Comparison of short-axis and oblique-axis approaches for ultrasound-guided right internal jugular vein cannulation in the left decubitus position: a randomized clinical trial study protocol

Comparison of short-axis and oblique-axis approaches for ultrasound-guided right internal jugular vein cannulation in the left decubitus position: a randomized clinical trial study protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of short-axis and oblique-axis approaches for ultrasound-guided right internal jugular vein cannulation in the left decubitus position: a randomized clinical trial study protocol Wenjuan Liu, Zhe Su, Jingwei Zhou, Mingjiang Yi, Ling Han, Junfeng Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6611947/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Mar, 2026 Read the published version in Trials → Version 1 posted 5 You are reading this latest preprint version Abstract Background The internal jugular vein (IJV) cannulation in the decubitus position is required in some urgent and special clinical situations, increasing the difficulty of performance. Although ultrasound guidance can improve the efficiency and safety of IJV cannulation, ultrasound guidance for right internal jugular vein (RIJV) cannulation in the decubitus position has not been studied. This trial aims to compare the feasibility and safety of an ultrasound-guided oblique-axis approach with a short-axis approach for left decubitus RIJV cannulation. Methods A total of 74 patients undergoing IJV cannulation in the left decubitus position under general anesthesia will be randomly divided into two groups: the oblique-axis group (OA group) and the short-axis group (SA group). In both groups, the surgical bed will be rotated 20° to the Trendelenburg position prior to puncture to allow for better filling of the RIJV for catheterization. The primary endpoint is the first-time puncture rate. Secondary endpoints include overall catheterization success rate, overall catheterization time, number of venipuncture attempts, and incidence of mechanical complications. Discussion We hypothesize that the feasibility and safety of the ultrasound-guided oblique-axis approach for RIJV cannulation will be superior to those of the short-axis approach in the left decubitus position. Our findings may provide a clinical preference for central venous cannulation in certain position for surgical patients. Clinical Trial Registration: Chinese Clinical Trial Registry (chictr.org.cn)， identifier ChiCTR2400091385. Registered on October 28, 2024. https://www.chictr.org.cn/bin/project/edit?pid=247627 Ultrasonography Oblique axis Short axis the right internal jugular vein cannulation left decubitus position Figures Figure 1 Figure 2 Introduction Central venous cannulation (CVC) is a commonly performed procedure in emergency, intensive care, and perioperative settings. It provides safe vascular access for the precise administration of potent vasoactive drugs such as norepinephrine and dopamine, and rapid infusion of fluids. It also allows central venous pressure monitoring, transvenous cardiac pacing, and temporary hemodialysis. The CVC is also essential when peripheral venous access is not available or when frequent venous blood sampling is required [ 1 ] . The right internal jugular vein (RIJV) is the most commonly used site for perioperative cannulation, with fewer pneumothorax than subclavian vein cannulation and fewer catheter-related infections than femoral vein cannulation [ 2 ] . Current clinical studies of CVCs are based on the supine position, but the IJV is virtually the only alternative vein when the patient is in the decubitus position for lung, hip replacement, and renal surgery. However, the relatively fixed position of the head and neck, the inability to recognize body landmarks, and the increased overlap of the arteries and veins increase the difficulty of cannulation. Ultrasound guidance (USG) has fundamentally changed the practices of CVC access. Compared with the traditional landmark guidance approach, USG can reduce the overall complications, increase the success rates, shorten the overall catheterization time, and increase the overall catheterization success rates [ 3 ] . The Intensive Care Medicine [ 4 ] , European Society of Anesthesiology [ 5 ] , American Society of Anesthesiologists [ 6 ] , National Institute for Health and Clinical Excellence [ 7 ] , and American Society of Echocardiography [ 8 ] recommend USG techniques as the preferred method for central venous access [ 9 – 11 ] . The USG oblique-axis (OA) approach combines the advantages of the short-axis (SA) and long-axis (LA) approaches, visualizing the tip of the puncture needle and the entire process, while visualizing the arteriovenous and surrounding structures [ 12 ] . It is worth noting that most studies have been performed in the supine position, and the USG OA approach has not been seen in special positions such as left decubitus IJV catheterization. Methods Objectives of the study We designed the present study to evaluate the feasibility and safety of the USG OA approach compared with the USG SA approach in left decubitus position IJV catheterization. Trial design, setting, and ethics This prospective, single-center, randomized controlled trial. The Ethics Committee of Shanghai Tong Ren Hospital, China (No.2024-067-02) has approved version 2.0 of the proposal on 17 October 2024. This study has been registered with the Chinese Clinical Trial Registry (chictr.org.cn) (ChiCTR2400091385, PI: Wenjuan Liu). This protocol follows the Standards Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statements (Fig. 1). As the study does not involve the collection or storage of biological samples, no biobanking procedures are included. Participant recruitment and consent The study will be conducted at Shanghai Tongren Hospital, China, with participant recruitment planned from January 2025 to December 2026. The patients who present for elective surgery in the left decubitus position will be screened during the preoperative interview. The potentially eligible patients will be contacted by the researcher (LH), who will explain the study process in detail to ensure the patients understand the entire clinical trial. Written informed consent will be obtained from all participants prior to enrollment. Meanwhile, they will receive an informed consent form with detailed information, including the purpose, procedures, content of follow-up, data storage, benefits, and risks of the study, and will be given sufficient time to consider participation. Any questions about the study will be answered during the interview. The patients who agree to participate in the trial and sign the written informed consent will be recruited. They can withdraw from the trial at any point without depriving themselves of any treatment and care. All identifiable information will be kept confidential. The inclusion criteria include the following : Patients scheduled for elective surgery in the left decubitus position under general anesthesia require IJV catheterization. Patients aged between 18 and 65 years. American Society of Anesthesiologists (ASA) classification I-III. Body mass index (BMI) between 18.5 and 30 kg/m 2 . The exclusion criteria include the following : Patients with abnormal blood coagulation function. Patients with a puncture site infection. Ultrasound scanning detects patients with IJV anatomical variations or venous thrombosis. Patients with superior vena cava syndrome. Presence of a central venous catheter during the past 72 hours (in the same vein in which the present cannulation was planned). Patients refuse to participate in the trial. Randomization, allocation, and blinding Eligible patients will be randomly assigned to either the SA group or the OA group in a 1:1 ratio using a computer-generated sequence. Group assignments will be placed into opaque, sealed, sequentially numbered envelopes by the investigator (LH) who will not be involved in the subsequent research. The envelopes will be opened just prior to surgery. If a subject withdraws in the middle of the study, the random number will be voided to ensure that the randomness is not destroyed, and subsequent subjects will be sequentially assigned the next randomly numbered envelope. The investigators during the study will be divided into anesthesiologist A ( ZS) and anesthesiologist B (YM). Anesthesiologist A is responsible for the preoperative follow-up assessment and the puncture placement operation. Anesthesiologist B is responsible for the timing of the puncture placement operation, intraoperative management, and postoperative follow-up. On the day of