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Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter

[La position de Trendelenburg, l’élévation de la tête et une position médiane augmentent le diamètre de la veine jugulaire interne droite]

From the Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada.

Address correspondence to: Dr. Gareth Parry, Department of Anaesthetics, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, United Kingdom. Phone: 029 2074 3110; Fax: 029 2074 7203; E-mail: garethandantonia{at}ntlworld.com

	Abstract

TOP Abstract Introduction Methods Results Discussion References

 
Purpose: The right internal jugular (RIJ) is commonly used to provide central venous access, and success of cannulation shows a positive correlation with the vein’s diameter. The purpose of this study is to establish the patient position resulting in the largest RIJ diameter.

Method: 2D ultrasound was used to measure RIJ diameter, in varying body positions, in 21 healthy volunteers.

Results: In the neutral position (table flat, head on the table in midline) the RIJ diameter was (mean ± standard deviation) 9.2 ± 2.18 mm. A small pillow under the head increased RIJ diameter (10.6 ± 2.16 mm, P < 0.001). Trendelenburg tilt of 15° increased RIJ diameter (12.1 ± 2.34 mm, P < 0.001). In the Trendelenburg position (15° of tilt), a small pillow under the head further increased RIJ diameter (13.3 ± 2.26, mm P < 0.001), palpating for the carotid artery decreased RIJ diameter (8.2 ± 1.98 mm, P < 0.001), and rotation of the head 45° to the left did not reduce RIJ diameter significantly (11.7 ± 2.52 mm, P = 0.12).

Conclusion: The patient position to achieve maximal RIJ diameter cannulation is: 15° of Trendelenburg tilt; a small pillow or head ring under the head; the head in or close to midline; and after palpation of the carotid artery, it should be released prior to vein cannulation.

	Introduction

TOP Abstract Introduction Methods Results Discussion References

 
CANNULATION of the right internal jugular vein (RIJ) is a common method of providing central venous access. The larger the cross-sectional area of the RIJ, the easier it should be to locate. A significant correlation has been shown between increased RIJ diameter, and first pass success of RIJ cannulation.¹ The purpose of this study was to identify the position that results in the largest diameter of RIJ, and thus the greatest chance of successful first pass cannulation of that vein.

	Methods

TOP Abstract Introduction Methods Results Discussion References

 
After explanation of the methodology, 21 anesthesiologists and recovery room nurses at Vancouver General Hospital volunteered for the study, and gave their informed consent. All subjects were ASA I or II, no subject had had neck surgery, and no subject was fasting. 2D ultrasonography [Hewlett Packard Sonos 2000 (Palo Alto, CA, USA) at 5 MHz] was used to measure the internal diameter of the RIJ, in an anterior-posterior plane, at the level of the cricoid cartilage. Different body positions were adopted, simulating patient positioning that may be used while attempting to cannulate the RIJ (Table I, left column). The mean of the higher two of three measurements was recorded, in each of the ten positions. A second observer palpated the carotid artery with the minimum necessary pressure to feel the arterial pulse. All results are presented as mean ± standard deviation. A paired Student’s t test was used to test for significance. A P value of 0.05 was used to indicate statistical significance.

	Results

TOP Abstract Introduction Methods Results Discussion References

Fifteen degree Trendelenburg tilt gave significantly larger RIJ diameters than a flat table (Table II, section 1). The use of a small pillow under the head gave significantly larger RIJ diameters than all corresponding positions without a pillow (Table II, section 2). Rotation of the head 45° to the left reduced RIJ diameter compared to corresponding positions with the head in the midline, but not in all positions (Table II, section 3). Palpation of the carotid artery significantly reduced RIJ diameter compared to corresponding positions without carotid artery palpation (Table II, section 4).

