Ultrasound guided internal jugular vein cannulation in pediatric patients: a randomized controlled trial

1. Introduction

Central venous catheters are essential for precise hemodynamic monitoring and rapid fluid administration during complex surgical procedures, particularly in facilitating timely interventions and improving clinical outcomes in pediatric patients undergoing surgery [1, 2]. Among the available central venous access routes, the internal jugular vein (IJV) is frequently used for cervicothoracic venous access in children. Given the clinical importance of IJV cannulation, efforts to improve the success rate while minimizing complications are of particular relevance in pediatric practice [2, 3, 4]. However, the anatomical and physiological characteristics of pediatric patients, such as smaller vessel diameter, shorter neck length, and limited operative space, significantly increase the technical difficulty of venous cannulation [3]. The adoption of ultrasound-guided techniques has markedly enhanced both the success rate and safety of IJV puncture. This modality has been shown to reduce the incidence of complications, including hematoma, thrombosis, infection, carotid artery puncture, pneumothorax, hemothorax, and nerve injury, thereby contributing to safer and more effective procedures [5, 6, 7, 8]. Despite these advancements, ultrasound-guided IJV cannulation in pediatric patients remains challenging, particularly for resident physicians. Therefore, identifying an optimal technique that enhances procedural success while remaining feasible for less experienced operators is needed.

Conventional ultrasound-guided IJV cannulation includes the short-axis out-of-plane (SAX-OOP) and long-axis in-plane (LAX-IP) approaches. Although both methods are commonly used, the optimal approach remains a matter of debate [9, 10, 11, 12, 13], particularly regarding their applicability for novice users, such as residents. There are currently two modified ultrasound-guided techniques in clinical use: the modified dynamic needle tip positioning (MDNTP) technique and the real-time biplane technique. The MDNTP method enhances needle tip visibility and enables precise localization of the IJV relative to the adjacent common carotid artery, thereby improving puncture accuracy [14]. The real-time biplane technique, a proven method for IJV cannulation in critically ill patients [15], simplifies the puncture procedure and improves needle visibility, offering clear advantages and potentially increased safety for patients [15, 16]. However, its application in pediatric populations has not yet been documented.

Hence, the present study aimed to compare the MDNTP technique with the real-time biplane technique to identify the more suitable approach for ultrasound-guided IJV cannulation performed by resident physicians in pediatric patients.

2. Materials and methods

This study was approved by the Institutional Review Board of the Children’s Hospital of Chongqing Medical University (Approval No. 440/2023). Written informed consent was obtained from the parents or legal guardians of all participating children. The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2300077334; principal investigator: LL; registration date: 06 November 2023) before patient enrollment and conducted in the operating rooms of the Department of Anesthesiology at the Children’s Hospital of Chongqing Medical University.

From 01 November 2023, to 10 April 2024, pediatric patients aged 0–6 years scheduled for thoracic or cardiac surgery were consecutively screened for inclusion. Eligibility was determined by two attending anesthesiologists based on the clinical requirement for central venous access to facilitate continuous hemodynamic monitoring. Children were excluded if they had local skin infections, vascular malformations at the puncture site as identified by ultrasound, or if parental consent was not obtained. All included patients met the criteria for central venous access device (CVAD) placement as outlined in the Italian Group of Venous Access Devices (GAVeCeLT) consensus guidelines, such as severe cases requiring continuous infusion of hypertonic solution and hemodynamic monitoring [17].

The intervention measures for all patients were performed by 11 residents from our department who had no prior experience in pediatric IJV cannulation but were proficient in performing the procedure in adult patients. Before the start of the study, all residents underwent comprehensive theoretical training, which included detailed instruction and live demonstrations of both the MDNTP and real-time biplane techniques. To ensure familiarity and technical competence, each resident practiced both techniques seven times using an internal jugular puncture simulator. A senior physician with over eight years of experience in ultrasound-guided procedures supervised and documented all puncture attempts conducted by the residents.

The participants, outcome evaluators, and data managers were blinded to group allocation. A total of 88 pediatric patients were randomly assigned to either the MDNTP group or the real-time biplane group, with 44 patients in each group. Eleven residents were each allocated eight random numbers, corresponding to four patients in the MDNTP group and four in the real-time biplane group. The outcome trial effect evaluators were not involved in recording or managing any trial-related data. Informed consent was obtained for all the 88 patients (Fig. 1).

Fig. 1.Flowchart of patient enrollment.