surgery, Anesthesiologist A determines that the subjects meet the inclusion criteria, and then opens the envelope and randomly assigns the patient to either the ultrasound-guided short-axis group (SA group, control group) or the ultrasound-guided oblique-axis group (OA group, experimental group). The entire intervention procedure, including allocation, is blinded to the outcome assessor (JZ). He will not be allowed to ask any questions about the intervention procedure. Double blinding is not feasible in this study, while patients are under general anesthesia and unaware of their group assignment, the anesthesiologist A cannot be blinded due to the inherent differences in the SA and OA approaches requiring distinct probe orientations and needle insertion approaches. Emergency un-blinding rules will be applied if serious adverse events occur (e.g., cardiopulmonary arrest). The patient will be withdrawn, and the adverse events will be reported to the ethics committee. Preparation before operation In both groups, patients will be admitted to the operating room for standard monitoring procedures, including ECG, invasive arterial pressure, and SpO 2 . Peripheral vein catheters (18G) will be established for the infusion of lactated Ringer’s solution. The anesthesia will be induced with propofol 1–2 mg/kg, sufentanyl 0.3–0.4 µg/kg, and rocuronium 0.6 mg/kg. Afterward, tracheal intubation will be performed, and mechanical ventilation will be carried out and adjusted to maintain an end-tidal CO 2 (ETCO 2 ) level of 35–45 mmHg. Patients in both groups will be positioned in the left decubitus position following tracheal intubation. The trunk will be angled approximately 120° to the surface of the operating table. The trunk, head, and neck will be properly immobilized in a normal relationship with the torso, and a high pillow will be placed under the head. The legs will be positioned with the hips and knees flexed to nearly 90° to facilitate the stability of the decubitus position and relax the abdominal muscles. The upper leg will remain straight, with a soft pad placed between the legs for comfort and to prevent sore. Both arms will be extended forward and kept parallel to the torso, secured using a double brace. To promote venous filling of the right internal jugular vein (IJV), the surgical bed will be tilted to a 20° Trendelenburg position. A linear array probe (6–13 MHz) from the EDGE II ultrasound system (FUJIFILM Sonosite, USA) will be used to scan the right IJV, carotid artery, and adjacent structures to rule out anatomical variations and venous thrombosis. The cannulation procedure will be performed by a single operator under ultrasound guidance, with the same individual managing both the probe and the needle. Sterilization will follow standard aseptic techniques, and the ultrasound probe will be enclosed in a sterile cover. Interventions The trial flowchart is shown in Fig. 2 . The intervention procedures will be performed by the operator (ZS), who has over 15 years of experience in ultrasound-guided IJV cannulation. All the procedures will be performed by a modified Seldinger technique, using an 18-Ga, 6.5 cm introducer needle (Centra-Line™, Biometrix, Israel) with a 5 ml syringe. Once the needle tip is identified inside the vein, the syringe will be removed before a J-wire is introduced through the needle. After identifying the guidewire inside the jugular vein, the Seldinger technique will be continued until catheter insertion. Cannulation will be considered successful in the designated approach if the guidewire is advanced smoothly without resistance and is ultrasonographically confirmed inside the jugular vein. Following the completion of the IJV catheterization, the surgical bed will be returned to the horizontal position. In SA group (control group), the ultrasound probe will be initially positioned transversely on the neck, aligned parallel to the clavicle. Following clear visualization of the IJV at the central position of the ultrasound image, the needle will be inserted using an out-of-plane technique, maintaining a trajectory perpendicular to the long axis of the transducer [ 13 ] . In OA group (experimental group) (Fig. 3), the oblique-axis technique will be implemented as followed: Initially, the target vessel will be identified using standard short-axis orientation as mentioned above. Then, the probe will be rotated almost midway between the SA and LA views [ 14 ] . With this technique, both vessels are still visualized on the screen but in a slightly elongated view. The needle will enter along the long axis of the probe, providing a long-axis view of the needle as it enters the vessel and allowing real-time visualization of the entire needle trajectory during vascular access. Outcomes Primary outcome evaluation First-time puncture rate (%): A needle puncture will be considered as such if the Seldinger needle was advanced forward without any backward movement [ 5 ] . Every successive needle withdrawal with subsequent advance will be considered another needle puncture, whether or not a new skin puncture site will be chosen. Secondary outcomes evaluation Overall cannulation success rate (%): the first anesthesiologist fails to puncture the IJV after three needle puncture attempts, the case will be classified as a failed IJV catheterization. Overall procedure time (min): from first needle tip puncture of the skin to completion of catheter fixation. Number of venipuncture attempts: number of puncture attempts until successful cannulation. Mechanical complications (detected during or after the procedure) (%): arterial puncture, venous posterior wall penetration, pneumothorax, air embolism, and catheter malposition, etc. Adverse event risk prevention and treatment Placement failure: The inability to properly place the catheter in the intended location. Anesthesiologist A pauses the procedure to call a senior anesthesiologist. Arterial cannulation: The insertion of the catheter into an artery. Remove the catheter and press on the artery until the bleeding stops. anesthesiologist A pauses the procedure and changes to a senior anesthesiologist. Arterial puncture: Puncture of an artery with a needle during catheter placement. Pause the procedure and press on the artery until the bleeding stops. Pneumothorax: A collection of air or gas in the pleural cavity, which can cause the lung to collapse. Lung compression of less than 10% is self-absorbing, and ≥ 10% requires thoracic closed drainage. Catheter malfunction: Any issue or problem that arises with the catheter, such as fibrin sheath formation, catheter fracture, or catheter embolization. We considered catheter occlusion as catheter malfunction (not deep vein thrombosis). Remove the catheter, anesthesiologist A pauses the procedure and changes to a senior anesthesiologist. Bleeding events requiring intervention: Any event that results in bleeding that requires medical intervention, including holding pressure, transfusion, bedside procedures, interventional radiology procedures, and surgery. Anesthesiologist A pauses the procedure and changes to a senior anesthesiologist. Arrhythmia: An irregular heartbeat. The anesthesiologist pauses the procedure and administers antiarrhythmic drugs if needed. All adverse events must be managed according to clinical best practices. Investigators have the right to terminate participation at any time if they believe that the subject's participation is not in their best interest. The case report form (CRF) should include a record of the circumstances and reasons for stopping the trial. Patients have the right to withdraw from the trial at any stage and at any time without compromising their medical treatment and rights [ 15 ] . Sample size calculation PASS23.0 software (SPSS Inc., Chicago, Illinois, United States) will be used to compute the sample size. Due to the lack of reference data in the previously published studies, the calculation of the sample size was based on our pilot study, which included 20 participants. We reported the first-time puncture rate of the two groups to be 50% (experimental group) and 16.67% (control group), respectively. A two-tailed hypothesis test for proportion difference was designed with α = 0.05 and β = 0.2 (power = 80%). Power analysis using these parameters yielded a minimum requirement of 31 participants per group. The sample size will be increased to 37 in each group for a total of 74 cases, including the estimated 20% dropouts. Provisions for posttrial care Participants will have access to study clinics for posttrial care through the routine health system. Data collection and management All patient information