	Discussion

TOP Abstract Introduction Methods Results Discussion References

 
Internal jugular cannulation with sonographic guidance is more likely to result in success as compared to a blind technique, is considered safer, and has also been found to be quicker.^1–6 However, portable sonographic devices are not always available, and sometimes achieving central venous access is difficult. Logically, the larger a target, the easier it is to hit and one should aim to maximize the diameter of the RIJ before attempting to cannulate it. It has been shown that the larger the diameter of the RIJ the more likely one is to achieve first pass cannulation¹ and therefore the less the chance of complications. The RIJ is usually very compliant;⁷ relatively small changes in pressure produce large changes in volume and thus in cross sectional area. Armstrong⁸ showed that maneuvers that increase central venous return increase RIJ diameter. This observer also found 15° Trendelenburg tilt significantly increased RIJ diameter, as compared to a flat table (position A vs position C, P < 0.001). At 20° or more of Trendelenburg tilt the subjects started to slide on the table, and no measurements were taken.

Reduction in cross-sectional area will occur with any external pressure on the RIJ. Armstrong⁸ showed palpation of the carotid artery significantly reduced the diameter of the RIJ. This reduction by carotid artery pressure is also seen in the Trendelenburg position (position C vs position I, P < 0.001).

A significant increase in RIJ diameter can be accomplished by positioning a small pillow under the head (position A vs position B, P < 0.001), this is also found in the Trendelenburg position (position C vs position D, P < 0.001). Increased tension of structures in the neck, either compressing or preventing expansion of the RIJ is thought to be the mechanism. Armstrong⁸ showed a marked reduction in diameter of the RIJ when a bolster was positioned under the shoulders probably through the same, but more exaggerated mechanism.

In the Trendelenburg position, rotation of the head 45° to the left reduced the size of the RIJ with a pillow (position D vs position E, P < 0.001) but not without (position C vs position H, P = 0.12); a similar reduction was shown by Muhammad.⁹

First pass success in cannulation should be the objective. Blind puncture techniques require the optimum patient position in order to increase success. In self ventilating subjects, the maximum RIJ diameter can be accomplished in the following fashion: 15° Trendelenburg tilt; a small pillow or head ring under the head; the head in or close to the midline; carotid artery palpation released prior to insertion of the RIJ line. The effect of positive pressure ventilation on RIJ size was not examined. Increased intrathoracic pressure is likely to increase RIJ diameter in all positions.

	Footnotes

 
Accepted for publication June 18, 2003. Revision accepted November 13, 2003.

	References

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2 Caridi JG, Hawkins IF Jr, Wiechmann BN, Pevarski DJ, Tonkin JC. Sonographic guidance when using the right internal jugular vein for central vein access. Am J Roentgenol 1998; 171: 1259–63.[Abstract/Free Full Text]

3 Docktor B, So CB, Saliken JC, Gray RR. Ultrasound monitoring in cannulation of the internal jugular vein: anatomic and technical considerations. Can Assoc Radiol J 1996; 47: 195–201.[Medline]

4 Koski EM, Suhonen M, Mattila MA. Ultrasound-facilitated central venous cannulation. Crit Care Med 1992; 20: 424–6.[Medline]

5 Keenan SP. Use of ultrasound to place central lines. J Crit Care 2002; 17: 126–37.[Medline]

6 Teichgraber UK, Benter T, Gebel M, Manns MP. A sonographically guided technique for central venous access. Am J Roentgenol 1997; 169: 731–3.[Abstract/Free Full Text]

7 Denys BG, Uretsky BF. Anatomical variations of internal jugular vein location: impact on central venous access. Crit Care Med 1991; 19: 1516–9.[Medline]

8 Armstrong PJ, Sutherland R, Scott DH. The effect of position and different manoeuvres on internal jugular vein diameter size. Acta Anaesthesiol Scand 1994; 38: 229–31.[Medline]

9 Muhammad JK, Pugh ND, Boden L, Crean SJ, Fardy MJ. The effect of head rotation on the diameter of the internal jugular vein: implications for free tissue transfer. J Craniomaxillofac Surg 2001; 29: 214–8.[Medline]

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