Internal Jugular Vein Lcatin and Anatmy n Ultrasund Cppens S. MD Btermans W.
Internal Jugular Vein Lcatin and Anatmy n Ultrasund Intrductin Methds Results Discussin Cnclusin References
Intrductin
Venus access Peripheral Central Jugular Subclavicular Femral PICC Mixed (surgical)
Jugular catheterisatin Landmark apprach (1) Anterir (2) Central (3) Psterir (4) Supraclavicular Ultrasund-guided Indirect Direct (RTUS) LAX (in-plane) SAX (ut-f-plane) http://www.thecardiacicu.cm [hmepage n the internet]. Cardiac Surgical ICU at Leningrad Regin Hspital; 2006 [cited 5 April 2017]. Available frm: http://www.thecardiacicu.cm/fr_experts/jugular_intr_eng.html
US SAX
Prblem?
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
Methds
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 Timing @ level f cricid Frm start needling until aspiratin f bld ver catheter
Parameters Patient-related Gender Age... Ultrasngraphic Outcme Vein diameter Vein psitin relative t the ICA Success rate Time until success Number f attempts Cmplicatins
Parameters Patient-related Gender Age... Ultrasngraphic Outcme Vein diameter Vein psitin relative t the ICA Success rate Time until success Number f attempts Cmplicatins
Parameters Patient-related Gender Age... Ultrasngraphic Outcme Vein diameter Vein psitin relative t the ICA Success rate Time until success Number f attempts Cmplicatins
Results
Diameter Average: Diameter: 13.11 mm Crss-sectinal area: 135.52 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
Diameter
Diameter
Diameter Age: ρ* = -0.06 Length: ρ = 0.05 Weight: ρ = 0.11 BMI: ρ = 0.09 * Pearsn s crrelatin cefficient
Psitin
Psitin
Psitin Side: Left (83%*) vs. right (29%) RR 2.86; 1.39-5.86** p = 0.03 Gender: (right) (25%) vs. (33%) RR 0.75; 0.21-2.66 (left) (100%) vs. (67%) RR 1.5; 0.67-3.34 * Percentage f cases with significant verlap ** 95% cnfidence interval
Psitin Age: ρ = 0.04
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%)
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
Discussin
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)
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)
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
Cnclusin
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
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
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
References
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.: CD006962. 2 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. 2013 Feb;118(2):361-75. 3 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) 11:148 155. 4 Czyzewska D, Ustymwicz A, Ksel J. Internal jugular veins must be measured befre catheterizatin. Jurnal f Clinical Anesthesia (2015) 27, 129 131. 5 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, 142 145. 6 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): 54-59.