will be monitored continuously during the study period, including electronic medical records, monitor machines, anesthesia records, hospitalization records, and daily visits during hospitalization. Baseline data on participants will be collected preoperatively, and intraoperative data will be collected by the blinded research staff LH. The data will be stored in a password-protected computer accessed only by LH. All serious adverse, unexpected, or potentially relevant times will be recorded in the CRF by ZS. Uniform standard operating procedures will be developed, and effective training will be provided to each investigator before the start of the study. Participants will be followed up by MY during the patient's hospitalization, and diagnostic and therapeutic recommendations will be provided to improve patient compliance. Data to be entered into the database will not contain subject names or other personal information, only the corresponding unique code identifier of the subject. The results of the studies to be published will contain only the information in the database. To avoid human input errors, data will be entered independently and synchronously by both groups of data entry personnel, and then the machine will compare the data to extract duplicates. No interim analysis is designed for this study. Oversight and monitoring The data monitoring committee (DMC) consists of an anesthesiologist, an ethics expert, a statistician, and a clinical trial management expert. There are no conflicts of interest. The DMC will hold a monthly meeting to review research progress, check data integrity, and monitor the occurrence of serious adverse events (SEAs). Statistical analysis Statistical analyses will be performed using SPSS 21.0 (SPSS Inc., Chicago, IL, USA). All data will be expressed as mean ± SD (standard deviation), median, and interquartile range(IQR, 25–75% percentile), or proportions (%) according to the type of variables. All categorical variables will be expressed as numbers (percentages). The number of venipuncture attempts and total procedure time between the two groups will be analyzed using Student's t-test or Mann-Whitney test as appropriate. The rate of first-time puncture, the success rate of total procedure, and the complication rate will be analyzed using the chi-square test or Fisher's exact test. P < 0.05 will be considered significant. Harms All the severe adverse events related to the study intervention will be recorded and reported as required to the Ethics Committee of Tongren Hospital, Shanghai Jiao Tong University School of Medicine. Consent of assent Written informed consent will be obtained by LH from all subjects before enrolment. Participant withdrawal and confidentiality Participants may withdraw from the study at any stage, and the reasons will be recorded. In addition, the private information of participants will be kept confidential to the public. The data collected will be stored securely for five years after the study is finished. Discussion CVC is the most common medical procedure for perioperative and critically ill patients. Approximately 27 million central venous cannulations are performed annually [ 16 ] . With the popularity of portable ultrasound machines in the clinic, USG has improved the efficiency, safety, and comfort of CVCs [ 17 ] . The USG SA approach has traditionally been preferred by clinicians for performing and teaching USG IJV cannulation. However, its higher mechanical complications cannot be avoided. Complications of posterior venous wall puncture are higher in the SA approach [ 13 , 18 ] . Especially, when urgent IJV catheterization is required in the emergency department, there is a 50% incidence of posterior venous wall puncture in the SA group [ 19 ] . The number of puncture attempts and needle redirections for IJV puncture is higher for SA approach [ 20 ] . In addition, IJV catheterization in the decubitus position is a more difficult procedure to perform with greater time urgency than IJV catheterization in the supine position. Therefore, special attention should be paid to IJV catheterization in the left decubitus position. An effective, safe, and satisfactory approach to IJV catheterization in the decubitus position for both patients and anesthesiologists is currently unknown. The USG OA approach involves placing the ultrasound probe between the short and long axis, and allows for optimal imaging of the IJV and the carotid artery side by side and following the needle throughout the insertion from skin to vessel penetration [ 21 ] . Our previous study found that arteriovenous overlap increases in a decubitus position. Kosnik et al. have reported that increased arteriovenous overlap greatly increases the probability of arterial injury when penetrating the posterior wall of the vein with the puncture needle [ 22 ] . Moreover, in the decubitus position, due to the gravitational force of blood, the IJV collapses severely, and the cross-sectional area becomes smaller, which is very likely to result in a hematoma in the posterior wall of the penetrating vein or difficulty in catheterization [ 23 ] . Participants in this study used the USG OA approach for IJV catheterization in the left decubitus position, which effectively increased the anteroposterior and transverse diameters and cross-sectional area of the IJV for easier catheterization [ 24 ] based on the real-time observation of the tip of the puncture needle to avoid penetration of the posterior wall of the vein and puncture of the artery at the same time. The USG OA approach is expected to be better than the SA in terms of feasibility and safety in left decubitus position IJV catheterization. However, the USG OA approach will have a longer imaging time than the SA. In the left decubitus position, the slightly longer imaging time may be compensated for by the shorter cannulation time. However, the role of the USG OA approach for left decubitus position surgical patients requiring IJV catheterization has not been fully defined. To our knowledge, this will be the first randomized controlled trial comparing the USG OA approach with the SA approach for IJV catheterization in the left decubitus position. In our patient, tracheal intubation was induced sequentially with Vt 6–8 ml/kg to maintain E T CO 2 at 35–45 mmHg, followed by IJV catheterization by changing to left decubitus position with Trendelenbrug 20°. This strategy will minimize the impact of spontaneous ventilation or positional discomfort on the patient and thus on the intubation procedure. Several limitations must be noted in this study. Firstly, our study will include adult patients aged between 18 and 65 years, with a physical status of ASA I ~ III, and a BMI between 18 and 30 kg/m2 for left decubitus surgery. Although these inclusion criteria will allow us to evaluate the effectiveness of USG OA versus SA approaches of probe placement in this specific patient population, further research is needed to determine whether our findings can be fully extrapolated to other patients with older, higher ASA classifications, and obese individuals (BMI > 30 kg/m²). Second, the investigation specifically focuses on left decubitus internal jugular vein (IJV) catheterization, excluding right decubitus positioning cases. We only evaluate the USG OA approach compared with the SA approach for left decubitus position IJV catheterization because we intended to evaluate the safety and efficacy of the USG OA approach versus the SA approach for left decubitus position IJV catheterization based on the most commonly used RIJV catheterization. Third, the single-center design and modest sample size (n = 74) necessitate cautious interpretation of results. While adequately powered for primary endpoint analysis, multicenter validation with expanded cohorts will be required to confirm these preliminary findings. Despite these limitations, this trial will provide clinical insights into ultrasound-guided vascular access for left decubitus positioning. The OA approach will offer a potentially safer alternative to conventional SA techniques in this specific clinical context. Further investigations should prioritize the following three key extensions: 1) evaluation across diverse anatomical positions, 2) inclusion of high-risk patient subgroups, and 3) multisite replication with longitudinal outcome tracking. In conclusion, this prospective, randomized, single-blind, controlled trial will demonstrates the clinical superiority of the USG OA approach over the SA approach for IJV catheterization in left decubitus position. This investigation will provide robust evidence supporting the OA approach as the preferred modality for vascular access in this specific patient orientation. Trial status Protocol version number V2.0/October 17, 2024. Date recruitment started, 1 January 2025. Completion of this trail is expected on 31 December 2026. Timeline 2024: Development of research strategy and study protocol. 