. Only 39 (65%) subjects (paramedics or residents) succeeded to catheterise both antecubital and external jugular veins. Two (6%) paramedics and two (7%) residents failed to catheterise the antecubital vein. Nine (28%) paramedics and 10 (36%) residents failed to catheterise the external jugular vein. In three cases, external jugular vein catheterisation was not attempted at all because no visible vein was found. In all patients, antecubital vein was found and catheterisation was attempted. In successful attempts, antecubital vein catheterisation was faster (92 ± 57 s) than external jugular vein catheterisation (108 ± 69 s), p = 0.293. Catheterisation times did not differ between paramedics and residents in either site. Similarly, we found no difference in relation to the order of catheterisation (which site first). In logistic regression analysis, working experience, theoretical guidance for catheterisation, number of performed catheterisations, central venous pressure or PCWP did not explain the differences in catheterisation success (Table 3). There was a trend towards better external jugular vein catheterisation results with a greater number of previous catheterisation (p = 0.05). 4. Discussion The main finding of this prospective study was that it took 43 s longer to catheterise the external jugular vein compared with an antecubital vein in cardiac surgery patients simulating resuscitation. Success rate of establishing a venous access was 93% for the antecubital vein and 68% for the external jugular vein. Subjects needed more than one attempt in every five (20%) antecubital vein catheterisations and in every two (55%) external jugular vein catheterisations. One-third of the study subjects needed all three attempts to establish i.v. access in the external jugular vein compared with one-tenth in the antecubital vein. No attempts were successful if the external jugular vein was not visible. To our knowledge, this is the first study evaluating the clinical feasibility of external jugular compared with antecubital vein catheterisation.
Our results indicate that longer time is needed to establish venous access in the external jugular compared to antecubital veins and one-third of the attempts fail. In the pilot study, we determined the clinically meaningful time difference to be 60 s, thus we actually failed to show a difference of this magnitude between the catheterisation times in our study. However, even though the time difference was shorter than the clinically meaningful time, a failure rate of 30% for internal jugular vein catheterisation is clearly not acceptable in a critical situation. In a previous study, Emerman et al. studied femoral vein versus subclavian vein catheterisation during cardiac arrest and found a 94% success rate for subclavian and 77% for the femoral vein.8 Westfall et al. examined i.v. access in critically ill trauma patients and compared saphenous cut-down and percutaneous femoral vein catheterisation. They detected 2.5 min faster i.v.-line access with femoral vein catheterisation compared with saphenous venous cut-down (the actual catheterisation times were 5.63 ± 2.58 and 3.18 ± 1.19 min for saphenous and femoral lines, respectively).9 The failure and complication rates in this study were similar with incidences of 17 and 9%, respectively. A more recent study found ultrasound-guided femoral vein catheterisation during cardiopulmonary resuscitation (CPR) was more successful and faster with a 90% success rate and 2 min catheterisation time compared with landmark-guided catheterisation with 65% success and a 2-min time to catheterisation.10 In a French observational study, an out-of-hospital team succeeded in 76% of i.v.-line placements on the first attempt and in 98% on the second attempt. The time for intravenous line placement was 4.4 ± 2.8 min with one to eight attempts.11 Our results are in concordance with the previous studies, which clearly show the peripheral approach for i.v.-line placement should be the primary approach whenever feasible. In our study, the antecubital site was faster and more successful. Antecubital catheterisation has also other advantages in emergency situations compared with external jugular vein catheterisation as it does not interfere with intubation nor does it require delays in cardiac compressions. Furthermore, most health-care professionals are more familiar with the antecubital site. The emergency department residents and paramedics included in our study were quite inexperienced in i.v.-line placement (Table 2), which may have affected our results. However, our protocol with cross-over design may have limited the bias in this respect. These subjects may face emergency i.v. cannulation regularly in the future.
