Position and relative size of the vertebral artery according to age: Implications for internal jugular vein access

Anatomical relationship between the internal jugular vein and the vertebral artery: An observational study in pre-school children using ultrasound imaging

Background and Aims

Central venous cannulation is performed in children requiring vasopressor use, long-term antibiotics, chemotherapy or parenteral nutrition. The internal jugular vein is the preferred site for cannulation. Though, there are several studies describing the relation of the common carotid artery (CCA) and internal jugular vein (IJV) in the neck, there is a paucity of data regarding the anatomical relationship between the vertebral artery (VA) and the IJV. This study aims to describe the anatomical relationship between the IJV and the VA using ultrasound imaging in pre-school children in India.

Material and Methods

Prospective observational cross-sectional study of 67 randomly selected children (age <5 years) who underwent an ultrasound examination of the right side of the neck, in a position mimicking central venous cannulation, to identify the relationship between the IJV and VA. The skin to the vertebral artery depth (D), width of the VA (W), distance between the IJV and the VA (DIV) was measured. Based on these, children were classified into high risk, moderate risk and low risk category for VA puncture.

Results

Of the 67 children, 15 (22.4%) patients belonged to the high-risk group, 25 (37.3%) belonged to the moderate-risk group and 27 (40.23%) belonged to the low-risk group.

Conclusion

In addition to localizing the carotid artery, pre-procedural scanning or real-time ultrasound examination to establish the anatomical relation of the IJV to the VA is imperative to alert the clinician of the possible risk of VA puncture.

The Right Internal Jugular at the Cricoid Cartilage Level May Represent the Optimal Central Vein Puncture Site in Pediatric Patients

OBJECTIVE

Internal jugular vein puncture or cannulation is far more difficult in children compared with adults. Anthropometric measures of the internal jugular vein acquired by two-dimensional ultrasound are useful in the practice of puncture and catheterization. The aim of this study is to measure anthropometric parameters of bilateral internal jugular veins in children and to determine the best puncture site based on these parameters.

MATERIALS

A total of 107 pediatric patients undergoing elective operation were included. Ultrasound-visible evaluation of bilateral internal jugular veins was used to obtain the depth from skin, maximum antero-posterior diameter, and cross-sectional area at the levels of the superior border of thyroid cartilage and cricoid cartilage. Statistical analysis was performed using these anthropometric data and demographic variables of all studied pediatric patients, such as age, height, and weight.

RESULTS

A very weak correlation was noted between the depth, maximal antero-posterior diameter, and cross-sectional area of both internal jugular veins and the age, height, weight, and body surface index of all included children. All Pearson's R correlation coefficients were <0.45. The largest diameter and cross-sectional area were in the right internal jugular vein at the cricoid cartilage level (p < 0.01) followed by the left internal jugular vein at this level (p < 0.01). In addition, the internal jugular vein at the cricoid cartilage level was more superficial than that of the superior border of the thyroid cartilage (p < 0.01).

CONCLUSION

The right internal jugular vein at the cricoid cartilage level is the best site for puncture. The most appropriate alternative site is the left internal jugular vein on the same level. Better correlation was not observed between the anthropometric parameters of the internal jugular vein and children's biological characteristics. This finding should be confirmed in a larger-scale demographical study in the future.

Brachial Plexus Injury due to Central-line Insertion during Kypho-scoliosis Deformity Correction

Introduction:

Internal Jugular Venous (IJV) cannulation or central-line insertion is frequently performed during kyphoscoliosis deformity correction surgery or spine surgery with high risk. This helps monitor central venous pressure and administer medicines when required. Although many complications of IJV cannulation have been reported in the literature, its effect on brachial plexus is not known. The objective of this paper was to report a rare complication of IJV during scoliosis surgery.