2025–2026: Recruitment and treatment of patients in the trial. 2027: Completion of data analysis. Declarations Authors` contributions WJ L is the principal investigator for this trial and drafted the manuscript. JF Z contributed to the study design. Z S, MJ Y and L H will collect and interpret the data. JW Z is the statistician responsible for the sample size calculation and the statistical design of the study. All the authors have read and approved the final manuscript. Ethics approval and consent to participate The Institutional Ethical Committee of Shanghai Tongren Hospital (No.2024-067-02) approved the study on October 17, 2024. All participants will sign a written informed consent form and be informed of the right to withdraw from this study at any time. Competing interests The authors declare no competing interests. Consent for publication Not applicable. References Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med 2007, 35 (5) : 1390-1396. Hentrich M, Böll B, Teschner D, Panse J, Schmitt T, Naendrup JH, Schmidt-Hieber M, Neitz J, Fiegle E, Schalk E. Impact of the insertion site of central venous catheters on central venous catheter-related bloodstream infections in patients with cancer: results from a large prospective registry. Infection 2023, 51 (4) : 1153-1159. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. 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Anatomical review of internal jugular vein cannulation. Folia Morphol (Warsz) 2024, 83 (1) : 1-19. Whittle RS, Diaz-Artiles A. Gravitational effects on carotid and jugular characteristics in graded head-up and head-down tilt. J Appl Physiol (1985) 2023, 134 (2) : 217-229. Kurien M, Teo R, Zainuddin K, Azidin AM, Izaham A, Budiman M, Tang SSP. Ultrasound Probe Positions for Internal Jugular Vein Cannulation: A Prospective Study of Different Techniques. Clin Ter 2021, 172 (4) : 278-283. Supplementary Files SPIRITchecklist0716.docx Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2026 Read the published version in Trials → Version 1 posted Editorial decision: Minor revision 05 Jan, 2026 Reviewers agreed at journal 24 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Editor assigned by journal 17 Jul, 2025 First submitted to journal 16 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6611947","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":543253096,"identity":"7de007d5-5267-43f9-a9ce-7d5800c8bb4d","order_by":0,"name":"Wenjuan 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01:13:42","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":142311,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6611947/v1/3ef19d312925aa2fed6817e0.html"},{"id":96423007,"identity":"7d4dce35-51f6-43b7-957c-73ed8b664a7b","added_by":"auto","created_at":"2025-11-21 01:13:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33577,"visible":true,"origin":"","legend":"\u003cp\u003eSchedule of enrollment, intervention, and assessment according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statements\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6611947/v1/17962eea59c37c32b3f7fa91.png"},{"id":96454549,"identity":"80db3275-0374-4d05-9750-a6bd4a8d5af9","added_by":"auto","created_at":"2025-11-21 10:02:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":89338,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of trial procedures.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6611947/v1/801862cc0b03bc8dae3572a3.png"},{"id":105755922,"identity":"e188c4e0-6567-46a8-9a85-d7f172ab4126","added_by":"auto","created_at":"2026-03-30 16:33:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":864370,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6611947/v1/e6490162-c65f-4677-b12b-7e68a64c699e.pdf"},{"id":96423011,"identity":"d3cf4e42-8af3-4125-aab7-1a0b0b56c46c","added_by":"auto","created_at":"2025-11-21 01:13:42","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":56192,"visible":true,"origin":"","legend":"","description":"","filename":"SPIRITchecklist0716.docx","url":"https://assets-eu.researchsquare.com/files/rs-6611947/v1/ec1adcfefcc8c01e9cf0ca18.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eComparison of short-axis and oblique-axis approaches for ultrasound-guided right internal jugular vein cannulation in the left decubitus position: a randomized clinical trial study protocol\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCentral venous cannulation (CVC) is a commonly performed procedure in emergency, intensive care, and perioperative settings. It provides safe vascular access for the precise administration of potent vasoactive drugs such as norepinephrine and dopamine, and rapid infusion of fluids. It also allows central venous pressure monitoring, transvenous cardiac pacing, and temporary hemodialysis. The CVC is also essential when peripheral venous access is not available or when frequent venous blood sampling is required\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The right internal jugular vein (RIJV) is the most commonly used site for perioperative cannulation, with fewer pneumothorax than subclavian vein cannulation and fewer catheter-related infections than femoral vein cannulation\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Current clinical studies of CVCs are based on the supine position, but the IJV is virtually the only alternative vein when the patient is in the decubitus position for lung, hip replacement, and renal surgery. However, the relatively fixed position of the head and neck, the inability to recognize body landmarks, and the increased overlap of the arteries and veins increase the difficulty of cannulation. Ultrasound guidance (USG) has fundamentally changed the practices of CVC access. Compared with the traditional landmark guidance approach, USG can reduce the overall complications, increase the success rates, shorten the overall catheterization time, and increase the overall catheterization success rates\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The Intensive Care Medicine\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, European Society of Anesthesiology\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, American Society of Anesthesiologists\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, National Institute for Health and Clinical Excellence\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, and American Society of Echocardiography\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e recommend USG techniques as the preferred method for central venous access\u003csup\u003e[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The USG oblique-axis (OA) approach combines the advantages of the short-axis (SA) and long-axis (LA) approaches, visualizing the tip of the puncture needle and the entire process, while visualizing the arteriovenous and surrounding structures\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. It is worth noting that most studies have been performed in the supine position, and the USG OA approach has not been seen in special positions such as left decubitus IJV catheterization.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eObjectives of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe designed the present study to evaluate the feasibility and safety of the USG OA approach compared with the USG SA approach in left decubitus position IJV catheterization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial design, setting, and ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective, single-center, randomized controlled trial. The Ethics Committee of Shanghai Tong Ren Hospital, China (No.2024-067-02) has approved version 2.0 of the proposal on 17 October 2024. This study has been registered with the Chinese Clinical Trial Registry (chictr.org.cn) (ChiCTR2400091385, PI: Wenjuan Liu). This protocol follows the Standards Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statements (Fig. 1). As the study does not involve the collection or storage of biological samples, no biobanking procedures are included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant recruitment and consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study will be conducted at Shanghai Tongren Hospital, China, with participant recruitment planned from January 2025 to December 2026. The patients who present for elective surgery in the left decubitus position will be screened during the preoperative interview. The potentially eligible patients will be contacted by the researcher (LH), who will explain the study process in detail to ensure the patients understand the entire clinical trial. Written informed consent will be obtained from all participants prior to enrollment. Meanwhile, they will receive an informed consent form with detailed information, including the purpose, procedures, content of follow-up, data storage, benefits, and risks of the study, and will be given sufficient time to consider participation. Any questions about the study will be answered during the interview. The patients who agree to participate in the trial and sign the written informed consent will be recruited. They can withdraw from the trial at any point without depriving themselves of any treatment and care. All identifiable information will be kept confidential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe inclusion criteria include the following\u003c/strong\u003e:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003ePatients scheduled for elective surgery in the left decubitus position under general anesthesia require IJV catheterization.