A Shift in Technique: Study Assessed Efficacy of Oblique Internal Jugular Cannulation in Children

Recent study evaluated the success rates of two ultrasound-guided approaches, the oblique and transverse methods, for internal jugular venous cannulation in pediatric cardiac surgery patients. Internal jugular venous access is generally more challenging in pediatric patients due to anatomical differences, such as smaller, more collapsible veins. This clinical trial involved sixty pediatric patients aged between 3 months to 12 years, who were undergoing open-heart surgeries at a Jakarta hospital. Participants were randomized into two groups, one for each approach.

Outcomes and Results

The primary outcome measured was the first needle pass success rate, while secondary outcomes included the total number of puncture attempts and incidence of mechanical complications. Results showed that the first needle pass success rate was 86.7% for the oblique group compared to 73.3% for the transverse group. However, this difference was not statistically significant (P = 0.19). The average number of needle attempts required for successful cannulation was similar for both groups, with 1.3 attempts for the oblique technique and 1.43 for the transverse approach.

Complications and Comparison

Mechanical complications were noted in seven patients across both groups, including arterial punctures and hematomas, with three from the oblique group experiencing artery puncture. The study highlighted that although the oblique approach showed improved visualization of both veins and arteries compared to the transverse method, it did not significantly reduce the likelihood of complications like arterial punctures, particularly given the elastic nature of pediatric veins.

Conclusions on Technique Efficacy

The study underscores that while ultrasound guidance has improved the overall success of internal jugular venous cannulation, the anatomical challenges presented in pediatrics, such as vascular instability and smaller vessel size, still pose significant risks during the procedure. Notably, the oblique method incorporates advantages of both the transverse and longitudinal approaches, potentially offering better needle visualization and control, but these benefits did not translate into higher success rates in pediatric patients. Various factors could influence the study's outcomes, including the varying proficiency levels among the 11 resident anesthetists involved, the lack of blinding due to the inherent differences in the two techniques, and the functional characteristics of pediatric patients’ vessels. While the oblique approach demonstrated potential benefits in visual control, it did not statistically outperform the transverse approach in this specific pediatric cohort. Hence, the findings suggest no significant advantage of the oblique method over the transverse for this patient population.

Key Points

- A clinical trial evaluated two ultrasound-guided techniques, oblique and transverse, for internal jugular venous cannulation specifically in pediatric patients undergoing cardiac surgery, highlighting the complexity due to smaller and more collapsible veins.

- The study included sixty participants aged 3 months to 12 years, randomized into two groups for each cannulation method, focusing on the primary outcome of first needle pass success rate, with the oblique group achieving 86.7% and the transverse group 73.3%.

- Although the oblique technique had a higher first pass success rate, this difference was not statistically significant (P = 0.19), and both methods required a similar average number of needle attempts (1.3 for oblique and 1.43 for transverse).

- Mechanical complications were observed in seven patients, including arterial punctures and hematomas, with a notable occurrence of arterial puncture (three cases) in the oblique group, indicating that both techniques present risks despite the use of ultrasound guidance.

- The study concluded that anatomical challenges in pediatric patients continued to pose risks, as the oblique method, while showing improved vein and artery visualization, did not result in significantly improved outcomes when compared to the transverse approach.

- Factors influencing the study's results included the varying experience levels of the anesthetists, the absence of blinding between techniques, and the specific vascular characteristics of pediatric patients, leading to the conclusion that there is no significant advantage of the oblique method over the transverse approach for jugular cannulation in this cohort.

Reference -

Aldy Heriwardito et al. (2025). Randomized Comparison Of Oblique Versus Transverse Orientation For Ultrasound-Guided Internal Jugular Venous Cannulation In Pediatric Heart Surgery Patients. *Annals Of Cardiac Anaesthesia*, 28, 149 - 155. https://doi.org/10.4103/aca.aca_167_24.