Upon entering the operating room, standard vital sign monitoring was performed, including three-lead electrocardiography (ECG), peripheral oxygen saturation, heart rate (HR), respiratory rate, and non-invasive blood pressure (BP) measurements. All patients were intubated and received general anesthesia via intravenous and inhalational routes. Anesthesia was induced using routine intravenous midazolam (0.05–0.1 mg/kg), propofol (2–3 mg/kg), sufentanil (0.5–1 µg/kg), and cisatracurium (0.15 mg/kg).

The patients were carefully positioned in the Trendelenburg position with a shoulder roll, and the head was gently rotated 30–40 degrees toward the side opposite the planned IJV cannulation site to optimize venous distension and procedural access. Before each procedure, the ultrasound probe was covered with a sterile sleeve, and sterile ultrasound gel was applied inside the sleeve to ensure aseptic technique. A 22-G, 25 mm puncture needle and a 0.018′′ nitinol guidewire were used together with a central venous catheter (Arrow International, Inc., USA). The MDNTP technique was performed using the EPIQ 7C ultrasound system (Philips Ultrasound, Inc., Cambridge, MA, USA) equipped with a high-frequency linear array probe (eL18-4). The real-time biplane technique also utilized the EPIQ 7C system but required a biplane probe (XL14-3) (Fig. 2). Both ultrasound-guided techniques for pediatric IJV cannulation followed the seven-step strategy outlined in the Standardized Institutional Central (SIC) protocol, which aims to reduce complications associated with central venous catheter (CICC) placement through standardized procedures [18].

Fig. 2.Real-time biplane ultrasound probe.

2.1 Modified dynamic needle tip positioning group

In the MDNTP group, the ultrasound probe was placed perpendicular to the long axis of the IJV for precise localization. An appropriate puncture site was selected by adjusting the probe’s position such that the IJV was centered in the ultrasound image and located beneath the midpoint of the probe’s long axis. The puncture site corresponded to the intersection between the probe’s long-axis midpoint and the skin surface. The needle was inserted in the direction of the center of the vein. The detailed steps of the puncture procedure are illustrated in Fig. 3. Successful IJV cannulation was confirmed by removing the inner stylet, advancing the catheter smoothly into the vessel, attaching a syringe, and confirming free aspiration of venous blood. Then, a guidewire was inserted, and an ultrasound was performed to verify its correct placement within the vessel lumen. The MDNTP technique uses single-plane imaging in the SAX-OOP view to enhance needle tip visualization through continuous dynamic tracking of the probe (Fig. 3). Its key characteristic is the “needle-probe collaborative displacement under single-plane guidance”, which is useful in pediatric patients with superficially located vessels, as it minimizes probe pressure and improves procedural safety.

Fig. 3.Procedure for ultrasound-guided internal jugular vein cannulation in infants using the modified dynamic needle tip positioning method. (A) The puncture needle is inserted at the contact point between the midpoint of the ultrasound probe and the skin, with the needle tip appearing as a highly reflective bright spot on the ultrasound image. (B) The needle is directed toward the center of the vein, where the needle tip appears as a hyperechoic bright spot on the ultrasound image. (C) Once the needle becomes visible, the ultrasound probe is advanced forward and gently positioned alongside the needle. When the needle reappears on the ultrasound image, the probe is moved proximally to allow real-time tracking of the needle as it passes through the subcutaneous tissue and cervical fascia, and ultimately penetrates the anterior wall of the internal jugular vein. (D) This process was repeated to ensure complete insertion of both the needle and catheter into the vessel.

2.2 Real-time biplane group

In the real-time biplane group, the procedure began by aligning the long axis of the ultrasound probe vertically with the long axis of the IJV for the simultaneous display of two ultrasound views: one in the long-axis plane and the other in the short-axis plane of the IJV. The probe was then gently slid to identify an appropriate puncture site, the puncture needle was inserted at a point directly beneath the center of the probe’s long axis, and upon visualizing the needle on both ultrasound planes, its trajectory was carefully adjusted based on its spatial relationship with the target vessel. The detailed steps of the puncture procedure are illustrated in Fig. 4. After needle insertion, the inner stylet was removed, and the catheter was advanced into the vein. Successful venous access was confirmed by attaching a syringe to the catheter and observing smooth blood aspiration. Then, a guidewire was introduced, and ultrasound imaging was performed to verify the correct intravascular position of the wire. The biplane technique utilizes a real-time orthogonal plane fusion method for simultaneously visualizing the vessel’s cross-sectional (short-axis) and longitudinal (sagittal) views through a matrix array probe. During needle advancement, the spatial orientation of the needle can be observed in both the anteroposterior (cross-sectional) and craniocaudal (sagittal) planes. Its primary advantage lies in providing “real-time, two-view navigation for precise three-dimensional control”, making it particularly beneficial in pediatric patients with complex vascular anatomy or in cases where adjacent critical structures, such as the carotid artery, must be avoided.