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePatients aged between 18 and 65 years.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAmerican Society of Anesthesiologists (ASA) classification I-III.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eBody mass index (BMI) between 18.5 and 30 kg/m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eThe exclusion criteria include the following\u003c/strong\u003e:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003ePatients with abnormal blood coagulation function.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePatients with a puncture site infection.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eUltrasound scanning detects patients with IJV anatomical variations or venous thrombosis.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePatients with superior vena cava syndrome.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePresence of a central venous catheter during the past 72 hours (in the same vein in which the present cannulation was planned).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePatients refuse to participate in the trial.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization, allocation, and blinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible patients will be randomly assigned to either the SA group or the OA group in a 1:1 ratio using a computer-generated sequence. Group assignments will be placed into opaque, sealed, sequentially numbered envelopes by the investigator (LH) who will not be involved in the subsequent research. The envelopes will be opened just prior to surgery. If a subject withdraws in the middle of the study, the random number will be voided to ensure that the randomness is not destroyed, and subsequent subjects will be sequentially assigned the next randomly numbered envelope. The investigators during the study will be divided into anesthesiologist A ( ZS) and anesthesiologist B (YM). Anesthesiologist A is responsible for the preoperative follow-up assessment and the puncture placement operation. Anesthesiologist B is responsible for the timing of the puncture placement operation, intraoperative management, and postoperative follow-up. On the day of surgery, Anesthesiologist A determines that the subjects meet the inclusion criteria, and then opens the envelope and randomly assigns the patient to either the ultrasound-guided short-axis group (SA group, control group) or the ultrasound-guided oblique-axis group (OA group, experimental group). The entire intervention procedure, including allocation, is blinded to the outcome assessor (JZ). He will not be allowed to ask any questions about the intervention procedure. Double blinding is not feasible in this study, while patients are under general anesthesia and unaware of their group assignment, the anesthesiologist A cannot be blinded due to the inherent differences in the SA and OA approaches requiring distinct probe orientations and needle insertion approaches. Emergency un-blinding rules will be applied if serious adverse events occur (e.g., cardiopulmonary arrest). The patient will be withdrawn, and the adverse events will be reported to the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreparation before operation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn both groups, patients will be admitted to the operating room for standard monitoring procedures, including ECG, invasive arterial pressure, and SpO\u003csub\u003e2\u003c/sub\u003e. Peripheral vein catheters (18G) will be established for the infusion of lactated Ringer’s solution. The anesthesia will be induced with propofol 1–2 mg/kg, sufentanyl 0.3–0.4 µg/kg, and rocuronium 0.6 mg/kg. Afterward, tracheal intubation will be performed, and mechanical ventilation will be carried out and adjusted to maintain an end-tidal CO\u003csub\u003e2\u003c/sub\u003e (ETCO\u003csub\u003e2\u003c/sub\u003e) level of 35–45 mmHg.\u003c/p\u003e\n\u003cp\u003ePatients in both groups will be positioned in the left decubitus position following tracheal intubation. The trunk will be angled approximately 120° to the surface of the operating table. The trunk, head, and neck will be properly immobilized in a normal relationship with the torso, and a high pillow will be placed under the head. The legs will be positioned with the hips and knees flexed to nearly 90° to facilitate the stability of the decubitus position and relax the abdominal muscles. The upper leg will remain straight, with a soft pad placed between the legs for comfort and to prevent sore. Both arms will be extended forward and kept parallel to the torso, secured using a double brace. To promote venous filling of the right internal jugular vein (IJV), the surgical bed will be tilted to a 20° Trendelenburg position. A linear array probe (6–13 MHz) from the EDGE II ultrasound system (FUJIFILM Sonosite, USA) will be used to scan the right IJV, carotid artery, and adjacent structures to rule out anatomical variations and venous thrombosis. The cannulation procedure will be performed by a single operator under ultrasound guidance, with the same individual managing both the probe and the needle. Sterilization will follow standard aseptic techniques, and the ultrasound probe will be enclosed in a sterile cover.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe trial flowchart is shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The intervention procedures will be performed by the operator (ZS), who has over 15 years of experience in ultrasound-guided IJV cannulation. All the procedures will be performed by a modified Seldinger technique, using an 18-Ga, 6.5 cm introducer needle (Centra-Line™, Biometrix, Israel) with a 5 ml syringe. Once the needle tip is identified inside the vein, the syringe will be removed before a J-wire is introduced through the needle. After identifying the guidewire inside the jugular vein, the Seldinger technique will be continued until catheter insertion. Cannulation will be considered successful in the designated approach if the guidewire is advanced smoothly without resistance and is ultrasonographically confirmed inside the jugular vein. Following the completion of the IJV catheterization, the surgical bed will be returned to the horizontal position.\u003c/p\u003e\n\u003cp\u003eIn SA group (control group), the ultrasound probe will be initially positioned transversely on the neck, aligned parallel to the clavicle. Following clear visualization of the IJV at the central position of the ultrasound image, the needle will be inserted using an out-of-plane technique, maintaining a trajectory perpendicular to the long axis of the transducer\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn OA group (experimental group) (Fig.\u0026nbsp;3), the oblique-axis technique will be implemented as followed: Initially, the target vessel will be identified using standard short-axis orientation as mentioned above. Then, the probe will be rotated almost midway between the SA and LA views\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. With this technique, both vessels are still visualized on the screen but in a slightly elongated view. The needle will enter along the long axis of the probe, providing a long-axis view of the needle as it enters the vessel and allowing real-time visualization of the entire needle trajectory during vascular access.