The use of ultrasound has been advocated for central venous catheter placement. Previous studies have shown that by using ultrasound the placements were performed more efficiently with fewer complications.1Serafimidis K. Sakorafas G.H. Konstantoudakis G. et al.Ultrasound-guided catheterization of the internal jugular vein in oncologic patients: Comparison with the classical anatomic landmark technique: A prospective study.Int J Surg. 2009; 7: 526-528Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The authors present another advantage of using ultrasound in the management of internal jugular venous catheter placement as shown by the following case. The patient was a 75-year-old man (170 cm and 70 kg) who originally presented to the hospital for an open 6-cm abdominal aortic aneurysm repair. He had a history of hypertension, atrial fibrillation, coronary artery disease, and renal insufficiency. General plus thoracic epidural anesthesia was planned with arterial and central venous catheters. In the operating room, the epidural catheter was placed uneventfully, and general anesthesia was induced. The patient then was prepared for right internal jugular venous catheter placement. The 8.5F percutaneous sheath introducer kit (Product No. AK007802; Arrow International, Reading PA) was used for the traditional anterior approach.2Chudhari L.S. Karmarkar U.S. Dixit R.T. et al.Comparison of two different approaches for internal jugular vein cannulation in surgical patients.J Postgrad Med. 1998; 44: 57-62PubMed Google Scholar The patient exhibited good anatomic features, and, therefore, the authors decided to proceed without ultrasound guidance.3Hessel II, E.A. Con: We should not enforce the use of ultrasound as a standard of care for obtaining central venous access.J Cardiothorac Vasc Anesth. 2009; 23: 725-728Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar After identifying the superficial anatomic landmarks, the patient's right neck was punctured with an 18-gauge entry needle. Venous needle placement was identified by the color of the blood and the lack of pulsations. After a guidewire was inserted and the needle was withdrawn, the 8.5F percutaneous sheath introducer was inserted using the Seldinger technique. Blood was aspirated; however, it soon became apparent that the carotid artery was entered rather than the internal jugular vein. Pulsatile flow and brightly colored blood were noted. An ultrasound machine (Sonosite, Bethel, WA) then was brought into the operating room and confirmed the suspected position of the sheath introducer. Accidental carotid artery cannulation was verified. Additionally, an intimal tear with a pseudoaneurysm was noted (Fig 1). The sheath introducer was left in place, and a vascular surgeon was consulted. A confirmatory carotid angiogram was performed, and, again, the right carotid pseudoaneurysm was noted (Fig 2). Endovascular repair of the pseudoaneurysm was proposed, and the patient's family was notified. Within an hour, an endovascular stent was placed successfully, and the carotid blood flow was re-established (Fig 3). The patient then was awakened from anesthesia. No neurologic deficits were noted. The patient was discharged home 2 days later, and the aortic aneurysm repair surgery was rescheduled for a later date.Fig 2A fluoroscopic image of the carotid artery before the repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3A fluoroscopic image of the carotid artery after the repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Carotid artery puncture is one of the common complications of internal jugular venous cannulation. Using the traditional landmark technique, it was noted to occur in as many as 10% of the attempts.4Guilbert M.C. Elkouri S. Bracco D. et al.Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm.J Vasc Surg. 2008; 48: 918-925Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar A recent article examined the clinical implications of the carotid artery punctures and found that approximately 50% of accidental punctures resulted in complications including strokes and deaths.5Karakitsos D. Labropoulos N. De Groot E. et al.A Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients.Crit Care. 2006; 10: 162Crossref PubMed Scopus (480) Google Scholar Using ultrasound has dramatically decreased the complications rates of internal jugular venous catheter placements.4Guilbert M.C. Elkouri S. Bracco D. et al.Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm.J Vasc Surg. 2008; 48: 918-925Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar A few of the advantages of using ultrasound include improved vein visualization, higher success rate among novice operators, and greater cost-effectiveness.6Augoustides J.G. Cheung A.T. Pro: Ultrasound should be the standard of care for central catheter insertion.J Cardiothorac Vasc Anesth. 2009; 23: 720-724Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar After an accidental carotid artery puncture, the standard practice is to keep the needle/introducer in place and consult a vascular surgeon. Known complications, such as intimal tear with a pseudoaneurysm and hematoma formation, should be suspected and checked. In 2006, 106 vascular surgeons were surveyed, and the majority agreed that the pseudoaneurysm of the carotid artery indeed needed surgical intervention.7Mussa F.F. Towfigh S. Rowe V.L. et al.Current trends in the management of iatrogenic cervical carotid artery injuries.Vasc Endovasc Surg. 2006; 40: 354-361Crossref PubMed Scopus (16) Google Scholar Ultrasound guidance for the placement of central catheters has increased in operating rooms. It is a very helpful tool in placing central venous catheters. However, as this case shows, ultrasound can further be useful in managing the complications such as accidental carotid artery punctures. The intimal tear with a pseudoaneurysm, which may not have been recognized from external examination alone, can be identified quickly and assessed by using ultrasound. Routine ultrasound examination of the carotid artery after its accidental puncture should be encouraged.

Background:The ACGME has proposed changes to the curriculum for anesthesia residents.These changes include increasing critical care from 2 to 4 months, pain from 1 to 3 months, and obstetrics, pediatric, neuroanesthesia, and cardio thoracic anesthesia from 1 to 2 months.In addition, they have included a preoperative clinic for 1 month.Methods: With IRB approval, a survey of the anesthesia residents at New York University was distributed.The residents questioned ranged from the CA-1 to the Ca-3 class.The survey questioned the residents on their current curriculum and the proposed changes.Results: 22 Residents completed the questionnaire.Seventy-seven percent of the residents polled felt they had enough experience in critical care with the current requirements and 82% did not want the increase to 4 months (p=0.007).Seventy-three percent of the residents responded that their pain management exposure was sufficient and 82% did not want it increased (p=0.011).Overwhelmingly, 82% of those polled felt an entire month of preoperative clinic was not necessary.Seventy-three percent of those residents polled would not be comfortable on subspecialty rotations as early as August of their CA-1 year.82% felt that too much of their training would be spent outside of the operating room, and the majority (59%) thought more residents would be on each rotation.Moreover, 55% think that the proposed changes will adversely affect residents in training. Discussion:The results of this survey demonstrate that most residents at New York University do not think the current curriculum should change.The majority opinion is that it will negative impact their education.