Journal of Clinical Anesthesia (2015) 27, 129–131
Original Contribution
Internal jugular veins must be measured before catheterization Dorota Czyzewska MD (Resident)a,⁎, Andrzej Ustymowicz MD, PhD (Associate Professor)b , Juliusz Kosel MD, PhD (Assistant Professor)c a
Department of Radiology, Medical University of Bialystok Children's Clinical Hospital, Bialystok, Poland Department of Radiology, Medical University of Bialystok, Bialystok, Poland c Department of Anesthesiology and Intensive Therapy, Medical University of Bialystok, Bialystok, Poland b
Received 4 October 2013; revised 1 September 2014; accepted 10 September 2014
Keywords: Cannulation; Internal jugular vein; Ultrasound
Abstract Study objective: The study objective is to determine the cross-sectional area (CSA) of the right and left internal jugular vein (IJV) in supine position in healthy subjects. Design: This is a prospective, nonrandomized study. Setting: The setting is a university hospital. Patients: The patients are 185 consenting healthy subjects. Interventions: B-mode ultrasonography examinations of the right and left IJV were performed with the use of a linear 14-MHz transducer at the level of the cricoid cartilage. The CSA of the examined vessels was measured in a supine position. Measurements and main results: The CSA on both sides differed by up to 850%. There were no statistically significant differences between CSA of IJVs in men and women. The CSA of the IJV on the right side was significantly greater than on the left side. The right IJV was more often classified as the “dominant” vessel (CSA being more than twice as large as the opposite side). A “small” vessel (CSA ≤ 0.4 cm2) was found in 54 cases (14.6%). In 9 subjects (4.9%), they were detected bilaterally. Conclusion: The CSA of IJVs varies widely. Although the CSA was found to be often greater on the right than on the left side, a “small” vessel may occur on both sides. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Internal jugular vein (IJV) catheterization is an essential and commonly performed procedure in the management of critically ill patients. It allows for invasive hemodynamic ⁎ Corresponding author at: Department of Diagnostic Imaging, The Medical University of Bialystok Children's Clinical Hospital of L. Zamenhof, ul. Waszyngtona 17, 15-274 Bialystok, Poland. Tel.: +48 857450626; fax: +48 857421838. E-mail address: [email protected] (D. Czyzewska). http://dx.doi.org/10.1016/j.jclinane.2014.09.010 0952-8180/© 2014 Elsevier Inc. All rights reserved.
monitoring with pulmonary artery catheter, total parenteral nutrition, drug delivery, temporary cardiac pacing, venous blood sampling, and renal replacement therapy. However, procedure failure and complications after catheter placement are not rare [1,2]. These may be the result of the small crosssectional area (CSA) of IJVs, which are difficult, sometimes even impossible to palpate transcutaneously and insert a catheter. Small vessels are also more prone to endothelial damage during cannulation and to the following thrombosis than large ones [3]. Unfortunately, there is a shortage of data about morphologic parameters of IJVs in healthy subjects.
130
D. Czyzewska et al.
The aim of the study was to evaluate the CSA of IJVs in healthy subjects.
Table Cross-sectional area of the left and right internal jugular vein in men and women a
2. Materials and methods The examined group consisted of 185 healthy White subjects: 101 women and 84 men, aged 18-89 years (mean 46.2 ± 20.9). Subjects for the study were volunteers recruited from students of the medical center, hospital staff, and their relatives. The study was approved by the Commission of Bioethics at Bialystok Medical University, and each subject gave informed consent. All ultrasonography examinations were performed in gray-scale by radiologist with 6 years' experience in ultrasonography (DC) using Toshiba Aplio XG (Tokyo, Japan) machine equipped with a linear 14-MHz transducer. Examinations were performed in the supine position at the level of the cricoid cartilage with a neutral position of the head (no rotation) during a short period of apnea. The landmark for identification of the IJV was the common carotid artery. The CSA of the IJVs on both sides was measured automatically after manual tracing of the vessel on a frozen image (Fig. 1). The vessel which CSA was more than twice that of the opposite side was taken as the “dominant” vessel. Vessels with a CSA ≤ 0.4 cm2 were considered as “small.” Special attention was taken to avoid compression or displacement of the examined vessels.