\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Outcomes","content":"\u003cp\u003e\u003cstrong\u003ePrimary outcome evaluation\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFirst-time puncture rate (%): A needle puncture will be considered as such if the Seldinger needle was advanced forward without any backward movement\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Every successive needle withdrawal with subsequent advance will be considered another needle puncture, whether or not a new skin puncture site will be chosen.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSecondary outcomes evaluation\u003c/strong\u003e\u003c/p\u003e\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eOverall cannulation success rate (%): the first anesthesiologist fails to puncture the IJV after three needle puncture attempts, the case will be classified as a failed IJV catheterization.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eOverall procedure time (min): from first needle tip puncture of the skin to completion of catheter fixation.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eNumber of venipuncture attempts: number of puncture attempts until successful cannulation.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMechanical complications (detected during or after the procedure) (%): arterial puncture, venous posterior wall penetration, pneumothorax, air embolism, and catheter malposition, etc.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\u003cp\u003e\u003cstrong\u003eAdverse event risk prevention and treatment\u003c/strong\u003e\u003c/p\u003e\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003ePlacement failure: The inability to properly place the catheter in the intended location. Anesthesiologist A pauses the procedure to call a senior anesthesiologist.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eArterial cannulation: The insertion of the catheter into an artery. Remove the catheter and press on the artery until the bleeding stops. anesthesiologist A pauses the procedure and changes to a senior anesthesiologist.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eArterial puncture: Puncture of an artery with a needle during catheter placement. Pause the procedure and press on the artery until the bleeding stops.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePneumothorax: A collection of air or gas in the pleural cavity, which can cause the lung to collapse. Lung compression of less than 10% is self-absorbing, and ≥ 10% requires thoracic closed drainage.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eCatheter malfunction: Any issue or problem that arises with the catheter, such as fibrin sheath formation, catheter fracture, or catheter embolization. We considered catheter occlusion as catheter malfunction (not deep vein thrombosis). Remove the catheter, anesthesiologist A pauses the procedure and changes to a senior anesthesiologist.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eBleeding events requiring intervention: Any event that results in bleeding that requires medical intervention, including holding pressure, transfusion, bedside procedures, interventional radiology procedures, and surgery. Anesthesiologist A pauses the procedure and changes to a senior anesthesiologist.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eArrhythmia: An irregular heartbeat. The anesthesiologist pauses the procedure and administers antiarrhythmic drugs if needed.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\u003cp\u003eAll adverse events must be managed according to clinical best practices. Investigators have the right to terminate participation at any time if they believe that the subject's participation is not in their best interest. The case report form (CRF) should include a record of the circumstances and reasons for stopping the trial. Patients have the right to withdraw from the trial at any stage and at any time without compromising their medical treatment and rights\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSample size calculation\u003c/strong\u003e\u003c/p\u003e\u003cp\u003ePASS23.0 software (SPSS Inc., Chicago, Illinois, United States) will be used to compute the sample size. Due to the lack of reference data in the previously published studies, the calculation of the sample size was based on our pilot study, which included 20 participants. We reported the first-time puncture rate of the two groups to be 50% (experimental group) and 16.67% (control group), respectively. A two-tailed hypothesis test for proportion difference was designed with α = 0.05 and β = 0.2 (power = 80%). Power analysis using these parameters yielded a minimum requirement of 31 participants per group. The sample size will be increased to 37 in each group for a total of 74 cases, including the estimated 20% dropouts.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eProvisions for posttrial care\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants will have access to study clinics for posttrial care through the routine health system.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData collection and management\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAll patient information will be monitored continuously during the study period, including electronic medical records, monitor machines, anesthesia records, hospitalization records, and daily visits during hospitalization. Baseline data on participants will be collected preoperatively, and intraoperative data will be collected by the blinded research staff LH. The data will be stored in a password-protected computer accessed only by LH. All serious adverse, unexpected, or potentially relevant times will be recorded in the CRF by ZS.\u003c/p\u003e\u003cp\u003eUniform standard operating procedures will be developed, and effective training will be provided to each investigator before the start of the study. Participants will be followed up by MY during the patient's hospitalization, and diagnostic and therapeutic recommendations will be provided to improve patient compliance.\u003c/p\u003e\u003cp\u003eData to be entered into the database will not contain subject names or other personal information, only the corresponding unique code identifier of the subject. The results of the studies to be published will contain only the information in the database. To avoid human input errors, data will be entered independently and synchronously by both groups of data entry personnel, and then the machine will compare the data to extract duplicates. No interim analysis is designed for this study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOversight and monitoring\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe data monitoring committee (DMC) consists of an anesthesiologist, an ethics expert, a statistician, and a clinical trial management expert. There are no conflicts of interest. The DMC will hold a monthly meeting to review research progress, check data integrity, and monitor the occurrence of serious adverse events (SEAs).\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses will be performed using SPSS 21.0 (SPSS Inc., Chicago, IL, USA). All data will be expressed as mean ± SD (standard deviation), median, and interquartile range(IQR, 25–75% percentile), or proportions (%) according to the type of variables. All categorical variables will be expressed as numbers (percentages). The number of venipuncture attempts and total procedure time between the two groups will be analyzed using Student's t-test or Mann-Whitney test as appropriate. The rate of first-time puncture, the success rate of total procedure, and the complication rate will be analyzed using the chi-square test or Fisher's exact test. \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05 will be considered significant.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHarms\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAll the severe adverse events related to the study intervention will be recorded and reported as required to the Ethics Committee of Tongren Hospital, Shanghai Jiao Tong University School of Medicine.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent of assent\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eWritten informed consent will be obtained by LH from all subjects before enrolment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eParticipant withdrawal and confidentiality\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants may withdraw from the study at any stage, and the reasons will be recorded. In addition, the private information of participants will be kept confidential to the public. The data collected will be stored securely for five years after the study is finished.