Anatomic variations of neck vessels and the course of pediatric internal jugular veins

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.

[Central Venous Access in Children: Technique and Complications]

Children with complex diseases often need central venous catheter, not only for intraoperative use, but also for parenteral nutrition, multiple blood draw due to lab examination and to administer drugs that cannot be given via peripheral lines. Whereas the landmark driven vascular access was teached for years, nowadays the routine use of ultrasound based techniques can be called the gold standard. This article highlights standard locations for central venous access like cannulation of the internal jugular vein as well as novel alternatives such as the cannulation of the brachiocephalic vein. The correct insertion depth of central lines is essential to avoid serious complications. Several different formulas are available and can be used. Independent of the used formula, you have to make sure that complications due to incorrect depth of central venous line are a topic of the past. Finally, important tips and tricks to avoid failure and serious complications are discussed.

Ultrasound-guided anatomical evaluation of right internal jugular vein in children aged 0-2 years: A prospective observational study

BACKGROUND

The right internal jugular vein is commonly preferred for central venous cannulation, and ultrasonographic assessment and guidance is the recommended technique for this procedure. Despite the safety and reliability of this technique, it requires specific training and experience as well as thorough knowledge of anatomy.

AIM

The position of the right internal jugular vein with respect to carotid artery and its transverse diameter free from overlap with the carotid artery were evaluated using ultrasound in patients aged 0-2 years.

METHODS

This single-center, prospective, observational study included patients aged 0-2 years who underwent elective surgery between July 2018 and July 2019. The diameters and anatomical position were evaluated using ultrasound. All parameters were compared between groups classified according to postmenstrual ages. The correlations of these parameters with weight and postmenstrual ages were analyzed.

RESULTS

A total of 156 patients were included. The diameters (P < .001) and depth (P = .012) were smaller in patients with postmenstrual age <45 weeks. The anteroposterior diameter was significantly correlated with weight in patients with postmenstrual age <45 weeks, but not in older patients. Right internal jugular vein was lateral and anterolateral with respect to carotid artery in 51.3% and 42.9% of patients, respectively, and >80% of the transverse diameter was free from overlap with the carotid artery.

CONCLUSION

Our results support the current data for the high anatomical variability of the right internal jugular vein, highlighting the recommendation of the Rapid Central Vein Assessment (RaCeVA) protocol prior to and ultrasound guidance during catheterization of central veins.

The surface projection line of internal jugular vein to guide the internal jugular vein catheterization

This study describes the use of a surface projection line of internal jugular vein to guide the internal jugular vein catheterization. The results in the study suggest that the internal jugular vein line has the similar effect on the internal jugular vein catheterization to real-time ultrasound guide. It may be an alternative choice for the unskilled ultrasound operators, and it can be quite useful in some developing countries and areas.