Left IJV area 0 Right IJV a area 0
Sex Minimum Q1
Median Q3
Maximum
F M F M
0.85 0.94 0.90 1.03
0.00 2.50 0.00 4.02
0.17 0.00 0.13 0.10
0.55 0.61 0.55 0.64
1.13 1.43 1.33 1.59
Abbreviation: Q, quartile. a Internal jugular vein.
3. Results The CSA of the IJVs varied widely in the entire examined group as well as in the separate sexes (Table). There were no statistically significant differences between sex groups. The CSA of the IJV on the right side was significantly greater than on the left side. The IJV on the right side was also more often classified as the “dominant” vessel (n = 36; 54%) compared with the left side (n = 31; 46%). The asymmetry between vessels on both sides differed by up to 850% when comparing right-to-left side and vice versa. “Small” vessels (CSA ≤ 0.4 cm2) were detected in 54 of 370 cases (14.6%): on the left side, 24 cases (6.5%) and on the right side, 30 cases (8.1%). In 9 subjects (4.9%), “small” IJVs were noted on both sides. In 1 of these subjects the CSA was 0 cm2 on the left side and only 0.34 cm2 on the opposite side.
2.1. Statistical analysis Nonparametric tests were used (Mann-Whitney U test and Wilcoxon pairs test) due to the variables not being distributed normally according to the Shapiro-Wilk test. The values of the variables are presented as median, first, and third quartiles. A P value of b .05 was considered as statistically significant. Statistical analysis was performed using SPSS software (Chicago, IL).
Fig. 1
Identification of the left internal jugular vein.
4. Discussion The CSA of IJVs in healthy subjects in the supine position is significantly greater on the right side than on the left, with the right being more often “dominant.” Similar trends were found by other authors. Lobato et al [4] reported greater CSAs of right IJVs in 80% and significantly smaller CSAs (defined as a CSA b 50% compared with the opposite vessel) of left IJVs in 34% of healthy subjects. Lichtenstein et al [5] also found that right IJVs were more commonly “dominant” than left IJVs in a group of intensive care unit (ICU) patients. This resulted in a higher frequency of right IJV catheterization and an increased risk of complications, when the left IJV was chosen for cannulation [6]. Nevertheless, “small” vessels (CSA ≤ 0.4 cm2) are not uncommon. Fifteen percent of IJVs were classified as “small” vessels in this study. In approximately 5% of healthy subjects, they were noted on both sides. Lichtenstein et al [5] found them in 23% of vessels in ICU patients. A possible explanation for the higher frequency of “small” IJVs in the ICU population compared with healthy subjects could have been attributed to hypovolemia, which is a frequent situation during admission to an ICU. A small CSA of IJV may account for difficulties during insertion of a catheter. Mey et al [7] [7] reported catheterization failure in 14.9% and complications in 8.5% of patients with IJV diameter b 7 mm
Jugular veins must be measured before catheterization
131 Because jugular veins have relatively much thinner wall than their accompanying arteries, they are susceptible to pressure. Therefore, their CSA may vary due to changes in the intrathoracic pressure as well as head and neck rotation or even slight compression of the ultrasonographic transducer during the examination. Repeated measurements of CSA would probably demonstrate high interobserver/intraobserver variability. In case of detecting “small” IJVs, measurements should be performed in Trendelenburg position and/or during the Valsalva maneuver; and when both IJVs are still small, other (sublcavian and femoral) access should be considered. However, results of other studies show that because of the size and relatively small ratio of complications, IJVs should be considered as the primary route for catheter insertion [3,8].
