The anatomic relationship between the internal jugular vein and the carotid artery in children after laryngeal mask insertion. An ultrasonographic study

Ultrasonographic Assessment of Anatomic Relationship Between the Internal Jugular Vein and the Common Carotid Artery in Infants and Children After ETT or LMA Insertion: A Prospective Observational Study

Background: Central venous catheterization is used for fluid management and infusion of drugs, but it is difficult to perform and carries a high incidence of complications in infants and children. In adults, the anatomic relationship and the overlap index between the internal jugular vein (IJV) and the common carotid artery (CCA) changed significantly after laryngeal mask airway (LMA) placement. However, there are conflicting results regarding the anatomic relationship between the IJV and the CCA after endotracheal tube (ETT) or LMA insertion in pediatric populations. Aim: The aim of this study was to compare the overlap index and anatomic relationship between the IJV and the CCA in infants and children after ETT or LMA insertion by ultrasonography. Method: This single-center, prospective, observational study including 92 infants and children, aged 1 month to 6 years, were grouped according to the airway devices placed: Group ETT (n = 44) and Group LMA (n = 48). The overlap index and anatomic relationship between the IJV and the CCA before and after airway device insertion at neutral and 30° head rotation position were evaluated by ultrasonography. Results: Before airway device insertion, as the head was rotated 30° to the contralateral side, the overlap index increased significantly on the right side of the neck compared to the neutral head position. In Group ETT, there was no significant difference in the overlap index after intubation in the neutral head position or 30° head rotated position on either side. In Group LMA, the overlap indexes were increased significantly after LMA insertion in the neutral head position on both sides. Likewise, the overlap indexes were increased significantly after LMA insertion in the 30° head rotated position on both sides. The most common positional relationship between the IJV and the CCA was anterolateral (AL) in both the right side and left side in the neutral head position. In Group ETT, the AL position was still the most common position relationship between the IJV and the CCA before and after intubation in the 30° head rotated position. In Group LMA, the anterior (A) position increased significantly after LMA insertion in the left side. In the 30° head rotated position, there was a significant increase to the A position after LMA insertion in both the right side and left side. The change from AL to A was increased after LMA insertion, especially in the 30° head rotated position. Conclusions: The overlap indexes of the IJV and the CCA increased significantly in both sides of the neck after LMA placement in the neutral head position, especially in 30° head rotated position. The IJVs after LMA placement had a tendency to become anterior to the CCA when the head of the patient rotated to the opposite direction in infants and children.

The airway device preference may affect the overlapping of the common carotid artery by the internal jugular vein

BACKGROUND

Anatomical variation in the internal jugular vein (IJV), as well as its small size, tendency to collapse, and proximity to the common carotid artery (CCA) makes central venous cannulation via the IJV a technically challenging procedure, especially in pediatric patients.

AIM

We evaluated the effects of laryngeal mask airway insertion and endotracheal intubation (ETT) on the anatomical relationship between the IJV and the CCA in neutral and 40° head away positions.

METHOD

After parental consent 92 patients with ASA physical status I-II, aged 0-17, undergoing elective urological surgery were enrolled and divided into two groups according to the airway management device used for anesthesia: Group laryngeal mask airway (n = 63) and Group ETT (n = 29). An ultrasonographic evaluation was performed before and after airway instrumentation at neutral and 40° head rotation. The IJV position in relation to the CCA was noted, and the overlap percentage of the CCA was calculated as the ratio of the CCA length covering by the internal jugular vein to the transverse diameter of the CCA.