Fig. 4.Procedure for ultrasound-guided internal jugular vein cannulation in infants using the real-time biplane method. (A) The biplane ultrasound probe is placed perpendicular to the long axis of the internal jugular vein, allowing the vein to be simultaneously visualized at the center of both ultrasound images in the long-axis in-plane and short-axis out-of-plane views. (B) The puncture needle is inserted below the midpoint of the probe’s long axis. Once the needle appears in both ultrasound images, its direction is adjusted based on its position relative to the vessel, ensuring it is guided close to the anterior wall of the vein. (C) The direction of needle advancement is continuously adjusted using both the long-axis in-plane and short-axis out-of-plane images, with the needle kept oriented toward the center of the vessel. (D) This process was repeated to enable complete insertion of both the needle and the catheter into the vessel under dual-plane ultrasound guidance.

3. Results

In this randomized controlled trial comparing ultrasound-guided IJV cannulation techniques in pediatric patients, significant differences were observed between the real-time biplane and MDNTP groups.

Data from all 88 enrolled cases were included in the analysis, with an equal distribution of 44 patients in each group. No statistically significant differences were found in baseline characteristics between the two groups (Table 1), confirming group comparability prior to intervention.

The MDNTP technique demonstrated significant advantages in both first-attempt success rates and procedural efficiency. Among the 44 patients in the MDNTP group, 35 (79.5%) achieved successful cannulation on the first attempt, compared to 24 (54.5%) in the real-time biplane group (p = 0.022; risk ratio (RR), 1.46; 95% confidence interval (CI), 1.07–1.99). Additionally, the median cannulation time was significantly shorter in the MDNTP group (82.50 (55.50–115.50) seconds) compared to the biplane group (108.00 (71.80–174.00) seconds) (p = 0.023; median difference, 26.00 seconds; 95% CI, 3.00–47.00).

Despite differences in first-attempt success and procedure duration, both groups achieved comparable overall success rates, with 43 of 44 patients (97.7%) successfully cannulated in each group (p = 1.000; RR, 1.00; 95% CI, 0.938–1.066), indicating no statistically significant difference in the final procedural success. However, the MDNTP group required significantly fewer puncture attempts than the biplane group (median (interquartile range), 1.0 (1.0–1.0) vs. 1.0 (1.0–2.0); p = 0.015). No cases of thrombosis were observed in either group (Table 2).

4. Discussion

This study demonstrates that the MDNTP technique for IJV cannulation in pediatric patients results in a higher first-attempt success rate. Additionally, this method required fewer puncture attempts and a shorter cannulation time compared to the real-time biplane technique. It is important to highlight that although cannulation was performed exclusively on the right IJV in both groups, no statistically significant differences were observed in the overall success rate or complication rates between the two techniques.

The development of ultrasound visualization technologies has substantially improved the safety and efficacy of ultrasound-guided IJV cannulation while also reducing the incidence of complications such as hematoma, thrombosis, infection, carotid artery puncture, pneumothorax, hemothorax, and nerve injury [6, 19, 20]. In our previous research, we successfully employed a combined LAX-IP and SAX-OOP ultrasound-guided approach for IJV puncture in premature neonates [19], which integrates the advantages of both orientations. The LAX-IP method enables continuous visualization of the needle trajectory and its entry into the vessel lumen [21], while the SAX-OOP approach provides a single-plane image of the IJV, adjacent arteries, and surrounding anatomical structures, thereby enhancing procedural accuracy and safety [22]. However, the combined LAX-IP and SAX-OOP technique requires rotational adjustments of the ultrasound probe, rendering it technically challenging, particularly for inexperienced operators. To simplify the IJV cannulation procedure while maintaining simultaneous visualization of both the long- and short-axis views, we opted for a 3D ultrasound probe, which enhanced both visualization and procedural efficiency. The real-time biplane method is a derivative of the long and short-axis combination method, with the main benefit being its ability to display both axes simultaneously for improved needle visualization and accuracy during cannulation, thereby enhancing procedural precision and patient safety outcomes [16].

