Emergency. 2016; 4 (3): 155-158 BRIEF REPORT Proper Angle of Sono-guided Central Venous Line Inser- tion Hassan Barzegari1, Arash Forouzan1, Mohammad Ali Fahimi1∗, Behzad Zohrevandi2, Mandana Ghanavati1 1. Department of Emergency Medicine, Imam Khomeini General Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. 2. Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran. Received: November 2015; Accepted: February 2016 Abstract: Introduction: Determining the proper angle for inserting central venous catheter (CV line) is of great impor- tance for decreasing the complications and increasing success rate. The present study was designed to deter- mine the proper angle of needle insertion for internal jugular vein catheterization. Methods: In the present case series study, candidate patients for catheterization of the right internal jugular vein under guidance of ul- trasonography were studied. At the time of proper placing of the catheter, photograph was taken and Auto Cad 2014 software was used to measure the angles of the needle in the sagittal and axial planes, as well as patient’s head rotation. Results: 114 patients with the mean age of 56.96 ± 14.71 years were evaluated (68.4% male). The most common indications of catheterization were hemodialysis (55.3%) and shock state (24.6%). The mean angles of needle insertion were 102.15 ± 6.80 for axial plane, 36.21 ± 3.12 for sagittal plane and the mean head rotation angle was 40.49 ± 5.09. Conclusion: Based on the results of the present study it seems that CV line insertion under the angles 102.15 ± 6.80 degrees in the axial plane, 36.21 ± 3.12 in the sagittal plane and 40.49 ± 5.09 head rotation yield satisfactory results. Keywords: Central venous catheters; vascular access devices; ultrasonography; emergencies; catheterization © Copyright (2016) Shahid Beheshti University of Medical Sciences Cite this article as: Barzegari H, Forouzan A, Fahimi MA, Zohrevandi B, Ghanavati M. Proper Angle of Sono-guided Central Venous Line Insertion. Emergency. 2016; 4 (3): 155-158. 1. Introduction Insertion of central venous catheter (CV line) is a common procedure to reach the central veins with the aim of monitor- ing the patients regarding hemodynamic status, measuring central venous pressure (CVP), fluid therapy, infusion of va- soactive agents, etc. (1, 2). CV line insertion may be done ei- ther with the guidance of anatomic landmarks or ultrasonog- raphy. One of the problems caused by this procedure is the risk of pneumothorax and arterial puncture, which usually occur due to improper selection of angle and depth of nee- dle insertion. The angle for needle insertion in both meth- ods is suggested to be 30 - 45 degrees. Yet, determining the angle, which minimizes the mentioned complications, is still needed (3-5). In a study, the proper needle tilt angle for inter- nal jugular vein catheterization was shown to be 75 degrees ∗Corresponding Author: Mohammad Ali Fahimi; Department of Emergency Medicine, Imam Khomeini General Hospital, Ahvaz Jundishapur University of Medical Sciences, Azadegan Avenue, Ahvaz, Khuzestan Province, Iran. Postal code: 6193673166 Tel/Fax: +986112229166 Email:fahimi76@yahoo.com and higher (6). The present study aimed to determine the proper angle of needle insertion for right internal jugular vein catheterization. 2. Methods 2.1. Study design and settings The present case series study was designed to determine the proper angle of CV line insertion in internal jugular vein. Patients admitted to Imam Khomeini and Golestan Hospi- tals, Ahvaz, Iran were included. Based on the principles of Helsinki Declaration, researchers adhered to confidentiality of patient information and used the information only for re- search purposes. The study was approved by the Ethical Committee of Ahvaz Jondi Shapour University of Medical Sci- ences, Ahvaz, Iran. Written informed consent was obtained from all participants. 2.2. Participants The participants were patients in need for catheterization of the right internal jugular vein, who were free of any ev- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Barzegari et al. 156 ident deformity in chest and neck. Unsuccessful insertion of catheter, change in hemodynamic status or occurrence of dysrhythmia during procedure, and not permitting frequent photography and venipuncture, were among the most im- portant exclusion criteria. 