Department of Emergency Medicine, Nagoya University Hospital, Nagoya, Aichi, Japan
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To the Editor:We read with great interest the article published in Critical Care Medicine by Lim et al (1). They demonstrated that the bevel-down approach for the central venous puncture reduced the complications, including the prevalence of posterior venous wall damage and hematoma formation. The accompanying editorial by Gilchrist (2) is highly suggestive and really helpful for our understanding of the issue. Theoretically, the penetration of only anterior vessel wall could be an ideal procedure for internal jugular vein catheterization (3), and the bevel-down method requires no complicated device and preparation for preventing from injuries. However, there is room for discussions for technical feasibility.In our emergency and medical intensive care unit, almost all punctures for central venous catheterization were performed under real-time ultrasound sonography (4). We prefer the guidance under longitudinal ultrasound view and endeavor to display whole-needle echoic signals with neighboring anatomical structures (Fig. 1A). In general, a patient who required critical care medicine is hypovolemic or in a near shock status, and the circulatory insufficiency collapsed the vessels, thus the puncture becomes very difficult (Fig. 1B). When the needle tip reached the anterior wall of internal jugular vein during a filling moment, piercing could be enabled (Fig. 1C). If the penetrating force for piercing the vessel wall was smaller than the strain of vein determined by circulating volume and venous pressure, only anterior wall puncture would be possible. However, the advanced needle tip is ultimately close to the posterior wall immediately after the puncture, even though in a success case (Fig. 1D). The prevention of double-wall puncture, not only the anterior but also the posterior wall of vessels, might be quite arduous and sometimes impractical. Many central vein punctures might be accompanied by the double-wall puncture in daily clinical settings, and occasionally followed by unexpected penetration to other vital structures (5, 6).One of the solutions for avoiding more severe complications, especially carotid puncture, is the use of longitudinal view of real-time ultrasound sonography, as we demonstrated (Fig. 1D). If the longitudinal ultrasound plane of internal jugular vein without imaging of carotid artery could be established, the needle advancing within the plane never injures the vital structure (Fig. 1E), even with the piercing of posterior vessel wall. The prevention from unanticipated penetration to critical organs should be considered as the most important complication.Central venous catheterization is an absolute important measure in the area of critical care medicine. An endless effort to develop safer and more reliable techniques is indispensable. The bevel-down approach could be one fascinating option and everyone should verify the result continuously.Yushi U.