Fig. 2 Cross-sectional area of “small” vessel (black circle) in relation to 7F and 12F catheters.
and failure of 3.9% and complication rate of 3.8% in patients with IJV diameter N 7-10 mm. Relations between the CSA of a “small” vessel (b 0.4 cm2) and the size of commonly used central venous catheter (7F) and dual-lumen dialysis catherer (12F) are presented on Fig. 2. The diameter and CSA of IJVs may be affected by dynamic maneuvers such as the Valsalva maneuver or position of the body such as the Trendelenburg position. Lobato et al [4] reported an increase of the CSA of the IJVs of approximately 55% during the Valsalva maneuver and 35% in the Trendelenburg position. However, the increase of the CSA does not correspond with a significant increase of the vascular diameter, especially in case of “small” vessels. When considering the CSA of IJVs to be a circle and the area of the circle being equal to πr2, the mentioned above increase of the CSA would result in b 1.8 mm increase of the diameter of a “small” vessel.
References [1] Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization, failure and complications rates by three percutaneous approaches. Arch Intern Med 1986;146:259-61. [2] Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev 2007;3:CD004084. http:// dx.doi.org/10.1002/14651858.CD004084.pub2. [3] Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000;217(1):89-93. [4] Lobato EB, Sulek CA, Moody RL, Morey TE. Cross-sectional area of the right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999;13:136-8. [5] Lichtenstein D, Saifi R, Augarde R, Prin S, Schmitt JM, Page B, Pipien I, Jardin F. The internal jugular veins are asymmetric. Usefulness of ultrasound before catheterization. Intensive Care Med 2001;27:301-5. [6] Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth 2000;12:142-5. [7] Mey U, Glasmacher A, Hahn C, Gorschlüter M, Ziske C, Mergelsberg M, Sauerbruch T, Schmidt-Wolf IG. Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients. Support Care Cancer 2003;11:148-55. [8] Breschan C, Platzer M, Jost R, Stettner H, Likar R. Size of internal jugular vs subclavian vein in small infants: an observational, anatomical evaluation with ultrasound. Br J Anaesth 2010;105(2):179-84.
Original Contribution
Internal jugular veins must be measured before catheterization Dorota Czyzewska MD (Resident)a,⁎, Andrzej Ustymowicz MD, PhD (Associate Professor)b , Juliusz Kosel MD, PhD (Assistant Professor)c a
Department of Radiology, Medical University of Bialystok Children's Clinical Hospital, Bialystok, Poland Department of Radiology, Medical University of Bialystok, Bialystok, Poland c Department of Anesthesiology and Intensive Therapy, Medical University of Bialystok, Bialystok, Poland b
Received 4 October 2013; revised 1 September 2014; accepted 10 September 2014
Keywords: Cannulation; Internal jugular vein; Ultrasound
Abstract Study objective: The study objective is to determine the cross-sectional area (CSA) of the right and left internal jugular vein (IJV) in supine position in healthy subjects. Design: This is a prospective, nonrandomized study. Setting: The setting is a university hospital. Patients: The patients are 185 consenting healthy subjects. Interventions: B-mode ultrasonography examinations of the right and left IJV were performed with the use of a linear 14-MHz transducer at the level of the cricoid cartilage. The CSA of the examined vessels was measured in a supine position. Measurements and main results: The CSA on both sides differed by up to 850%. There were no statistically significant differences between CSA of IJVs in men and women. The CSA of the IJV on the right side was significantly greater than on the left side. The right IJV was more often classified as the “dominant” vessel (CSA being more than twice as large as the opposite side). A “small” vessel (CSA ≤ 0.4 cm2) was found in 54 cases (14.6%). In 9 subjects (4.9%), they were detected bilaterally. Conclusion: The CSA of IJVs varies widely. Although the CSA was found to be often greater on the right than on the left side, a “small” vessel may occur on both sides. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Internal jugular vein (IJV) catheterization is an essential and commonly performed procedure in the management of critically ill patients. It allows for invasive hemodynamic ⁎ Corresponding author at: Department of Diagnostic Imaging, The Medical University of Bialystok Children's Clinical Hospital of L. Zamenhof, ul. Waszyngtona 17, 15-274 Bialystok, Poland. Tel.: +48 857450626; fax: +48 857421838. E-mail address: [email protected] (D. Czyzewska). http://dx.doi.org/10.1016/j.jclinane.2014.09.010 0952-8180/© 2014 Elsevier Inc. All rights reserved.
