Internal Jugular Vein Location and Anatomy on Ultrasound. Coppens S. MD Botermans W.

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1 Internal Jugular Vein Lcatin and Anatmy n Ultrasund Cppens S. MD Btermans W.

2 Internal Jugular Vein Lcatin and Anatmy n Ultrasund Intrductin Methds Results Discussin Cnclusin References

3 Intrductin

4 Venus access Peripheral Central Jugular Subclavicular Femral PICC Mixed (surgical)

5 Jugular catheterisatin Landmark apprach (1) Anterir (2) Central (3) Psterir (4) Supraclavicular Ultrasund-guided Indirect Direct (RTUS) LAX (in-plane) SAX (ut-f-plane) [hmepage n the internet]. Cardiac Surgical ICU at Leningrad Regin Hspital; 2006 [cited 5 April 2017]. Available frm:

6 US SAX

7 Prblem?

8 Gals T investigate the incidence f anatmical variants f the internal jugular vein T express a relatinship between these variants and specific patient characteristics T assess whether certain variants yield an increased risk f cmplicatins

9 Methds

10 Methds Infrmed cnsent after ethical apprval 50 patients t be included Patient psitining Trendelenburg (10-15 ) RTUS Right-sided (unless cntra-indicated) Head rtated cntralaterally (CAVE extreme rtatin) Linear transducer (BK Medical) High frequency (10-12 mhz) SAX level f cricid Frm start needling until aspiratin f bld ver catheter

11 Parameters Patient-related Gender Age... Ultrasngraphic Outcme Vein diameter Vein psitin relative t the ICA Success rate Time until success Number f attempts Cmplicatins

12 Parameters Patient-related Gender Age... Ultrasngraphic Outcme Vein diameter Vein psitin relative t the ICA Success rate Time until success Number f attempts Cmplicatins

13 Parameters Patient-related Gender Age... Ultrasngraphic Outcme Vein diameter Vein psitin relative t the ICA Success rate Time until success Number f attempts Cmplicatins

14 Results

15 Diameter Average: Diameter: mm Crss-sectinal area: mm² Side: Left (12.85 mm) vs. right (13.17 mm) p = 0.85 Gender: (12.48 mm) vs. (13.73 mm) p = 0.42

16 Diameter

17 Diameter

18 Diameter Age: ρ* = Length: ρ = 0.05 Weight: ρ = 0.11 BMI: ρ = 0.09 * Pearsn s crrelatin cefficient

19 Psitin

20 Psitin

21 Psitin Side: Left (83%*) vs. right (29%) RR 2.86; ** p = 0.03 Gender: (right) (25%) vs. (33%) RR 0.75; (left) (100%) vs. (67%) RR 1.5; * Percentage f cases with significant verlap ** 95% cnfidence interval

22 Psitin Age: ρ = 0.04

23 Outcme measures Success rate 28 / 30 (93.5%) Number f attempts Difficult cannulatins (mre than 3 attempts): 3 / 30 (f which 2 failed) Time until success Average: 03:54 (00:50 t 11:08) Lnger in... Left-sided cannulatin Smaller veins Significant verlap Presence f c-assistants in a 10ft radius Cmplicatins Unsuccessful cannulatin: 2 / 30 (6.5%) Accidental arterial puncture: 2 / 30 (6.5%)

24 Cmplicatins based n... Side Left 2 / 6 (33.33%) vs. right 2 / 24 (8.33%) RR = 4 (nt statistically significant) Diameter Average diameter in cmplicated (12.04 mm) vs. nn-cmplicated cannulatins (13.27 mm) p = 0.63 Cmplicatin rate in smallest quartile (25%) vs. larger veins (9,09%) RR 2.75 (nt statistically significant) Psitin Cmplicatin rate with nn-significant 0 / 18 (0%) vs. wíth significant verlap 4 / 12 (33.33%) p = 0.02

25 Discussin

26 Landmarks versus ultrasund Literature Study Higher success rate with US in a Success rate f 93.5% (attempts shrter time windw, in general and perfrmed by residents) at first attempt (98% vs. 87%) 1,2 Lwer general cmplicatin rate General cmplicatin rate 13% (13.5% vs. 3.9%) 1 (attempts perfrmed by residents) Higher failure rate in left-sided Higher failure rate in left-sided cannulatin 5 cannulatin (nt statistically significant)

27 Vein diameter Literature Higher failure rate in smaller vessels 3 Study Higher failure rate and lnger time until success in smaller vessels (nt statistically significant) Left IJV is mre ften the smaller Difference in right- and left-sided vein (and is less prne t dilatin vein nt significant with Valsalva manever) 4 Higher failure rate in left-sided Higher failure rate in left-sided cannulatin 5 cannulatin (nt statistically significant)

28 Vein psitin Literature Study The IJV ften lcates mre anterirly t the artery (41,9%) with a variable degree f verlap 6 Significant verlap in 40% The vein tends t verlap mre in the elderly and when the head is rtated cntralaterally, and t a lesser extend n the left side and in men 6 Higher degree f significant verlap n the left side (83% vs. 29%) N strng crrelatin with gender and age Higher cmplicatin rate when significant verlap is present

29 Cnclusin

30 What we already knew Real-time ultrasngraphic guidance fr central line placement increases success rati and decreases the risk f cmplicatins Smaller vessels are mre difficult t cannulate The left IJV is ften smaller than the right ne The IJV ften des nt lie lateral t the ICA but mre anterirly with a varying degree f verlap

31 What this study adds On average the left IJV tends t verlap with the ICA t a further extend than the right ne des The hypthesis that an anterirly lcated IJV yields an increased risk f cmplicatins has been cnfirmed

32 Limitatins Relatively small sample size Central line placement perfrmed by residents Different residents, nt always same perfrmer Study was nt pwered fr VJI puncture cmplicatins

33 References

34 References 1 Brass P, Hellmich M, Kldziej L, Schick G, Smith AF. Ultrasund guidance versus anatmical landmarks fr internal jugular vein catheterizatin. Cchrane Database f Systematic Reviews 2015, Issue 1. Art. N.: CD Wu SY, Ling Q, Ca LH, Wang J, Xu MX, Zeng WA. Real-time tw-dimensinal ultrasund guidance fr central venus cannulatin: a meta-analysis. Anesthesilgy Feb;118(2): Mey U, Glasmacher A, Hahn C, Grschlüter M, Ziske C, Mergelsberg M. Evaluatin f an ultrasund-guided technique fr central venus access via the internal jugular vein in 493 patients. Supprt Care Cancer (2003) 11: Czyzewska D, Ustymwicz A, Ksel J. Internal jugular veins must be measured befre catheterizatin. Jurnal f Clinical Anesthesia (2015) 27, Sulek CA, Blas ML, Lbat EB. A Randmized Study f Left Versus Right Internal Jugular Vein Cannulatin in Adults. Jurnal f Clinical Anesthesia (2000) 12, Umaña M, García A, Bustamante L, Castill JL, Martínez JS. Variatins in the anatmical relatinship between the cmmn cartid artery and the internal jugular vein: An ultrasngraphic study. Clmb Med. 2015; 46(2):

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