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Our study has several limitations. First, instead of a real CPR setting, our study was conducted in the OR with anaesthetised cardiac surgery patients. We may have lost the pressure of the real situation; however, the subjects were in unfamiliar surroundings with the whole surgical team as an audience, replacing one stress factor with another. We aimed to ensure safety of the subjects and to establish a more organised, tranquil study environment. Second, the patients in this study were not in cardiac arrest, which may have lessened the visibility and distension of the external jugular vein compared to real cardiac arrest. We tried to minimise this bias by targeted control of PCWP and central venous pressure with fluid administration and the Trendelenburg position, but our results may not be directly applicable with real cardiac arrest. 5. Conclusions Antecubital vein was a faster and more reliable site for intravenous access compared with the external jugular vein. Recommendations for preferred primary intravenous access in emergency care should be evaluated accordingly. Role of the funding source This study was supported by a research grant from the Kuopio University Hospital; no other sponsorship was obtained. Conflicts of interest All the authors declare that they have no conflicts of interest to disclose.
Acknowledgements We thank all paramedics and ER residents who participated in this study and RN P. Toroi for his indispensable work during the study. References 1. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67S1:S39–86. 2. Gonzalez RP, Cummings GR, Phelan HA, Mulekar MS, Rodning CB. On-scene intravenous line insertion adversely impacts prehospital time in rural vehicular trauma. Am Surg 2008;74:1083–7. 3. Lapostolle F, Catineau J, Garrigue B, et al. Prospective evaluation of peripheral venous access difficulty in emergency care. Intensive Care Med 2007;33:1452–7. 4. Spaite DW, Valenzuela TD, Criss EA, Meislin HW, Hinsberg P. A prospective in-field comparison of intravenous line placement by urban and nonurban emergency medical services personnel. Ann Emerg Med 1994;24:209–14. 5. Steen S, Liao Q, Pierre L, Paskevicius A, Sjöberg T. The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation 2003;58:249–58. 6. Chamberlain D, Frenneaux M, Steen S, Smith A. Why do chest compressions aid delayed defibrillation? Resuscitation 2008;77:10–5. 7. Hedges JR, Barsan WB, Doan LA, et al. Central versus peripheral intravenous routes in cardiopulmonary resuscitation. Am J Emerg Med 1984;2:385–90. 8. Emerman CL, Bellon EM, Lukens TW, May TE, Effron D. A prospective study of femoral versus subclavian vein catheterization during cardiac arrest. Ann Emerg Med 1990;19:26–30. 9. Westfall MD, Price KR, Lambert M, et al. Intravenous access in the critically ill trauma patient: a multicentered, prospective, randomized trial of saphenous cutdown and percutaneous femoral access. Ann Emerg Med 1994;23:541–5. 10. Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 1997;29:331–7. 11. Minville V, Pianezza A, Asehnoune K, Cabardis S, Smail N. Prehospital intravenous line placement assessment in the French emergency system: a prospective study. Eur J Anesthesiol 2006;23:594–7.
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients夽,夽夽 Pasi Lahtinen a,∗ , Tadeusz Musialowicz a , Harri Hyppölä b , Vesa Kiviniemi c , Jouni Kurola a a
Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland c IT Centre, Kuopio University, Finland b
a r t i c l e
i n f o
Article history: Received 30 June 2009 Accepted 24 August 2009 Keywords: Intravenous catheterisation Emergency care External jugular vein Cubital vein Catheterisation time
a b s t r a c t The optimal intravenous catheterisation site for emergencies is unknown. The external jugular vein might be preferable route compared to cubital veins in emergencies due to more rapid circulation time to heart and faster cardiac responses. However, the feasibility of the different venous catheterisation sites has not been compared in relation to catheterisation time and success rate. Methods: We examined the time differences and success rates of external jugular compared to antecubital vein catheterisations. 32 paramedics and 28 emergency department residents performed external jugular and antecubital venous catheterisations on anesthetized patients scheduled for elective cardiac surgery. The primary outcome was catheterisation time and the secondary outcomes the failure rate and catheterisation times needed to succeed. Results: Antecubital venous catheterisation was faster (113 ± 89 s) compared to external jugular vein catheterisation (156 ± 112 s), p = 0.008 and the success rate was higher (93% compared to 68%, respectively, p = 0.001). Less attempts were needed for antecubital vein catheterisations compared to external jugular vein catheterisations (p = 0.002). For the antecubital vein, subjects needed two attempts in 6 patients and three attempts in 6 patients. For the external jugular vein, subjects needed two attempts in 13 patients and three attempts in 20 patients. Two (6%) paramedics and two (7%) residents failed to catheterise the antecubital vein. Nine (28%) paramedics and 10 (36%) residents failed to catheterise the external jugular vein. Conclusions: Antecubital vein catheterisation was faster and had a superior success rate compared to external jugular vein catheterisation. © 2009 Elsevier Ireland Ltd. All rights reserved.
