Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2013  |  Volume : 16  |  Issue : 1  |  Page : 21-22
Invited Commentary

Director, Pediatric Cardiac Anesthesia, Associate Professor of Anesthesiology, Mount Sinai Medical Center, New York, USA

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Date of Web Publication2-Jan-2013

How to cite this article:
Mittnacht A. Invited Commentary. Ann Card Anaesth 2013;16:21-2

How to cite this URL:
Mittnacht A. Invited Commentary. Ann Card Anaesth [serial online] 2013 [cited 2022 Dec 8];16:21-2. Available from:

In this issue of Annals of Cardiac Anesthesia, Tempe et al, [1] report on their success rate of internal jugular vein (IJV) cannulation in 976 cardiac surgery patients, by using the anatomic landmark technique. In times when most publications, with regard to perioperative vascular access, focus on ultrasound-guided techniques, the authors should be congratulated on providing a contemporaneous cohort of patients using this traditional method of obtaining central venous access. The authors' success rate was 100%, and the risk of carotid puncture, the most feared complication, was comparatively low. Despite many practitioners embracing technological advances such as using ultrasound for real-time visualization cannulation, there have always been skeptics and master clinicians, rightfully reminding us of the vast experience with long taught traditional techniques. Technological advances in medicine are expected to help improve patient safety and reduce the risk of complications. The low rate of carotid puncture in the study of Tempe et al, reminds us that traditionally taught techniques in well-trained hands can be equally safe, with studies on ultrasound-guided techniques showing carotid puncture in up to 4%. [2] Therefore, the questions that could be asked are: Is the use of ultrasound for vascular access truly beneficial? Are the existent and emerging guidelines and recommendations from various specialty societies promoting the use of ultrasound to guide central venous access premature, or not based on adequate scientific evidence? Most recently, the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) developed guidelines for performing ultrasound-guided vascular access, [3] and the American Society of Anesthesiologists (ASA) released practice guidelines for central venous access. All of the above-mentioned guidelines recommend real-time ultrasound for IJV cannulation in adults. [4] These recommendations are based on an extensive review of the existing literature; however, critics may notice that the level of evidence is often surprisingly low. Although the majority of prospective studies show a higher first attempt success rate, fewer attempts overall, and fewer complications when using ultrasound guidance, [5] it is almost impossible to perform these studies in a truly controlled or even blinded environment. In all studies, the operator bias cannot be excluded, moreover, they poorly control for operator skill and experience. [6]

In the presented study by Tempe et al, operator experience using the traditional landmark technique was high, partially explaining the high success and low complication rate. Comparisons made to other published studies or techniques are inherently difficult. One could argue that similar training in an ultrasound-guided technique would also yield very good results. Comparisons made with studies reporting on the success rate and complications of ultrasound-guided techniques fail to acknowledge the fact that ultrasound-guided vascular access requires training and experience in order to maximize the benefits of this technique, and even more so as to decrease the potential complications.

The 100% success rate obtained in the present study with minimal complications, indicate that ultrasound guidance is not necessary in adults undergoing cardiac surgery. However, very few would advocate and opt to solely rely on landmark-guided regional blocks. Similarly, with the rapidly spreading video-assisted laryngoscopy, it is highly unlikely that anesthesiologists, 10 years from now, will still solely rely on traditional laryngoscopy when intubating a patient, despite the high success rate in experienced hands. In the world of cardiac anesthesia, ultrasound technology is rapidly being adopted, not just because of guidelines and recommendations, but also because of the obvious advantages that a traditional landmark technique cannot offer. Although it is true that ultrasound does not eliminate complications, particularly the risk of carotid puncture; with adequate training and experience it can almost always be completely avoided. The key point is adequate training. It would be novice to believe that a novice ultrasound user can operate this technology, without any complications. Experienced practitioners however, will without any doubt, value this technology for example in recognizing anatomic variations and vascular patency, for needle guidance in patients with difficult anatomy including obese patients, as a rescue technique after prior attempts resulting in hematoma formation, in anticoagulated patients, and so on. The question about potential benefits has already been answered; however, the question that needs to be addressed is how we train future generations of young apprentices in vascular access. Is there a place for both techniques? There is no doubt that lack of practice in either technique will increase complications. Hence, should we do as Luke Skywalker did in the original Star Wars movie from 1977, close our eyes and let us be guided by the force, in our case during IJV cannulation? Probably not; but studies such as the one presented by Tempe et al., remind us that there is room for maintaining traditional skills and including them in the training of future generations of cardiac anesthesiologists.

   References Top

1.Tempe DK, Virmani S, Agarwal J, Hemrajani M, Satyarthy S, Minhas HS. The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery. Ann Card Anaesth 2013;16:16-20.  Back to cited text no. 1
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2.Augoustides JG, Horak J, Ochroch AE, Vernick WJ, Gambone AJ, Weiner J, et al. A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth. 2005;19:310-5.  Back to cited text no. 2
3.Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, et al. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2012;114:46-72.  Back to cited text no. 3
4.Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, et al. Practice guidelines for central venous access. A report by the American Society of Anesthesiologists Task Force on central venous access. Anesthesiology 2012;116:539-73.  Back to cited text no. 4
5.Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361-4.  Back to cited text no. 5
6.Weiner MM, Geldard P, Mittnacht AJ. Ultrasound-guided vascular access: A comprehensive review. J Cardiothorac Vasc Anesth 2012. pii: S1053-0770(12)00350-3.  Back to cited text no. 6

Correspondence Address:
Alexander Mittnacht
Director, Pediatric Cardiac Anesthesia, Associate Professor of Anesthesiology, Mount Sinai Medical Center, New York
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Source of Support: None, Conflict of Interest: None

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