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LETTER TO THE EDITOR

Unexpected Internal Jugular Vein Obstruction Revealed by Ultrasound Surface Scan Before Central Venous Catheter Insertion

Department of Anesthesiology and Critical Care Medicine; Asahikawa Medical College; Hokkaido, Japan; masuikasuzuki{at}yahoo.co.jp

To the Editor:

Although the use of ultrasound (screening technique and/or real-time use) to assist central venous catheter insertion is known to reduce the incidence of complications, a recent study revealed that only a limited number of anesthesiologists use this tool.1 We routinely perform ultrasound scan of central vessel anatomy before attempting central venous cannulation following a case of unexpected internal jugular vein (IJV) obstruction.

An 85-yr-old woman was scheduled for gastrojejunal bypass surgery. While demonstrating the technique for using ultrasound to assist central venous cannulation, the anesthesiologist noted a large thrombus in the right IJV (Fig. 1). The left IJV was intact, and the catheter was inserted via left IJV. A postoperative interview revealed that the patient had a history of previous catheter insertion via the right subclavian vein, but not via right IJV in the past.

View larger version (38K): [in this window] [in a new window]   Figure 1. Two dimensional ultrasound images and internal jugular vein (IJV). Left: short-axis view of the obstructed IJV. A huge thrombus with crack occupied in the IJV was observed. Right: long-axis view with power flow image. A small blood flow was detected inside the IJV. IJV = internal jugular vein; CA = carotid artery. Aloka Prosound SSD 4000SV (Aloka Tokyo, Japan) with 7.5 MHz linear probe was used.

In this case, catheterizing the IJV using only surface anatomy as the guide for catheter insertion, might have resulted in a pulmonary embolism if the intraluminal thrombus had been disrupted by the needle and or the catheter. While experienced operators using surface anatomic landmarks alone can achieve a relatively high success rate with few complications, our department now requires all anesthesiologist to "look" with ultrasound before attempting central venous cannulation. This seems especially important in children and other high risk situations such as patients with a coagulopathy.

REFERENCE

1. Bailey PL, Glance LG, Eaton MP, Parshall B, McIntosh S. A survey of the use of ultrasound during central venous catheterization. Anesth Analg 2007;104:491–7[Abstract/Free Full Text]

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