2.3. Procedure After screening the cases in need of CV line insertion based on common standards (not being able to reach a peripheral vein, CVP monitoring, need to vasopressor agent, and . . . ), patients underwent cardiopulmonary monitoring, pulse- oximetry, and nasal oxygen therapy. Then CV lines were in- serted using the Seldinger method, under sterilized condi- tions, under ultrasonography guidance, and local anesthesia with lidocaine 1%. All patients were in supine or trendelen- burg position. Sonography was done using a 7.5 MHz lin- ear superficial probe under a sterilized nylon covering with a short axis approach on the right side of the neck in the anatomical position of internal jugular vein. Catheter needle was aimed at the apex of a triangle made from the crossing of the medial one-third of the clavicle bone in the base and 2 sternal and clavicular heads of sternocleidomastoid mus- cle towards the right nipple. After blood aspiration and en- suring the needle has entered the jugular vein, the needle and patient’s head position were kept fixed and photographs were taken from two perpendicular views, patient’s right side (sagittal plane) and patient’s down side (axial plane) (figure 1). The camera was equipped with a protractor application and the camera lens was in horizontal state. Taking a photo from the sagittal plane: While the patient was in supine po- sition, the protractor was set to be parallel with the sagit- tal plane and when the needle entered the jugular vein and blood was aspirated, the center mark of the protractor was set at the place of needle insertion and the angle of needle with the horizontal line was measured. Taking a photo from the axial plane: While the patient was in supine position, the protractor was set to be parallel with the axial plane on the thoracic area and the center mark of the protractor was set at the place of needle insertion. Finally, when the needle en- tered the jugular vein and blood was aspirated, the angle of needle with horizontal line was measured. In addition, head rotation angle was measured in this plane by setting the zero point of the protractor on the mid sagittal line and measuring the angle of the line crossing the middle of the patient’s chin and the center mark of the protractor with vertical line. Chest imaging was done to verify the place of the catheter and eval- uate complications such as pneumothorax and hemothorax. All Imaging and photography was performed by a trained emergency resident and 2 nurses. The angles were measured using Auto Cad 2014 software. Demographic data of partici- pants as well as duration of procedure and measured angles were collected via a predesigned checklist. In the end, data Table 1: Baseline characteristics of studied patients Variables Age (year) Mean 56.96 ± 14.71 Range 19 - 88 Sex number (%) Male 78 (68.4) Female 36 (31.6) Body mass index > 30 102 (89.5) < 30 12 (10.5) Cause of catheterization Shock 28 (24.6) Post resuscitation 13 (11.4) Hemodialysis 63 (55.3) Inaccessible peripheral vein 8 (7) Catheter change 1 (0.9) CVP measurement 1 (0.9) Number of performers 1 103 (90.4) 2 11 (9.6) Procedure time (minutes) Mean 18.73 ± 1.51 Range 15 - 23 CVP: central venous pressure. Table 2: Measured angles of head and needle in sagittal and axial planes Angles Mean ± SD (range) Needle tilt (degree) In sagittal plane 36.21 ± 3.12 (28-45) In axial plane 102.15 ± 6.80 (90-115) Head rotation (degree) In axial plane 40.49 ± 5.09 (29-52) SD: standard deviation. were presented as mean ± standard deviation and frequency and percentage using SPSS version 20. 3. Results 120 patients were evaluated, 6 of which were excluded due to complications such as hematoma (4 cases) and carotid artery perforation (2 cases). The mean age of participants was 56.96 ± 14.71 years (68.4% male). The most common in- dications of catheterization were dialysis (55.3%) and shock state (24.4%). Table 1 depicts the baseline characteristics of studied patients. Table 2 shows the measured angles of head and needle in sagittal and axial planes. 