Peripheral veins are widely used as the primary route for fluid and drug administration during emergencies and resuscitations from cardiac arrest.1 During cardiac arrest and emergency trauma care, fast and reliable cannulation without interfering with other life-saving interventions, such as cardiopulmonary resuscitation (CPR) and defibrillation, is of outmost importance. Delays in patient care related to prolonged intravenous (i.v.) cannulation have been reported, especially with trauma patients.2
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.08.026. 夽夽 Trial registration: Study registered at www.ClinicalTrials.gov with the identifier number NCT00631098. ∗ Corresponding author at: Department of Anesthesiology and Intensive Care, Kuopio University Hospital, BO 1777, 70210 Kuopio, Finland. Tel.: +358 17 173311; fax: +358 17 173443. E-mail address: pasi.lahtinen@kuh.fi (P. Lahtinen). 0300-9572/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2009.08.026
The primary site of peripheral vein catheterisation is often chosen based on the previous experience of the performer, but preferred or recommended sites are poorly documented.3,4 The external jugular vein is often visible during cardiac arrest due to blood pooling and filling of the right ventricle causing elevated central venous pressure. Therefore, the external jugular vein might provide an alternative to the antecubital veins in the upper extremities that are normally used.5,6 Furthermore, the external jugular vein, which has rapid drainage through the internal jugular vein and upper vena cava into the heart, may have an advantage over antecubital veins due to rapid circulation time and faster onset of cardiac drug responses.7 Standard operating procedures (SOPs) with clearly defined, unambiguous instructions are preferred in emergencies. Therefore, the recommended approach to establish a rapid i.v. route for emergencies should be scrutinised. The aim of this study was to compare the feasibility of cannulation in the external jugular compared with that in the antecubital
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vein performed by medical residents and paramedics in the operating room (OR) on anaesthetised cardiac surgery patients.
Table 1 Demographic and preoperative data of patients (n = 60). Mean (SD)
1. Methods This study was approved by the Ethics Committee of the Kuopio University Hospital and registered in www.ClinicalTrials.gov with the identifier number NCT00631098. The study began in March 2004 and was conducted in accordance with the latest revision of the Declaration of Helsinki. Patients scheduled for elective primary cardiac surgery were eligible for inclusion. Patients with a body mass index (BMI) ≥ 35 and with severe cardiac insufficiency (ejection fraction ≤ 30%) were excluded. All participants were informed and they gave written consent. We initially studied eight pilot patients (and catheterisations) to estimate a reasonable sample size for calculating mean values and standard deviation (SD) for catheterisation times at both sites. We recruited eight intensive care unit (ICU), operative theatre or emergency department (ER) nurses, all with paramedic experience, from the Kuopio University hospital. The nurses completed catheterisations of the external jugular and antecubital veins of the pilot patients in a randomised order. The nurses worked as their own controls using their experience to establish venous access. Based on this pilot study, power analysis indicated a cohort of 60 patients was appropriate. The sample size for the main study was estimated using a two-sided p-level of 0.05 and a power of 0.80 to detect 60 s difference in catheterisation times between external jugular and antecubital veins. In the final study, emergency department residents and paramedics with advanced cardiac life-support skills and licensed by the Kuopio University Hospital performed cannulations. The order of the catheterisation site (which one first) was randomised to avoid bias in the setting and a possible learning effect. A computer-generated protocol with a block size of four was used for randomisation. The subjects catheterising the patients and the investigators were blinded to the order; however, the study nurse was not. Before the actual cannulation day, we informed residents and paramedics they were participating in a study involving a minor procedure in the OR that simulated a resuscitation situation. On the morning of the actual catheterisations, we gave detailed information on the study to avoid the learning effect and preoperative practice attempting to mimic the actual, sudden situation. All patients were pre-medicated