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Thyroid cyst puncture during cannulation of the internal jugular vein

Toronto Western Hospital, Toronto, Canada, E-mail: catherine.kim{at}utoronto.ca

To the Editor:

Central venous cannulation is an important aspect of anesthesia practice. It allows monitoring of central venous pressure and provides intraoperative vascular access for administering fluids, blood products and drugs. It is also used for insertion of pulmonary artery catheters, transvenous electrodes, and for observation and treatment of venous air embolism. The complication rate associated with internal jugular vein (IJV) catheterization may be as high as 10%.¹ There are reports of arterial puncture, hematoma, pneumothorax, malposition of catheter and injuries to the thoracic duct, nerves and trachea. We describe here a case of thyroid cyst puncture during cannulation of IJV.

A 62-yr-old woman with intractable seizures was scheduled for craniotomy and resection of skull base meningiomas. Her past medical history consisted of diabetes and hypertension. General anesthesia was induced without difficulty. The right IJV was selected for cannulation using the landmark method. There were no obvious neck masses or structural abnormalities, except that the carotid pulse was not palpable.

The needle was inserted at the apex of the triangle, defined by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle, aiming toward the ipsilateral nipple. Clear viscous fluid was aspirated during insertion (at a depth of approximately 4 cm). No air was encountered, and the needle was withdrawn. Another attempt using a more lateral insertion site encountered venous blood, and the catheter was successfully placed. The patient remained stable throughout the operation. A postoperative ultrasound revealed an enlarged thyroid gland with a partially cystic nodule measuring 3.6 x 3.1 x 1.9 cm. The thyroid nodule containing cysts overlay the right carotid artery. It displaced the carotid artery posteriorly and the IJV laterally (Figure). As a result, it was difficult to palpate the carotid pulse, and insertion of the needle according to the landmarks led to the thyroid cyst puncture.

View larger version (118K): [in this window] [in a new window]   FIGURE The partially cystic thyroid nodule (TC) displaced the carotid artery (CA) posteriorly and the internal jugular vein (IJV) laterally.

References

1 Muhm M. Ultrasound guided central venous access. BMJ 2002; 325: 1373–4.[Free Full Text]

2 Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003; 327: 361.[Abstract/Free Full Text]

3 Hatfield A, Bodenham A. Portable ultrasound for difficult central venous access. Br J Anaesth 1999; 82: 822–6.[Abstract/Free Full Text]

4 National Institute for Clinical Excellence. Technology Appraisal Guidance - No 49. Guidance on the use of ultrasound locating devices for placing central venous catheters. London: September, 2002. Available from URL; www.nice.org.uk/pdf/ultrasound_49_GUIDANCE.pdf

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