Currently, several researchers have conducted experiments on real-time biplane ultrasound-guided internal jugular venipuncture. One comparative study evaluated the short-axis and biplane techniques using the IE33 ultrasound system (Philips Ultrasound, Bothell, WA, USA), which features an advanced 3D phased-array transducer (X5-1) and optimized resolution settings to enhance imaging capabilities [23]. Another study compared the long-axis technique to the real-time biplane approach using a Philips CX50 system with an L12-3 probe and a Philips EPIQ system with an XL14-3 probe [15]. However, it is important to note that both studies were conducted exclusively in adult patients, and all procedures were performed by experienced anesthesiologists who were highly skilled in internal jugular venipuncture. Despite its potential, three-dimensional ultrasound has not achieved widespread adoption compared to conventional two-dimensional imaging, particularly in pediatric clinical settings, where its use remains limited. Our study aims to demonstrate the feasibility of real-time biplane ultrasound-guided IJV cannulation in pediatric patients and young children, with a specific focus on improving the technique among residents with limited experience in this challenging procedure.

The study results showed that the first-attempt success rate for IJV puncture and cannulation, assisted by real-time biplane ultrasound and conducted by residents who lacked experience in performing IJV cannulation in pediatric patients, was 54.5%, significantly lower compared to previous studies that involved more experienced operators using the MDNTP method [14]. In contrast, the first-attempt success rate achieved by residents using the MDNTP method in this study was 79.5%. We believe this discrepancy could be primarily attributed to the larger size of the biplane probe (XL14-3) (Fig. 2) compared to the linear array probe (eL18-4) used in the SAX-OOP technique. The linear array probe is compact and can be more easily positioned and secured on the necks of pediatric patients, which allows smooth probe manipulation during the procedure. Conversely, the larger size of the biplane probe presents challenges in terms of placement and stabilization in pediatric necks, especially when maneuvering the probe. As a result, the real-time biplane method was associated with longer cannulation times and increased number of puncture attempts compared with the modified technique.

No statistically significant differences in the overall success rate were observed between the two groups, potentially due to the ability of both methods to effectively visualize the spatial relationship between the IJV, arteries, and surrounding anatomical structures [15, 22]. Similarly, the incidence of complications did not differ significantly between the two groups. We also observed that among the 88 patients included in our study, only one case of postoperative neck hematoma was reported in the group utilizing the real-time biplane method. However, after applying pressure to the site by the anesthesiologist, no hematoma was observed at the puncture site upon re-examination. This complication may have resulted from tissue structure damage due to an excessive number of puncture attempts during the procedure.

5. Limitations

This study had several limitations. First, the short observation period limited the evaluation of catheter durability and the detection of long-term complications. Second, the removal of IJV catheters occurred after patients were transferred to the Intensive Care Unit (ICU) rather than immediately following surgery, which might have led to prolonged catheter retention time and differences in postoperative management strategies, both of which could affect complication rates. Third, the study involved 11 anesthesiologists with limited experience, which may limit the comparability of our findings to studies involving more experienced operators. Further research is needed to determine whether the real-time biplane approach provides additional benefits for clinicians who already have experience in ultrasound-guided IJV cannulation. Fourth, our patient population included a slightly broader age range (0 to 6 years) compared to previous studies [14, 19], which may affect generalizability. Fifth, a potential source of bias in ultrasound-guided vascular access is the inadvertent compression of neck structures by the operator, which may reduce venous diameter and influence the success of puncture and cannulation. Future research could consider restricting the age range or focusing on neonatal patients, explore factors that may influence success and safety, and develop improved techniques or technologies to assist ultrasound-guided IJV cannulation in infants, including neonates.

6. Conclusions

Residents performing ultrasound-guided IJV cannulation in pediatric patients had a significantly higher first-attempt success rate with the MDNTP technique for IJV cannulation compared to the real-time biplane technique. The MDNTP approach required less cannulation time and fewer puncture attempts, indicating greater procedural efficiency and practicality. However, no statistically significant differences were observed between the two techniques in terms of overall success rates or complication rates.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

SW—write, edit, revise, and submit the manuscript. YS and XC—write and edit the manuscript. WQC, PW and JWC—organize data. YZT and YHL—analyze the data. LFL—write, edit, revise, and supervise the manuscript.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of the Children’s Hospital of Chongqing Medical University (Approval No. 440/2023). Written informed consent was obtained from the parents or legal guardians of all participating children.

Acknowledgment

We appreciate the support given by the anesthesiologist and nursing teams from the Children’s Hospital of Chongqing Medical University.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.