Case Presentation:

We reported a case of 27-year-old male who was operated for severe kyphoscoliosis correction where preoperatively IJV cannulation was done. Repeated attempts were done during IJV cannula insertion due to altered anatomy. Eventually, cannula insertion was done using ultrasound modality and surgery for correction was done. Postoperatively patient developed right upper extremity weakness and sensory loss although the clinical result of kyphoscoliosis correction was acceptable. EMG-NCV study proved it brachial plexus injury. The patient was treated with intravenous steroid and physiotherapy. The patient recovered completely within 6 months of surgery.

Conclusion:

We reported a case of kyphoscoliosis deformity corrective surgery where IJV cannulation led to brachial plexus injury and was eventually recovered with medications and physiotherapy.

Comparison of the effect of different degrees of passive leg raising on the internal jugular vein cross-sectional area in patients before thoracic surgery

Background

This study investigated the effect of different degrees of passive leg raising (PLR) on the internal jugular vein (IJV) cross-sectional area (CSA) and on the success rate of IJV cannulation in patients waiting for thoracic surgery, to analyze whether body mass index (BMI), gender, age, fasting time and preoperative rehydration have any impact on changes in the IJV CSA.

Methods

Eighty-two patients scheduled for selective thoracic surgery were enrolled in this study. Patients were randomly assigned based on a computer-generated randomization sequence into 3 groups: 0, 30, and 50 degrees (n = 32, 25, and 25 patients, respectively). The right IJV CSA in the sequence of 0-degree (supine position), 30-degree and 50-degree PLR positions was recorded in all patients using an ultrasound probe. The relationship of BMI, gender, age, fasting time and preoperative rehydration to the IJV CSA was analyzed. Then, each patient was returned to a supine position. After waiting for at least 5 min, patients were placed in a PLR position at 0, 30, or 50 degrees, and then IJV cannulation was performed without ultrasound guidance. The success rate of IJV catheterization at different PLR angles was compared.

Results

The average CSA of the right IJV in the supine position, 30-degree PLR position and 50-degree PLR position was 1.39 ± 0.63 cm², 1.65 ± 0.73 cm², and 1.68 ± 0.71 cm², respectively. These results showed gradual increases in the IJV CSA of 18.5% (30-degree PLR) and 20.2% (50-degree PLR) when compared to that in the supine position (P = 0.045 and 0.025, respectively). However, only fasting time had a significant impact on the increase in the right IJV CSA at different PLR angles (P = 0.026). Other factors, such as BMI, gender, age and preoperative rehydration, had no significant effects. The success rates of IJV catheterization at angles of 0, 30 and 50 degrees were 84.3, 88 and 92%, respectively; however, there were no significant differences among the three groups (P = 0.674).

Conclusions

PLR increases the CSA of the right IJV, especially for patients with long fasting times before thoracic surgery. The effect of the 30-degree PLR position is similar to that of the 50-degree PLR position. However, the success rate of right IJV catheterization was not enhanced in this study using landmark-guided puncture, even though the CSA of the right IJV was increased.

Trial registration

Clinical trial registration number: ChiCTR1800015051. Date of registration: March 2018.

Vascular access in children

Securing stable vascular access is an important clinical skill for the anaesthesiologist. Sick children, complex surgeries, chronic illnesses, multiple hospitalisations, and prolonged treatments can make vascular access challenging. A search was done in the English language literature using the keywords "paediatric," "vascular access," "venous access," and "techniques" or "complications" in Pubmed, Embase, and Google scholar databases. Articles were screened and appropriate content was included. Intraosseous access is a lifesaving technique that can be performed even in hypovolaemic patients rapidly. Transillumination and near-infrared light improve visualisation of superficial veins in difficult access. Ultrasonography has become the standard of care in selecting the vessel, size of catheter, guide placement, and prevent complications. Fluoroscopy is used during insertion of long-term vascular access devices. This article reviews the various routes of access, their indications, most appropriate site, securing techniques, advantages, disadvantages, and complications associated with vascular access in children.