with 0.15 mg kg−1 diazepam 1 h before anaesthesia, and they received their routine beta blockers and long-acting nitrates. In the operating theatre, patients were first monitored (12-lead electrocardiography (ECG) and peripheral oxygen saturation) and catheterised (invasive blood pressure from right radial artery and pulmonary artery catheter to the right subclavian vein). Before study cannulations, pulmonary capillary wedge pressures (PCWPs) were treated to ≥6 mmHg to avoid hypovolaemia. Anaesthesia was standardised and induced with sufentanil, midatsolam, propofol and pancuronium. Patients were intubated and connected to a ventilator for positive pressure ventilation. Before cannulations, PCWP was measured in a 30◦ Trendelenburg position. If the PCWP was below 6 mmHg, an i.v. fluid (Ringer’s acetate or gelatine) bolus was administered until the PCWP reached at least 6 mmHg. The aim of this moderate right heart filling pressure was to avoid hypovolaemia and to facilitate distension of the external jugular vein in actual catheterisation. An infusion set was prepared and kept ready before the start of the study. An 18-gauge i.v. catheter (VenflonTM Pro, Beckton Dickinson Infusion Therapy, Helsingborg, Sweden) was used in all patients. Study subjects stood beside the patient’s head with the anaesthesiologist. Patients were placed in a 30◦ Trendelenburg
Gender (M/F) (n) Age (years) Height (cm) Weight (kg) BMI (kg m−2 ) SAPS (mmHg) SAPD (mmHg) CVP (mmHg) PCWP (mmHg) Operations (n) 1/2/3/4a
43/17 64 (10) 170 (8) 80 (14) 27 (4) 116 (19) 59 (10) 9 (3) 12 (4) 39/12/12/3
Values are mean (SD) unless stated otherwise. BMI = body mass index; SAPS = systemic arterial pressure in systole; SAPD = systemic arterial pressure in diastole; CVP = central venous pressure; PCWP = pulmonary capillary wedge pressure. a 1 = coronary artery bypass graft (CABG); 2 = mitral valvuloplasty/replacement with or without CABG; 3 = aortic valve reconstruction with or without CABG; 4 = composite graft.
position to avoid risk of air embolism and to establish rigorous venous filling. A venous tourniquet (same model for all patients) was employed in all antecubital cannulations for adequate venous filling. The study nurse started the study time which included finding the jugular or cubital vein, actual cannulation, connecting the infusion set and detecting the free backflow of blood confirmed by the anaesthesiologist. The study nurse recorded time spent for cannulation and the number of attempts, failures and adverse events (e.g., perforation of vein, arterial puncture and others). One of the study authors (an anaesthesiologist) attended each cannulation and observed if the antecubital or external jugular veins were visible and distended. The paramedics and residents provided self-information including age, experience in years, theoretical guidance of cannulation (self-estimated/h), practical guidance of cannulation (self-estimated/h) and experience in cannulation of the external jugular vein (self-estimated/times). 2. Statistical analysis The primary endpoint in this study was catheterisation time of the two sites (external jugular vein and antecubital vein). The secondary end points were failure/success of catheterisation and reliability of venous access as defined above. We compared the catheterisation times between the two sites using paired-samples t-test. Success of catheterisation was compared using McNemar’s test appropriate for comparing with related proportions. The difference in the number of catheterisation attempts needed was compared using the Wilcoxon signed-rank test. The catheterisation times and success rates in both sites were compared between paramedics and residents using two independent-samples t-test and Chi-squared test, respectively. Finally, univariate logistic regression was applied to explain the success of catheterisation with working experience, theoretical guidance for catheterisation, number of performed catheterisations, central venous pressure or PCWP. p-Values less than 0.05 is considered statistically significant. Results are given as mean (standard deviation (SD)) or number of patients and percentages. All statistical analyses were performed with SPSS version 14 software (SPSS Inc., Chicago, IL, USA). 3. Results Demographic and preoperative data of patients are presented in Table 1 and data on the paramedics and the residents are presented in Table 2. Antecubital venous catheterisation was faster (113 ± 89 s) compared with external jugular vein catheterisation
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Table 2 Paramedic (n = 32) and medical resident (n = 28) work and cannulation experience.
