In Reply:-Ball provides a useful alternative method of collecting information displayed on the small ultrasound device (Site Rite, Dymax, Pittsburgh, PA) used in our study. These transparent projector sheets avoid the need for camera modifications and are less costly. Drawbacks include the need for two operators (one to hold the probe and one to draw the figures). There is also the possibility of entering bias into a scientific project while outlining the size, shape, and relation of vascular structures. Polaroid photographs provide a more accurate recording and can be obtained at little to no cost. Our study used functional but outdated film donated by the Polaroid and Dymax corporations.
Bruner raises three important issues. The first issue questions the practice of rotating the head during cannulation of the internal jugular vein. The maneuver of head rotating is universally described by leading textbooks and is a widely accepted practice. Existing scientific work that examines the effect of head rotation on vascular anatomy should be expanded before conventional teaching and practice are disputed. Although Bruner's comments concerning head rotation may be warranted, evidence for this change is sparse.
The second issue describes the course of the internal jugular vein beneath a line that projects from the mastoid process to a notch on the clavicle. This technique, described by Rao et al., is yet another landmark-guided approach to the internal jugular vein. Numerous studies that compare landmark-guided techniques to ultrasound guided cannulation all favor the ultrasound-guided approach. Landmark-guided techniques are prone to failure and complications simply because superficial structures do not consistently match the underlying vein position. Our recent study demonstrated that the anatomic relation between the carotid artery and jugular vein is often conducive to carotid artery puncture despite normal surface anatomy. 
The third issue describes an approach to the internal jugular vein by identification of venous pulsations beneath the body of the sternocleidomastoid muscle. Sharrock and Fierro described their experience with this technique in 212 primarily elderly patients suffering from cardiac, renal, or respiratory diseases during positive pressure ventilation and general anesthesia. Identification of jugular venous pulsations in this patient population and under these specific conditions cannot be applied universally. Ultrasound-guided cannulation, however, can be used in all patients irrespective of their age, disease state, or level of consciousness, and is associated with a 100% cannulation success rate. The important question to ask is not which landmark guided technique is best, but whether to use ultrasound guidance routinely for cannulation of the internal jugular vein.
Christopher A. Troianos, M.D., Richard J. Kuwik, M.D., Department of Anesthesiology, The Mercy Hospital of Pittsburgh, 1400 Locust Street, Pittsburgh, Pennsylvania 15219.
(Accepted for publication September 21, 1996.)