Article Figures & Data
Figures
- Figure 1.
Cannulating needles used during the project. (A) Orifice views of needle tips. Black underlined letters (top) indicate manufacturer: A–Arrow-Teleflex Incorporated, N–Navilyst Medical Inc/AngioDynamics, C–Cook Medical, B–Becton, Dickinson and Company. Numbers (middle) indicate Birmingham gauge scale. White letters in black boxes (bottom) indicate sharpness categorization: A-, extra-sharp; B-, of lesser sharpness customary for vascular access; I-, of sharpness intermediate between A- and B-. Scale lines are 2 mm apart. (B) Braun 22-gauge intravenous catheter hub positioned to serve as a funnel to conduct a microaccess guidewire into the shaft of a 21-gauge Becton, Dickinson and Company needle. (C) Two nylon screw-on mechanical needle stops. The needle stop above the needle displays a hole drilled through the bolt shaft just below the bolt head through which the cannulating needle will be inserted. The lower needle stop is shown positioned along the shaft of an 18-gauge needle.
- Figure 2.
Trigonometry of needle length optimization to limit tip depth insertion to the internal jugular vein (IJV) mid-lumen. csc, cosecant (ratio Loptimal/Dmid); Dmid, distance from the skin to the internal jugular vein mid-lumen; Loptimal, optimal needle insertion distance; SCM, sternocleidomastoid muscle; subcut, subcutaneous tissue; θ, angle between cannulating needle and skin.
- Figure 3.
Frequency distribution of cannulating needle types used in project. Numbers in parentheses specify numbers of each type of cannulating needle used with or without a needle stop. Sharpness categories are as follows: A-, extra-sharp; B-, of lesser sharpness customary for vascular access; I-, of sharpness intermediate between A- and B-. In contrast to A- needles (always 21 gauge) and I- needles (always 20 gauge), some B- needles had 18-gauge diameter (*) and others were 21 gauge (•). ga, gauge; NS, needle stop; NS+, needle stop used; NS-, no needle stop used; NShub, manufacturer's hub used as needle stop; NSs-o, screw-on needle stop used.
- Figure 4.
Distribution of anatomic depth measurements for 3 points of internal jugular vein (IJV) anatomy relevant to achieving single-wall puncture during IJV cannulation. Ddeep, depth from the skin to the deepest point of the IJV wall; Dmid, depth from the skin to the IJV lumen central axis; Dsuperf, depth from the skin to the most superficial point of the IJV wall.
- Figure 5.
Internal jugular vein (IJV) double-wall puncture (DWP) rates during cannulations by needle type, with and without needle stop (NS). Ninety-five percent CIs are expressed as black or white lines starting within and extending above bars. Numbers in parentheses above bars are upper limits of 95% CIs that extend beyond the range of the graph. The white bottom portion of the leftmost bar (DWP rate for 21-gauge extra-sharp NS+ needles) denotes the 0% double-wall puncture rate achieved for subcategory of 40 venipunctures performed using NShub needles (original manufacturer's hub served as the needle stop). Needle diameters are expressed using Birmingham gauge scale. 21A-, 21-gauge, A-bevel; 21B-, 21-gauge, B-bevel; 20I-, 20-gauge, I-bevel; 18B-, 18-gauge, B-bevel; NS+, needle stop used; NS-, no needle stop used.
Tables
- Table 1.
Needle Overinsertion Injuries Reported to Have Occurred During Internal Jugular Venous Cannulation Despite Ultrasound Guidance
Injured Structure Complications Carotid artery1-4 Hematoma, stroke, arteriovenous fistula Subclavian artery5-7 Hematoma, arteriovenous fistula Vertebral artery8-10 (mainly pediatric) Hematoma, pseudoaneurysm Pleura/lung11,12 Pneumothorax, hemothorax Thoracic duct13,14 Cutaneous chyle leak Stellate ganglion15,16 Horner syndrome - Table 2.