Age (years) Work experience (years) Theoretical guidance for cannulation (h) Practical experience of central cannulation (n) Number of peripheral cannulations n (% of performers) 1/2/3/4a
Paramedics
Residents
33 (4) 4 (3) 7 (5) 7 (6) 1 (3%)/17 (53)/10 (31)/4 (13)
33 (4) 6 (4) 2 (3) 0 (1) 12 (43%)/11 (39)/4 (14)/1 (4)
Values are mean (SD) unless stated otherwise. a 1 = less than 100; 2 = 100–500; 3 = 500–1000; 4 = more than 1000. Table 3 Results for antecubital and external jugular vein cannulations.
Cannulation time (s) Failure rate (%) Attempts needed (n) 1/2/3/4a Vein not visible (n) Cannulation time in succeeded cannulations (s)
Antecubital vein
External jugular vein
p-Value
113 (89) 7 48/6/6/0 0 92 (57)
156 (112) 32 24/13/20/3 3 108 (69)
0.008 0.001 0.002 0.293
Values are mean (SD). a Number of successful cannulations in the first attempt (1), second attempt (2), third attempt (3), or not attempted at all (4).
(156 ± 112 s), p = 0.008 (mean difference 43 s; 95% confidence interval (CI): 12–74 s). In addition, the success rate of antecubital venous catheterisation was higher than that of external jugular vein catheterisation (93% compared with 68%, respectively, p = 0.001) and required fewer attempts (p = 0.002). For the antecubital vein, two attempts were needed in 6 and three attempts in 6 patients. For the external jugular vein two attempts were needed in 13 patients and three attempts in 20 patients. Only 39 (65%) subjects (paramedics or residents) succeeded to catheterise both antecubital and external jugular veins. Two (6%) paramedics and two (7%) residents failed to catheterise the antecubital vein. Nine (28%) paramedics and 10 (36%) residents failed to catheterise the external jugular vein. In three cases, external jugular vein catheterisation was not attempted at all because no visible vein was found. In all patients, antecubital vein was found and catheterisation was attempted. In successful attempts, antecubital vein catheterisation was faster (92 ± 57 s) than external jugular vein catheterisation (108 ± 69 s), p = 0.293. Catheterisation times did not differ between paramedics and residents in either site. Similarly, we found no difference in relation to the order of catheterisation (which site first). In logistic regression analysis, working experience, theoretical guidance for catheterisation, number of performed catheterisations, central venous pressure or PCWP did not explain the differences in catheterisation success (Table 3). There was a trend towards better external jugular vein catheterisation results with a greater number of previous catheterisation (p = 0.05). 4. Discussion The main finding of this prospective study was that it took 43 s longer to catheterise the external jugular vein compared with an antecubital vein in cardiac surgery patients simulating resuscitation. Success rate of establishing a venous access was 93% for the antecubital vein and 68% for the external jugular vein. Subjects needed more than one attempt in every five (20%) antecubital vein catheterisations and in every two (55%) external jugular vein catheterisations. One-third of the study subjects needed all three attempts to establish i.v. access in the external jugular vein compared with one-tenth in the antecubital vein. No attempts were successful if the external jugular vein was not visible. To our knowledge, this is the first study evaluating the clinical feasibility of external jugular compared with antecubital vein catheterisation.