RESULTS

With no airway device insertion, the position of the IJV was found to be anterolateral to the CCA in the majority of patients (48.8% vs 35.3%, right vs left IJV) in the neutral head position. While there was no significant change in the overlap percentages of the CCA after laryngeal mask airway insertion in the neutral head position [48.71% vs 57.30% for the right IJV (difference in median: -21.20; 95% confidence interval (CI) of difference: -56.92 to 14.52; P = 0.133); 52.54% vs 60.36% for the left IJV (difference in median: -10.3; 95% CI of difference: -41.49 to 20.89; P = 0.128)], it increased significantly in the 40° head away position on both sides [50.11% vs 64.83% for the right IJV (difference in median: -55; 95% CI of difference: -84 to -25.24; P = 0.01); 53.82% vs 71.20% for the left IJV (difference in median: -46; 95% CI of difference: -86.85 to -5.15; P = 0.004)]. However, the overlap percentages of CCA decreased significantly on the right side with patients in a neutral head position (31.23% vs 6.27%, difference in median: 19; 95% CI of difference: -5.68 to 43.68; P = 0.002) and on both sides in the 40° head away position [29.50% vs 16.19%, difference in median: 26; 95% CI of difference: 2.84 to 49.16; P = 0.03 and 47% vs 31.94%, difference in median: 9.50; 95% CI of difference: -40.87 to 59.87; P = 0.03 for the right and left sides, respectively] after ETT insertion.

CONCLUSIONS

Laryngeal mask airway with 40° head rotation increases, whereas ETT decreases, the overlap percentage of CCA by IJV. Both head position and airway management methods have an influence on the overlap of the CCA by the IJV in pediatric patients.

Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine

Supraglottic airway devices are routinely used for airway maintenance in elective surgical procedures where aspiration is not a significant risk and also as rescue devices in difficult airway management. Some devices now have features mitigating risk of aspiration, such as drain tubes or compartments to manage regurgitated content. Despite this, the use of these device may be associated with various complications including aspiration. This review highlights the types and incidence of these complications. They include regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury. The incidence of such complications is quite low, but as some carry with them a significant degree of morbidity the need to follow manufacturers' advice is underlined. The incidence of gastric content aspiration associated with the devices is estimated to be as low as 0.02% with perioperative regurgitation being significantly higher but underreported. Other serious, but extremely rare, complications include pharyngeal rupture, pneumomediastinum, mediastinitis, or arytenoid dislocation. Mild short-lasting adverse effects of the devices have significantly higher incidence than serious complications and involve postoperative sore throat, dysphagia, pain on swallowing, or hoarseness. Devices may have deleterious effect on cervical mucosa or vasculature depending on their cuff volume and pressure.

Laryngeal mask airway may result in false negative imaging for carotid medialization: A case report

Chromosome 22q11.2 microdeletions result in multiple congenital abnormalities, including an increased risk of carotid medialization, which is an important consideration for preoperative planning in children with velopharyngeal insufficiency. Preoperative imaging of the neck vasculature is recommended. Here we describe a case in which a child had negative imaging studies despite the presence of a medialized carotid artery on physical examination, likely secondary to the supraglottic airway use during sedated imaging, which displaced the carotid laterally. The type of airway used should be a consideration for children undergoing sedated imaging prior to pharyngeal procedures.

Displacement of the common carotid artery after laryngeal mask airway placement in infants and children

BACKGROUND

In adults, placement of the laryngeal mask airway causes increased overlapping of the internal jugular vein (IJV) and common carotid artery (CCA). However, few studies in children have been reported. The aim of this study was to describe the degree of overlap of the IJV and the CCA before and after laryngeal mask airway placement in infants and children.

METHOD

There were 160 children scheduled to undergo Protex(®) SoftSeal(®) and Ambu(®) placement. Patients were initially positioned in the 15° Trendelenburg position with their heads rotated 30° to the left. The ultrasound probe was placed perpendicular to the skin, and the images of the right IJV and CCA were collected at the level of the cricoid cartilage. Following laryngeal mask airway placement, images were collected in the same manner.

RESULTS

No statistically significant changes were observed in the overlap index before and after laryngeal mask airway placement. By inflating the laryngeal mask airway cuff, migration of the vessel forward was 24.38% and outward migration was 13.99%.

CONCLUSION

There was no remarkable change in the overlap index before and after laryngeal mask airway placement in children.