Point-of-care transthoracic echocardiography as an alternative to transesophageal echocardiography to confirm internal jugular guidewire position
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KeywordsInternal Jugular Vein Superior Vena Cava Transesophageal Echocardiography Right Atrium Introducer Sheath
Unintentional needle puncture of the carotid artery (CA) during internal jugular vein (IJV) cannulation occurs relatively frequently.1 Serious sequelae (e.g., hematoma, airway compromise, stroke, and death) usually occur when this error is not detected, and the CA is subsequently dilated with the large-bore introducer sheath. Methods employed to detect CA puncture include blood colour and flow characteristics, manometry, and pressure transduction of the needle. Ultrasonographic visualization of the IJV and CA prior to cannulation is endorsed as a method to improve safety.2 However, this technology does not completely eliminate accidental CA injury. Ultrasonography of the neck visualizes the guidewire for only a short distance, leaving room for posterior vein wall penetration outside the field of view.
In many centres providing cardiac anesthesia, transesophageal echocardiography (TEE) is used to visualize the guidewire in the superior vena cava (SVC) or right atrium (RA) before the introducer sheath is inserted.3 The guidewire, seen in the bicaval view, confirms appropriate wire placement.
Guidewire confirmation with point-of-care TTE during IJV cannulation provides an alternative to TEE for confirming appropriate guidewire placement. Also, it may aid in reducing the incidence of CA injury associated with IJV cannulation.
Conflicts of interest
Clip 1. Right atrium (RA) and right ventricle (RV) in subcostal view before and after injection of 5 mL of blood through the catheter. Microbubbles and resulting opacification of the RA + RV are apparent. (MPG 4.78 mb)
Clip 2. Subcostal view of the right atrium (RA) and right ventricle (RV). The guidewire is advanced, and the tip of the wire is visualized in the RA. (MPG 4.08 mb)
Clip 3. Subcostal bicaval view showing the RA, RV, and inferior vena cava (IVC). The guidewire is advanced and the tip of the wire is visualized in the IVC. (MPG 4.35 mb)