Our results indicate that longer time is needed to establish venous access in the external jugular compared to antecubital veins and one-third of the attempts fail. In the pilot study, we determined the clinically meaningful time difference to be 60 s, thus we actually failed to show a difference of this magnitude between the catheterisation times in our study. However, even though the time difference was shorter than the clinically meaningful time, a failure rate of 30% for internal jugular vein catheterisation is clearly not acceptable in a critical situation. In a previous study, Emerman et al. studied femoral vein versus subclavian vein catheterisation during cardiac arrest and found a 94% success rate for subclavian and 77% for the femoral vein.8 Westfall et al. examined i.v. access in critically ill trauma patients and compared saphenous cut-down and percutaneous femoral vein catheterisation. They detected 2.5 min faster i.v.-line access with femoral vein catheterisation compared with saphenous venous cut-down (the actual catheterisation times were 5.63 ± 2.58 and 3.18 ± 1.19 min for saphenous and femoral lines, respectively).9 The failure and complication rates in this study were similar with incidences of 17 and 9%, respectively. A more recent study found ultrasound-guided femoral vein catheterisation during cardiopulmonary resuscitation (CPR) was more successful and faster with a 90% success rate and 2 min catheterisation time compared with landmark-guided catheterisation with 65% success and a 2-min time to catheterisation.10 In a French observational study, an out-of-hospital team succeeded in 76% of i.v.-line placements on the first attempt and in 98% on the second attempt. The time for intravenous line placement was 4.4 ± 2.8 min with one to eight attempts.11 Our results are in concordance with the previous studies, which clearly show the peripheral approach for i.v.-line placement should be the primary approach whenever feasible. In our study, the antecubital site was faster and more successful. Antecubital catheterisation has also other advantages in emergency situations compared with external jugular vein catheterisation as it does not interfere with intubation nor does it require delays in cardiac compressions. Furthermore, most health-care professionals are more familiar with the antecubital site. The emergency department residents and paramedics included in our study were quite inexperienced in i.v.-line placement (Table 2), which may have affected our results. However, our protocol with cross-over design may have limited the bias in this respect. These subjects may face emergency i.v. cannulation regularly in the future.
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Our study has several limitations. First, instead of a real CPR setting, our study was conducted in the OR with anaesthetised cardiac surgery patients. We may have lost the pressure of the real situation; however, the subjects were in unfamiliar surroundings with the whole surgical team as an audience, replacing one stress factor with another. We aimed to ensure safety of the subjects and to establish a more organised, tranquil study environment. Second, the patients in this study were not in cardiac arrest, which may have lessened the visibility and distension of the external jugular vein compared to real cardiac arrest. We tried to minimise this bias by targeted control of PCWP and central venous pressure with fluid administration and the Trendelenburg position, but our results may not be directly applicable with real cardiac arrest. 5. Conclusions Antecubital vein was a faster and more reliable site for intravenous access compared with the external jugular vein. Recommendations for preferred primary intravenous access in emergency care should be evaluated accordingly. Role of the funding source This study was supported by a research grant from the Kuopio University Hospital; no other sponsorship was obtained. Conflicts of interest All the authors declare that they have no conflicts of interest to disclose.
Acknowledgements We thank all paramedics and ER residents who participated in this study and RN P. Toroi for his indispensable work during the study. References 1. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67S1:S39–86. 2. Gonzalez RP, Cummings GR, Phelan HA, Mulekar MS, Rodning CB. On-scene intravenous line insertion adversely impacts prehospital time in rural vehicular trauma. Am Surg 2008;74:1083–7. 3. Lapostolle F, Catineau J, Garrigue B, et al. Prospective evaluation of peripheral venous access difficulty in emergency care. Intensive Care Med 2007;33:1452–7. 4. Spaite DW, Valenzuela TD, Criss EA, Meislin HW, Hinsberg P. A prospective in-field comparison of intravenous line placement by urban and nonurban emergency medical services personnel. Ann Emerg Med 1994;24:209–14. 5. Steen S, Liao Q, Pierre L, Paskevicius A, Sjöberg T. The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation 2003;58:249–58. 6. Chamberlain D, Frenneaux M, Steen S, Smith A. Why do chest compressions aid delayed defibrillation? Resuscitation 2008;77:10–5. 7. Hedges JR, Barsan WB, Doan LA, et al. Central versus peripheral intravenous routes in cardiopulmonary resuscitation. Am J Emerg Med 1984;2:385–90. 8. Emerman CL, Bellon EM, Lukens TW, May TE, Effron D. A prospective study of femoral versus subclavian vein catheterization during cardiac arrest. Ann Emerg Med 1990;19:26–30. 9. Westfall MD, Price KR, Lambert M, et al. Intravenous access in the critically ill trauma patient: a multicentered, prospective, randomized trial of saphenous cutdown and percutaneous femoral access. Ann Emerg Med 1994;23:541–5. 10. Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 1997;29:331–7. 11. Minville V, Pianezza A, Asehnoune K, Cabardis S, Smail N. Prehospital intravenous line placement assessment in the French emergency system: a prospective study. Eur J Anesthesiol 2006;23:594–7.