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCVC is the most common medical procedure for perioperative and critically ill patients. Approximately 27 million central venous cannulations are performed annually \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. With the popularity of portable ultrasound machines in the clinic, USG has improved the efficiency, safety, and comfort of CVCs\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The USG SA approach has traditionally been preferred by clinicians for performing and teaching USG IJV cannulation. However, its higher mechanical complications cannot be avoided. Complications of posterior venous wall puncture are higher in the SA approach\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Especially, when urgent IJV catheterization is required in the emergency department, there is a 50% incidence of posterior venous wall puncture in the SA group\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. The number of puncture attempts and needle redirections for IJV puncture is higher for SA approach\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In addition, IJV catheterization in the decubitus position is a more difficult procedure to perform with greater time urgency than IJV catheterization in the supine position. Therefore, special attention should be paid to IJV catheterization in the left decubitus position. An effective, safe, and satisfactory approach to IJV catheterization in the decubitus position for both patients and anesthesiologists is currently unknown.\u003c/p\u003e\n\u003cp\u003eThe USG OA approach involves placing the ultrasound probe between the short and long axis, and allows for optimal imaging of the IJV and the carotid artery side by side and following the needle throughout the insertion from skin to vessel penetration\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Our previous study found that arteriovenous overlap increases in a decubitus position. Kosnik et al. have reported that increased arteriovenous overlap greatly increases the probability of arterial injury when penetrating the posterior wall of the vein with the puncture needle\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Moreover, in the decubitus position, due to the gravitational force of blood, the IJV collapses severely, and the cross-sectional area becomes smaller, which is very likely to result in a hematoma in the posterior wall of the penetrating vein or difficulty in catheterization\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Participants in this study used the USG OA approach for IJV catheterization in the left decubitus position, which effectively increased the anteroposterior and transverse diameters and cross-sectional area of the IJV for easier catheterization\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e based on the real-time observation of the tip of the puncture needle to avoid penetration of the posterior wall of the vein and puncture of the artery at the same time. The USG OA approach is expected to be better than the SA in terms of feasibility and safety in left decubitus position IJV catheterization. However, the USG OA approach will have a longer imaging time than the SA. In the left decubitus position, the slightly longer imaging time may be compensated for by the shorter cannulation time. However, the role of the USG OA approach for left decubitus position surgical patients requiring IJV catheterization has not been fully defined. To our knowledge, this will be the first randomized controlled trial comparing the USG OA approach with the SA approach for IJV catheterization in the left decubitus position. In our patient, tracheal intubation was induced sequentially with Vt 6\u0026ndash;8 ml/kg to maintain E\u003csub\u003eT\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e at 35\u0026ndash;45 mmHg, followed by IJV catheterization by changing to left decubitus position with Trendelenbrug 20\u0026deg;. This strategy will minimize the impact of spontaneous ventilation or positional discomfort on the patient and thus on the intubation procedure.\u003c/p\u003e\n\u003cp\u003eSeveral limitations must be noted in this study. Firstly, our study will include adult patients aged between 18 and 65 years, with a physical status of ASA I\u0026thinsp;~\u0026thinsp;III, and a BMI between 18 and 30 kg/m2 for left decubitus surgery. Although these inclusion criteria will allow us to evaluate the effectiveness of USG OA versus SA approaches of probe placement in this specific patient population, further research is needed to determine whether our findings can be fully extrapolated to other patients with older, higher ASA classifications, and obese individuals (BMI\u0026thinsp;\u0026gt;\u0026thinsp;30 kg/m\u0026sup2;). Second, the investigation specifically focuses on left decubitus internal jugular vein (IJV) catheterization, excluding right decubitus positioning cases. We only evaluate the USG OA approach compared with the SA approach for left decubitus position IJV catheterization because we intended to evaluate the safety and efficacy of the USG OA approach versus the SA approach for left decubitus position IJV catheterization based on the most commonly used RIJV catheterization. Third, the single-center design and modest sample size (n\u0026thinsp;=\u0026thinsp;74) necessitate cautious interpretation of results. While adequately powered for primary endpoint analysis, multicenter validation with expanded cohorts will be required to confirm these preliminary findings. Despite these limitations, this trial will provide clinical insights into ultrasound-guided vascular access for left decubitus positioning. The OA approach will offer a potentially safer alternative to conventional SA techniques in this specific clinical context. Further investigations should prioritize the following three key extensions: 1) evaluation across diverse anatomical positions, 2) inclusion of high-risk patient subgroups, and 3) multisite replication with longitudinal outcome tracking.\u003c/p\u003e\n\u003cp\u003eIn conclusion, this prospective, randomized, single-blind, controlled trial will demonstrates the clinical superiority of the USG OA approach over the SA approach for IJV catheterization in left decubitus position. This investigation will provide robust evidence supporting the OA approach as the preferred modality for vascular access in this specific patient orientation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProtocol version number V2.0/October 17, 2024.\u003c/p\u003e\n\u003cp\u003eDate recruitment started, 1 January 2025.\u003c/p\u003e\n\u003cp\u003eCompletion of this trail is expected on 31 December 2026.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTimeline\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e2024: Development of research strategy and study protocol. 2025\u0026ndash;2026: Recruitment and treatment of patients in the trial. 2027: Completion of data analysis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors` contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWJ L is the principal investigator for this trial and drafted the manuscript. JF Z contributed to the study design. Z S, MJ Y and L H will collect and interpret the data. JW Z is the statistician responsible for the sample size calculation and the statistical design of the study. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Institutional Ethical Committee of Shanghai Tongren Hospital (No.2024-067-02) approved the study on October 17, 2024. All participants will sign a written informed consent form and be informed of the right to withdraw from this study at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTaylor RW, Palagiri AV. Central venous catheterization. Crit Care Med 2007, \u003cstrong\u003e35\u003c/strong\u003e(5)\u003cstrong\u003e:\u003c/strong\u003e 1390-1396.\u003c/li\u003e\n\u003cli\u003eHentrich M, B\u0026ouml;ll B, Teschner D, Panse J, Schmitt T, Naendrup JH, Schmidt-Hieber M, Neitz J, Fiegle E, Schalk E. Impact of the insertion site of central venous catheters on central venous catheter-related bloodstream infections in patients with cancer: results from a large prospective registry. Infection 2023, \u003cstrong\u003e51\u003c/strong\u003e(4)\u003cstrong\u003e:\u003c/strong\u003e 1153-1159.\u003c/li\u003e\n\u003cli\u003eBrass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 2015, \u003cstrong\u003e1\u003c/strong\u003e(1)\u003cstrong\u003e:\u003c/strong\u003e Cd006962.