Smart Phrase Addendum to Central Venous Cannulation Note in the Electronic Medical Record
DEMOGRAPHICS VEIN ANATOMY NEEDLE OUTCOME date: IJ,SCL,Fem: gauge: Cannulation success? pt age: side (R/L): tip sharpness (A-,B-,I-) overshoot (DWP)? pt height: skin→superficial wall (mm): length (mm): # skin punctures: pt weight: skin→mid-lumen (mm): insertion angle (°): # needle re-directs: pt sex: skin→deep wall (mm): tip insertion depth (mm): notes: operator experience: A-P diameter (mm): M-L diameter (mm): needle stop used? needle stop type: A-,B-,I-, sharpness category: A-, extra-sharp; B-, of lesser sharpness customary for vascular access; I-, of sharpness intermediate between A- and B-; A-P, anteroposterior; DWP, double-wall puncture; IJ, SCL, Fem, internal jugular, subclavian, femoral (vein being cannulated); M-L, medial-lateral; pt, patient; R/L, right/left.
Outside Diameter Length Bevel Bias Angleb Tip Grind Typec W-t-P Siliconed W-t-P Latexd Sharpness Venipuncturesf, n=228 (122 male, 106 female) Manufacturer gaa mm mm degrees g g Classificatione Total, n (%) Male, n Female, n Becton, Dickinson and Companyg 21 0.8 25, 38, 51 15 LP^ 10.0 11.1 A- 93 (41) 45 48 Cook Medical SST-CSVh 21 0.8 40 14 LP^ 11.0 – A- 56 (25) 27 29 Navilyst Medical Inc/ AngioDynamicsi Cook Medical (SST)i 21 0.8 70 22 LP^ 18.5 26.3 B- 37 (16) 25 12 Arrow-Teleflex Incorporatedj 20 0.9 88 17 BB^ 18.1 13.7 I- 11 (5) 7 4 Arrow-Teleflex Incorporatedk 18 1.3 64 25 LP^ 19.9 25.7 B- 31 (14) 18 13 ↵aBirmingham wire gauge.
↵bPrimary (first) needle grind (bias) angle, measured with respect to needle long axis using light microscopy, computerized photographic enlargement, and protractor.
↵cNeedle tip geometric classifications: LP^ – lancet point with all 3 grinds on the same side of the needle tip; BB^ – back bevel point with the second and third grinds on the opposite side of the tip from the first.
↵dW-t-P is the weight in grams needed for a needle and attached syringe, perched atop an elastomeric membrane, to puncture the membrane. Membranes were 270-μm thick silicone rubber (McMaster-Carr) or 400-μm thick latex (Covidien). Each value is a mean of 5 consecutive trials performed with at least 7 needles of the same type.
↵eNearest traditional sharpness classification, usually based on primary grind (bias) angle (A-, bias angle ∼12° [ie, intramuscular bevel]; B-, bias angle ∼18° [ie, venous bevel]), but here also classified based on our W-t-P determinations. Arrow-Teleflex Incorporated 20-gauge needles, having a nontraditional back-bevel tip grind geometry (bias angle 14°) and W-t-P values between A- and B- needles, are categorized as intermediate sharpness (I-).
↵fNumber of internal jugular vein cannulations using each needle type.
↵gMarketed for intramuscular/subcutaneous injection.
↵hExtra-sharp Cook Medical Micropuncture needle.
↵iNavilyst Medical Inc/AngioDynamics and Cook Medical (SST) microaccess needles all had traditional B- tip geometry and nearly identical W-t-P measurements.
↵jNeedle in the Arrow-Teleflex Incorporated central venous cannulation kit that is provided as a component of an 18-gauge catheter-over-20-gauge needle device. During this project, such needles were used without the catheter as part of the microaccess technique.
↵kBare cannulating needle in the Arrow-Teleflex Incorporated central venous cannulation kit.
BB, back bevel point; LP, lancet point; W-t-P weight to puncture.