monitoring with pulmonary artery catheter, total parenteral nutrition, drug delivery, temporary cardiac pacing, venous blood sampling, and renal replacement therapy. However, procedure failure and complications after catheter placement are not rare [1,2]. These may be the result of the small crosssectional area (CSA) of IJVs, which are difficult, sometimes even impossible to palpate transcutaneously and insert a catheter. Small vessels are also more prone to endothelial damage during cannulation and to the following thrombosis than large ones [3]. Unfortunately, there is a shortage of data about morphologic parameters of IJVs in healthy subjects.
130
D. Czyzewska et al.
The aim of the study was to evaluate the CSA of IJVs in healthy subjects.
Table Cross-sectional area of the left and right internal jugular vein in men and women a
2. Materials and methods The examined group consisted of 185 healthy White subjects: 101 women and 84 men, aged 18-89 years (mean 46.2 ± 20.9). Subjects for the study were volunteers recruited from students of the medical center, hospital staff, and their relatives. The study was approved by the Commission of Bioethics at Bialystok Medical University, and each subject gave informed consent. All ultrasonography examinations were performed in gray-scale by radiologist with 6 years' experience in ultrasonography (DC) using Toshiba Aplio XG (Tokyo, Japan) machine equipped with a linear 14-MHz transducer. Examinations were performed in the supine position at the level of the cricoid cartilage with a neutral position of the head (no rotation) during a short period of apnea. The landmark for identification of the IJV was the common carotid artery. The CSA of the IJVs on both sides was measured automatically after manual tracing of the vessel on a frozen image (Fig. 1). The vessel which CSA was more than twice that of the opposite side was taken as the “dominant” vessel. Vessels with a CSA ≤ 0.4 cm2 were considered as “small.” Special attention was taken to avoid compression or displacement of the examined vessels.
Left IJV area 0 Right IJV a area 0
Sex Minimum Q1
Median Q3
Maximum
F M F M
0.85 0.94 0.90 1.03
0.00 2.50 0.00 4.02
0.17 0.00 0.13 0.10
0.55 0.61 0.55 0.64
1.13 1.43 1.33 1.59
Abbreviation: Q, quartile. a Internal jugular vein.
3. Results The CSA of the IJVs varied widely in the entire examined group as well as in the separate sexes (Table). There were no statistically significant differences between sex groups. The CSA of the IJV on the right side was significantly greater than on the left side. The IJV on the right side was also more often classified as the “dominant” vessel (n = 36; 54%) compared with the left side (n = 31; 46%). The asymmetry between vessels on both sides differed by up to 850% when comparing right-to-left side and vice versa. “Small” vessels (CSA ≤ 0.4 cm2) were detected in 54 of 370 cases (14.6%): on the left side, 24 cases (6.5%) and on the right side, 30 cases (8.1%). In 9 subjects (4.9%), “small” IJVs were noted on both sides. In 1 of these subjects the CSA was 0 cm2 on the left side and only 0.34 cm2 on the opposite side.
2.1. Statistical analysis Nonparametric tests were used (Mann-Whitney U test and Wilcoxon pairs test) due to the variables not being distributed normally according to the Shapiro-Wilk test. The values of the variables are presented as median, first, and third quartiles. A P value of b .05 was considered as statistically significant. Statistical analysis was performed using SPSS software (Chicago, IL).
Fig. 1
Identification of the left internal jugular vein.
