title: Is a neutral head position safer than 45-degree neck rotation during ultrasound-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial.
abstract: BACKGROUND
  The optimal degree of neck rotation during internal jugular vein (IJV) cannulation remains undetermined because previous studies suggested using sonography, but without puncturing the vein. We assessed whether a neutral position (NP) of the head (0 degrees) during ultrasound-guided cannulation of the IJV was safer than rotating the neck to 45 degrees head turned. The effect of these 2 positions during ultrasound-guided cannulation on major complications was the primary outcome. Overall complications, venous access time, and perception of difficulty during the procedure were also evaluated.
  
  
  METHODS
  A prospective, randomized, controlled, nonblinded study was conducted in a tertiary neurosurgical hospital. Patients undergoing major elective neurosurgical procedures requiring a central venous line were randomly allocated to 2 groups; ultrasound-guided cannulation of the IJV was then performed using an out-of-plane orientation.
  
  
  RESULTS
  One thousand four hundred twenty-four patients were evaluated, but 92 were excluded; 670 were allocated to the head turned group and 662 to the NP group. Cannulation was 100% successful. Demographic data were similar in the 2 groups except for IJV positions. There were only 10 major complications: 6 in the 0-degree NP group and 4 in the 45-degree head turned group. The frequency of these complications was not different between the 2 groups. The overall complication rate was 13%, and was higher in women, in patients with ASA physical status ≥II, and in patients with a smaller diameter vein, or when the vein was located deeper and lateral or in the anterolateral position. An increased venous access time was associated with an increased rate of overall complications. The perception of difficulty performing the procedure with the head placed in the 2 positions was not statistically different in either group.
  
  
  CONCLUSIONS
  A head NP was as safe as a 45-degree neck rotation during ultrasound-guided IJV cannulation with regard to both major and minor complications, and venous access time was similar. Ultrasound guidance helps determine optimal head rotation for IJV cannulation.
authors.affiliation: Department of Neuroanesthesia, Neurological Institute Besta, Via Celoria, 11 20136 Milan, Italy. doclampmd@gmail.com
authors.forename: Massimo
authors.initials: M
authors.lastname: Lamperti
authors.forename: Matteo
authors.initials: M
authors.lastname: Subert
authors.forename: Paolo
authors.initials: P
authors.lastname: Cortellazzi
authors.forename: Davide
authors.initials: D
authors.lastname: Vailati
authors.forename: Paola
authors.initials: P
authors.lastname: Borrelli
authors.forename: Cristina
authors.initials: C
authors.lastname: Montomoli
authors.forename: Giovanni
authors.initials: G
authors.lastname: D'Onofrio
authors.forename: Dario
authors.initials: D
authors.lastname: Caldiroli
mesh_terms: D000328:Adult; D000368:Aged; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006257:Head; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D009333:Neck; D011187:Posture; D011446:Prospective Studies; D012399:Rotation; D014463:Ultrasonography