Cannulation Outcome Age, years Height, m Weight, kg BMI, kg/m2 Single-wall puncture, n=207 (91%) 62 ± 14 1.7 ± 0.1 86 ± 30 29 ± 10 Male, n=113 (55%) 62 ± 15 1.8 ± 0.1 98 ± 38 30 ± 10 Female, n=94 (45%) 62 ± 15 1.6 ± 0.1 77 ± 24 29 ± 9 Double-wall puncture, n=21 (9%) 58 ± 15 1.7 ± 0.1 81 ± 18 29 ± 9 Male, n=9 (43%) 59 ± 16 1.8 ± 0.1 86 ± 15 26 ± 4 Female, n=12 (57%) 57 ± 15 1.6 ± 0.1 77 ± 20 31 ± 12 Note: Data are presented as mean ± SD unless otherwise indicated.
BMI, body mass index.
- Table 5.
Summary Statistics for Measurements of Adult Patient Internal Jugular Vein Anatomy, n=228
Anatomic Variable Mean ± SD Minimum, Median, Maximum Diameter Anteroposterior 11.6 ± 3.0 5, 11, 20 Medial-lateral 16.7 ± 4.8 6, 16, 30 Anteroposterior: medial-lateral ratio 0.7 ± 0.2 0.3, 0.7, 1.3 Distance Skin to superficial-most portion of wall (Dsuperf) 10.6 ± 3.6 3, 10, 25 Skin to mid-lumen (Dmid) 16.7 ± 3.9 8, 17, 30 Skin to deepest portion of wall (Ddeep) 22.6 ± 4.8 11, 23, 38 Mid-lumen to deepest portion of wall (Ddeep – Dmid) 5.9 ± 1.8 2, 6, 13 Note: All measurements taken perpendicular to plane of skin in mm except for (unitless) diameter ratio.
- Table 6.
Double-Wall Puncture Rates for Individual Needles and Some Groupings Based on Tip Sharpness, Gauge, and Length
Needle Characteristic Double-Wall Puncture Rate, % Double-Wall Puncture, n/n 95% CI, % Tip Sharpness A-bevel, 21 gauge 8.7 13/149 4.7-14.5 I-bevel, 20 gauge 0.0 0/11 0.0-28.5 B-bevel, all gauges 11.8 8/68 5.2-21.9 21 gauge 13.5 5/37 4.5-28.8 18 gauge 9.7 3/31 2.0-25.8 Gauge 21 gauge, any bevel, NS± 9.7 18/186 5.8-14.9 20 gauge, I-bevel, NSs-o 0.0 0/11 0.0-28.5 18 gauge, B-bevel, NS± 9.7 3/31 2.0-25.8 Length optimization NS-, all gauges 25.0 11/44 13.2-40.3 21 gauge, A-bevel and B-bevel 22.0 9/41 10.6-37.6 21 gauge, A-bevel 18.2 6/33 7.0-35.5 21 gauge, B-bevel 37.5 3/8 8.5-75.6 18 gauge B-bevel 66.7 2/3 9.4-99.2 NS+, all gauges 5.4 10/184 2.6-9.8 21 gauge, A-bevel 6.0 7/116 2.5-12.0 21 gauge, A-bevel, NSs-o 9.2 7/76 3.8-18.1 21 gauge, A-bevel, NShub 0.0 0/40 0.0-8.8 21 gauge, B-bevel, NSs-o 6.9 2/29 0.9-22.8 20 gauge I-bevel, NSs-o 0.0 0/11 0.0-28.5 18 gauge B-bevel, NSs-o 3.6 1/28 0.1-18.3 Note: A-bevel, extra-sharp; B-bevel, of lesser sharpness customary for vascular access; I-bevel, of sharpness intermediate between A-bevel and B-bevel.
NS±, with or without a needle stop; NS+, with a needle stop; NS-, without a needle stop; NShub, original manufacturer's hub served as the needle stop; NSs-o, nylon screw-on mechanical needle stop.
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