4. Discussion The findings of the present study showed that CV line inser- tion under the angles 102.15 ± 6.80 degrees in the axial plane, 36.21 ± 3.12 in the sagittal plane, and 40.49 ± 5.09 head ro- tation may yield good results. In recent years, the number This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 157 Emergency. 2016; 4 (3): 157-158 Figure 1: Sample photographs taken. of patients in need of CV line insertion has increased due to various reasons (7). Arterial puncture, hematoma, pneu- mothorax, hemothorax, nerve injury, arrhythmia, air em- bolism, cardiac tear, tamponade, and probability of infection after surgery, are among the most important complications of catheterization (8). Catheterization, based on superficial landmarks is done in 1 attempt in about 20% of the time, while with the help of bedside ultrasonography, catheteriza- tion can be done with fewer complications and higher suc- cess rate (8). In a study aiming to determine the proper angle of needle insertion in the sagittal plane on the internal jugu- lar vein, it was determined that a 16 degree insertion angle from the sagittal plane results in an increase in the probabil- ity of successful catheterization (9). In our study, mean sagit- tal angle of needle tilt from the horizontal line was about 36 degrees, which is vastly different from the mentioned study. In another study, the best angle for head rotation in internal jugular vein catheterization was reported to be ≥ 75 degrees (6). Head rotation in the present study was found to be 40 de- grees from vertical line. To date, few studies have been car- ried out for determining the accurate axial angle of the nee- dle. Considering the importance of this matter, it is suggested to design studies with proper sample size calculated based on existing data in the future. 5. Conclusion Based on the results of the present study it seems that CV line insertion under the angles 102.15 ± 6.80 degrees in the axial plane, 36.21 ± 3.12 in the sagittal plane and 40.49 ± 5.09 head rotation yield satisfactory results. 6. Appendix 6.1. Acknowledgements The authors wish to thank the staff of Imam Khomeini and Golestan Hospitals, Ahvaz, Iran, for their valuable assistance. 6.2. Author contribution All authors pass the four criteria for authorship contribution based on the International Committee of Medical Journal Ed- itors (ICMJE) recommendations. 6.3. Conflict of interest None 6.4. Funding/ Support None References 1. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Gar- land J, Heard SO, et al. Guidelines for the prevention of in- travascular catheter-related infections. American journal of infection control. 2011;39(4):S1-S34. 2. 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. Journal of the American Society of Echocardiography. 2011;24(12):1291-318. 3. Warkentine FH, Pierce MC, Lorenz D, Kim IK. The anatomic relationship of femoral vein to femoral artery in euvolemic pediatric patients by ultrasonography: impli- cations for pediatric femoral central venous access. Aca- demic emergency medicine. 2008;15(5):426-30. 4. Stone MB, Moon C, Sutijono D, Blaivas M. Needle tip visualization during ultrasound-guided vascular access: This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Barzegari et al. 158 short-axis vs long-axis approach. The American journal of emergency medicine. 2010;28(3):343-7. 5. Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Critical Care. 2006;10(6):R162. 6. DeAngelis V, Denny J, Chyu D, Jan T, Lemaire A, Chiricolo A, et al. The Optimal Angle of Head Rotation for Internal Jugular Cannulation as Determined by Ultrasound Evalu- ation. Journal of cardiothoracic and vascular anesthesia. 2015. 7. Ibrik O, Samon R, Roca R, Viladoms J, Mora J. Tun- neled catheters for hemodialysis of the type “twin Tesio catheters system” by ultrasound-guided technique. Retrospective analysis of 210 catheters. NEFROLOGIA. 2006;26(6). 8. Roberts JR, Hedges JR. Clinical procedures in emergency medicine: Elsevier Health Sciences; 2009. 9. Ozbek S, Apiliogullari S, Erol C, Kivrak AS, Kara I, Uysal E, et al. Optimal angle of needle entry for internal jugu- lar vein catheterization with a neutral head position: a CT study. Renal failure. 2013;35(4):492-6. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Methods Results Discussion Conclusion Appendix References