\u003c/li\u003e\n\u003cli\u003eLeibowitz A, Oren-Grinberg A, Matyal R. Ultrasound Guidance for Central Venous Access: Current Evidence and Clinical Recommendations. J Intensive Care Med 2020, \u003cstrong\u003e35\u003c/strong\u003e(3)\u003cstrong\u003e:\u003c/strong\u003e 303-321.\u003c/li\u003e\n\u003cli\u003eLamperti M, Biasucci DG, Disma N, Pittiruti M, Breschan C, Vailati D, Subert M, Tra\u0026scaron;kaitė V, Macas A, Estebe JP, Fuzier R, Boselli E, Hopkins P. European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access). Eur J Anaesthesiol 2020, \u003cstrong\u003e37\u003c/strong\u003e(5)\u003cstrong\u003e:\u003c/strong\u003e 344-376.\u003c/li\u003e\n\u003cli\u003ePractice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2020, \u003cstrong\u003e132\u003c/strong\u003e(1)\u003cstrong\u003e:\u003c/strong\u003e 8-43.\u003c/li\u003e\n\u003cli\u003eExcellence NIfHaC. NICE Technology Appraisal No 49：guidance on the use of ultrasound locating devices for placing central venous catheters.; 2011.\u003c/li\u003e\n\u003cli\u003eSheu R, Peterson C, Hall M, Liu M, Cormican D. Ultrasonic Enhancing Agents for the Cardiothoracic Anesthesiologist: A Focused Review of the 2018 American Society of Echocardiography Guidelines Update. J Cardiothorac Vasc Anesth 2019, \u003cstrong\u003e33\u003c/strong\u003e(3)\u003cstrong\u003e:\u003c/strong\u003e 755-767.\u003c/li\u003e\n\u003cli\u003eSchmidt GA, Blaivas M, Conrad SA, Corradi F, Koenig S, Lamperti M, Saugel B, Schummer W, Slama M. Ultrasound-guided vascular access in critical illness. Intensive Care Med 2019, \u003cstrong\u003e45\u003c/strong\u003e(4)\u003cstrong\u003e:\u003c/strong\u003e 434-446.\u003c/li\u003e\n\u003cli\u003eMar\u0026iacute;a LT, Alejandro GS, Mar\u0026iacute;a Jes\u0026uacute;s PG. Central venous catheter insertion: Review of recent evidence. 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Br J Anaesth 2016, \u003cstrong\u003e116\u003c/strong\u003e(3)\u003cstrong\u003e:\u003c/strong\u003e 370-376.\u003c/li\u003e\n\u003cli\u003ePhelan M, Hagerty D. The oblique view: an alternative approach for ultrasound-guided central line placement. J Emerg Med 2009, \u003cstrong\u003e37\u003c/strong\u003e(4)\u003cstrong\u003e:\u003c/strong\u003e 403-408.\u003c/li\u003e\n\u003cli\u003eTeja B, Bosch NA, Diep C, Pereira TV, Mauricio P, Sklar MC, Sankar A, Wijeysundera HC, Saskin R, Walkey A, Wijeysundera DN, Wunsch H. Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024, \u003cstrong\u003e184\u003c/strong\u003e(5)\u003cstrong\u003e:\u003c/strong\u003e 474-482.\u003c/li\u003e\n\u003cli\u003eResearch i. Central Venous Catheter Market Size, Share \u0026amp; Trends Analysis, Global, 2020-2026.; 2020.\u003c/li\u003e\n\u003cli\u003eBoulet N, Muller L, Rickard CM, Lefrant JY, Roger C. How to improve the efficiency and the safety of real-time ultrasound-guided central venous catheterization in 2023: a narrative review. Ann Intensive Care 2023, \u003cstrong\u003e13\u003c/strong\u003e(1)\u003cstrong\u003e:\u003c/strong\u003e 46.\u003c/li\u003e\n\u003cli\u003eChennakeshavallu GN, Gadhinglajkar S, Sreedhar R, Babu S, Sankar S, Dash PK. Comparison of Three Ultrasound Views for Internal Jugular Venous Cannulation in Patients Undergoing Cardiac Surgery: A Randomized Trial. J Med Ultrasound 2021, \u003cstrong\u003e29\u003c/strong\u003e(3)\u003cstrong\u003e:\u003c/strong\u003e 176-180.\u003c/li\u003e\n\u003cli\u003eSunny AE, Abraham SV, Krishnan SV, Rajeev PC, Palatty BU. A Comparison between Ultrasound-guided Short-axis Approach and Oblique Axis Approach for Internal Jugular Venous Cannulation in the Emergency Department. J Med Ultrasound 2022, \u003cstrong\u003e30\u003c/strong\u003e(2)\u003cstrong\u003e:\u003c/strong\u003e 81-86.\u003c/li\u003e\n\u003cli\u003ePanidapu N, Babu S, Koshy T, Sukesan S, Dash PK, Panicker VT. Internal Jugular Vein Cannulation Using a 3-Dimensional Ultrasound Probe in Patients Undergoing Cardiac Surgery: Comparison Between Biplane View and Short-Axis View. J Cardiothorac Vasc Anesth 2021, \u003cstrong\u003e35\u003c/strong\u003e(1)\u003cstrong\u003e:\u003c/strong\u003e 91-97.\u003c/li\u003e\n\u003cli\u003eDilisio R, Mittnacht AJ. The \u0026quot;medial-oblique\u0026quot; approach to ultrasound-guided central venous cannulation--maximize the view, minimize the risk. J Cardiothorac Vasc Anesth 2012, \u003cstrong\u003e26\u003c/strong\u003e(6)\u003cstrong\u003e:\u003c/strong\u003e 982-984.\u003c/li\u003e\n\u003cli\u003eKosnik N, Kowalski T, Lorenz L, Valacer M, Sakthi-Velavan S. Anatomical review of internal jugular vein cannulation. Folia Morphol (Warsz) 2024, \u003cstrong\u003e83\u003c/strong\u003e(1)\u003cstrong\u003e:\u003c/strong\u003e 1-19.\u003c/li\u003e\n\u003cli\u003eWhittle RS, Diaz-Artiles A. Gravitational effects on carotid and jugular characteristics in graded head-up and head-down tilt. J Appl Physiol (1985) 2023, \u003cstrong\u003e134\u003c/strong\u003e(2)\u003cstrong\u003e:\u003c/strong\u003e 217-229.\u003c/li\u003e\n\u003cli\u003eKurien M, Teo R, Zainuddin K, Azidin AM, Izaham A, Budiman M, Tang SSP. Ultrasound Probe Positions for Internal Jugular Vein Cannulation: A Prospective Study of Different Techniques. Clin Ter 2021, \u003cstrong\u003e172\u003c/strong\u003e(4)\u003cstrong\u003e:\u003c/strong\u003e 278-283.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ultrasonography, Oblique axis, Short axis, the right internal jugular vein cannulation, left decubitus position","lastPublishedDoi":"10.21203/rs.3.rs-6611947/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6611947/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe internal jugular vein (IJV) cannulation in the decubitus position is required in some urgent and special clinical situations, increasing the difficulty of performance. Although ultrasound guidance can improve the efficiency and safety of IJV cannulation, ultrasound guidance for right internal jugular vein (RIJV) cannulation in the decubitus position has not been studied. This trial aims to compare the feasibility and safety of an ultrasound-guided oblique-axis approach with a short-axis approach for left decubitus RIJV cannulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 74 patients undergoing IJV cannulation in the left decubitus position under general anesthesia will be randomly divided into two groups: the oblique-axis group (OA group) and the short-axis group (SA group). In both groups, the surgical bed will be rotated 20° to the Trendelenburg position prior to puncture to allow for better filling of the RIJV for catheterization. The primary endpoint is the first-time puncture rate. Secondary endpoints include overall catheterization success rate, overall catheterization time, number of venipuncture attempts, and incidence of mechanical complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe hypothesize that the feasibility and safety of the ultrasound-guided oblique-axis approach for RIJV cannulation will be superior to those of the short-axis approach in the left decubitus position. Our findings may provide a clinical preference for central venous cannulation in certain position for surgical patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChinese Clinical Trial Registry (chictr.org.cn)， identifier ChiCTR2400091385. Registered on October 28, 2024. https://www.chictr.org.cn/bin/project/edit?pid=247627\u003c/p\u003e","manuscriptTitle":"Comparison of short-axis and oblique-axis approaches for ultrasound-guided right internal jugular vein cannulation in the left decubitus position: a randomized clinical trial study protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-21 01:13:37","doi":"10.21203/rs.3.rs-6611947/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2026-01-05T09:55:53+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-11-25T02:44:55+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-11T10:29:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-17T05:07:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Trials","date":"2025-07-16T09:22:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fcf149bb-e408-49e0-ae94-aa8f87e73fcd","owner":[],"postedDate":"November 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:31:35+00:00","versionOfRecord":{"articleIdentity":"rs-6611947","link":"https://doi.org/10.1186/s13063-026-09603-9","journal":{"identity":"trials","isVorOnly":false,"title":"Trials"},"publishedOn":"2026-03-24 16:08:58","publishedOnDateReadable":"March 24th, 2026"},"versionCreatedAt":"2025-11-21 01:13:37","video":"","vorDoi":"10.1186/s13063-026-09603-9","vorDoiUrl":"https://doi.org/10.1186/s13063-026-09603-9","workflowStages":[]},"version":"v1","identity":"rs-6611947","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6611947","identity":"rs-6611947","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}