4. Discussion The CSA of IJVs in healthy subjects in the supine position is significantly greater on the right side than on the left, with the right being more often “dominant.” Similar trends were found by other authors. Lobato et al [4] reported greater CSAs of right IJVs in 80% and significantly smaller CSAs (defined as a CSA b 50% compared with the opposite vessel) of left IJVs in 34% of healthy subjects. Lichtenstein et al [5] also found that right IJVs were more commonly “dominant” than left IJVs in a group of intensive care unit (ICU) patients. This resulted in a higher frequency of right IJV catheterization and an increased risk of complications, when the left IJV was chosen for cannulation [6]. Nevertheless, “small” vessels (CSA ≤ 0.4 cm2) are not uncommon. Fifteen percent of IJVs were classified as “small” vessels in this study. In approximately 5% of healthy subjects, they were noted on both sides. Lichtenstein et al [5] found them in 23% of vessels in ICU patients. A possible explanation for the higher frequency of “small” IJVs in the ICU population compared with healthy subjects could have been attributed to hypovolemia, which is a frequent situation during admission to an ICU. A small CSA of IJV may account for difficulties during insertion of a catheter. Mey et al [7] [7] reported catheterization failure in 14.9% and complications in 8.5% of patients with IJV diameter b 7 mm
Jugular veins must be measured before catheterization
131 Because jugular veins have relatively much thinner wall than their accompanying arteries, they are susceptible to pressure. Therefore, their CSA may vary due to changes in the intrathoracic pressure as well as head and neck rotation or even slight compression of the ultrasonographic transducer during the examination. Repeated measurements of CSA would probably demonstrate high interobserver/intraobserver variability. In case of detecting “small” IJVs, measurements should be performed in Trendelenburg position and/or during the Valsalva maneuver; and when both IJVs are still small, other (sublcavian and femoral) access should be considered. However, results of other studies show that because of the size and relatively small ratio of complications, IJVs should be considered as the primary route for catheter insertion [3,8].
Fig. 2 Cross-sectional area of “small” vessel (black circle) in relation to 7F and 12F catheters.
and failure of 3.9% and complication rate of 3.8% in patients with IJV diameter N 7-10 mm. Relations between the CSA of a “small” vessel (b 0.4 cm2) and the size of commonly used central venous catheter (7F) and dual-lumen dialysis catherer (12F) are presented on Fig. 2. The diameter and CSA of IJVs may be affected by dynamic maneuvers such as the Valsalva maneuver or position of the body such as the Trendelenburg position. Lobato et al [4] reported an increase of the CSA of the IJVs of approximately 55% during the Valsalva maneuver and 35% in the Trendelenburg position. However, the increase of the CSA does not correspond with a significant increase of the vascular diameter, especially in case of “small” vessels. When considering the CSA of IJVs to be a circle and the area of the circle being equal to πr2, the mentioned above increase of the CSA would result in b 1.8 mm increase of the diameter of a “small” vessel.
References [1] Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization, failure and complications rates by three percutaneous approaches. Arch Intern Med 1986;146:259-61. [2] Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev 2007;3:CD004084. http:// dx.doi.org/10.1002/14651858.CD004084.pub2. [3] Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000;217(1):89-93. [4] Lobato EB, Sulek CA, Moody RL, Morey TE. Cross-sectional area of the right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999;13:136-8. [5] Lichtenstein D, Saifi R, Augarde R, Prin S, Schmitt JM, Page B, Pipien I, Jardin F. The internal jugular veins are asymmetric. Usefulness of ultrasound before catheterization. Intensive Care Med 2001;27:301-5. [6] Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth 2000;12:142-5. [7] Mey U, Glasmacher A, Hahn C, Gorschlüter M, Ziske C, Mergelsberg M, Sauerbruch T, Schmidt-Wolf IG. Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients. Support Care Cancer 2003;11:148-55. [8] Breschan C, Platzer M, Jost R, Stettner H, Likar R. Size of internal jugular vs subclavian vein in small infants: an observational, anatomical evaluation with ultrasound. Br J Anaesth 2010;105(2):179-84.
