Techniques, Advantages, and Pitfalls of Ultrasound-Guided Internal Jugular Cannulation: A Qualitative Study

• Ultrasound guidance has induced a change in needle angulation for internal jugular cannulation.
• New techniques such as medial and steep angulation have potential pitfalls.
• Clinicians should be aware of the unintended consequences of new technologies.

BackgroundNational guidelines advocating ultrasound guidance for internal jugular venous cannulation were introduced in the United Kingdom in 2002, followed by international guidelines a decade later. However, the benefits of ultrasound guidance do not appear to have universally translated into clinical practice. This study aimed to investigate the effect of ultrasound on the practice of internal jugular vein cannulation.MethodsWe conducted an ethnographic study incorporating observations, interviews, and focus groups in 2 hospitals in the north of England over a 4-month period.ResultsTwenty-seven clinical observations, 10 interviews, and 3 focus groups were conducted. In 25 clinical episodes, ultrasound guidance was used. Four distinct needling techniques were observed, which we classified in terms of needle angulation: the traditional landmark technique, the ultrasound-guided traditional approach, ultrasound-guided medial angulation, and the ultrasound-guided steep approach. The latter 2 techniques represent a departure from conventional practice and appear to have developed alongside ultrasound guidance. Although no serious complications were observed, there appears to be enhanced potential for complications to occur with medial angulation and the steep approach. Participants described a loss of anatomic knowledge and a false sense of security associated with the adoption of ultrasound guidance, which may account for the emergence of new, potentially riskier needling techniques.ConclusionsThe introduction of safe technologies may lead to unintended consequences, and clinicians should attempt to recognize and mitigate them when they occur. Education to increase awareness of the pitfalls of ultrasound guidance is recommended.