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PEDIATRIC ANESTHESIA

Right Internal Jugular Vein Venography in Infants and Children

Shin Nakayama, MD, Masao Yamashita, MD, Yoshiko Osaka, MD, Takeshi Isobe, MD^*, and Hiroyuki Izumi

Department of Anesthesiology, *Department of Pediatrics, and Department of Radiology, Ibaraki Children’s Hospital, Mito, Japan

Address correspondence and reprint requests to M. Yamashita, MD, Department of Anesthesiology, Ibaraki Children’s Hospital, 3-3-1, Futaba-dai, Mito, 311-4145, Japan. Address e-mail to myamashita{at}med.email.ne.jp

	Abstract

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We obtained venograms of the right internal jugular vein (RIJV) in 105 infants and children with congenital heart disease during cardiac catheterization. No major anomalies were found in the course of the RIJV. The diameter of the RIJV tended to increase with the patient’s age, weight, and height. However, some disproportionately small vessels were seen in 8% of the patients. The depth from the skin to the RIJV varied from 2.5 to 20 mm and did not significantly correlate with age, weight, or height. Confirmation of the diameter or the depth of the RIJV by venography may facilitate clinical decisions and may be useful for performing percutaneous cannulation.

IMPLICATIONS: We obtained venograms of the right internal jugular vein in children with congenital heart disease. Generally, the diameter increased with the patient’s body size, but disproportionately small vessels were seen in 8% of the patients. Preoperative internal jugular venography may facilitate identifying those patients.

	Introduction

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The right internal jugular vein (RIJV) is a useful site for monitoring and drug therapy in pediatric cardiovascular anesthesia (1–4); however, the cannulation technique is more difficult in infants than in adults (5). Two investigations have shown that ultrasonography provides useful information of IJV dimensions (6,7). However, RIJV anatomy has not been fully evaluated. Therefore, we sought to obtain more anatomic information about the RIJV by venography.

	Methods

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After institutional approval and informed parental consent, 105 pediatric patients scheduled for cardiac catheterization were studied. Those patients who had previous RIJV cannulation were excluded. Patients with a stable cardiovascular condition were anesthetized IV with ketamine and midazolam under spontaneous respiration. Neonates or patients with an unstable cardiovascular condition were ventilated with an orotracheal tube under nitrous oxide, oxygen, and sevoflurane anesthesia. The patient was placed in the horizontal position with a rolled towel placed under the shoulders to extend the neck. The head was placed in the midline position. Skin markers were placed directly above the RIJV at the level of cricoid cartilage ("high approach") and at the level of supraclavicular notch ("low approach") under fluoroscopic guidance. After their cardiac catheterization procedure was completed, an angiographic catheter was advanced into the RIJV from the femoral vein and venography was obtained using 0.3 mL/kg of iohexol. The depth from the skin marker to the vein at a right angle and the diameter of the vein were measured on the film.

Data are presented as mean ± SD. A simple regression was calculated to determine the lines best fit. Statistical comparisons between the two measured sites (high and low approach) were analyzed using paired Student’s t-test. P < 0.05 was considered to be significant.

	Results

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One-hundred-five patients ranging in age from 7 days to 10 yr weighing from 2.4 to 23.5 kg were studied (Table 1). No major anomalies of the course of the RIJV were found. The diameter of the RIJV at both levels tended to increase with the patient’s age, weight, and height (Fig. 1). Each regression equation is presented in Table 2. Small diameters of the RIJV (5 mm) were mainly seen in infants whose body weight was <5kg (73%: 19/26) and in all infants whose height was <50 cm (100%: 8/8). However, some disproportionately small vessels (defined as 3 mm for neonates and infants and 5 mm for older children) were seen in 8 patients (8%) and 3 patients had persistent left superior vena cava.

View larger version (21K): [in this window] [in a new window]   Figure 1. Correlation of the diameter of the right internal jugular vein (RIJV) at cricoid cartilage level to age, weight, and height. The solid line is obtained by analysis of linear regression. The dotted lines show 95% confidence interval for the mean.

The depth from the skin to the RIJV varied from 2.5 to 20 mm and did not significantly correlate with age, weight, or height (Fig. 2). The depths from the skin to RIJV were consistently greater at the supraclavicular level (14.0 ± 4.3 mm) compared with those at the cricoid cartilage level (10.7 ± 3.3 mm) (P < 0.001).

View larger version (22K): [in this window] [in a new window]   Figure 2. Correlation of the depth of the right internal jugular vein (RIJV) at cricoid cartilage level to age, weight, and height. The solid line is obtained by analysis of linear regression. The dotted lines show 95% confidence interval for the mean.

	Discussion

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The diameter generally increased with the patient’s age, weight, and height, similar to findings in a previous report (9). Disproportionately small RIJVs were found in 8% of our patients. Alderson et al. (6) reported that unusually small veins were seen in 4% of their patients. Denys and Uretsky (10) also reported in their adult series that unusually small veins (5 mm) were seen in 3% and that inability to visualize the IJV by ultrasound was observed in 2% of their patients. In our patients, RIJVs were all patent but unusually small veins were seen; these were not related to patient’s type of cardiac anomalies. The incidence of persistent left superior vena cava ranges from 0.3% in healthy individuals to 4.3% in patients with congenital heart disease (11,12). In this study, its incidence was 8%, but we did not perform left IJV. Therefore, our result is insufficient to clarify the relationship between the presence of persistent left superior vena cava and the unusually small RIJV.

The depth from the skin to the RIJV was not proportional to patient’s age, weight, or height. The vein can be reached within 20 mm at the cricoid cartilage level even in larger children (23.5 kg in our series).

Rao et al. (13) recommended the low approach because of its easily identifiable landmark (clavicle notch). Latson et al. (14) demonstrated that the low approach took a much shorter cannulation time because in this area the veins are relatively fixed in position and the jugular vein is more widely separated from the carotid artery than in the neck. Coté et al. (8) showed that cannulation by the high approach was more frequently associated with arterial puncture than by the low approach. However, they did not recommend the low approach because of the possibility of serious complications, such as pneumothorax and intrapulmonary hemorrhage. There are no reports that describe the diameter of the RIJV at each level. Our venograms showed that the diameter at the level of the high approach was slightly wider than that of the low approach. Coté et al. (8) also demonstrated that the distance from skin to the RIJV was greater with the low approach compared with the high approach. Our study confirms their results.

There are several limitations in our study. First, we could not obtain our venograms at a particular phase of the respiratory cycle. Also, the distal portion of the RIJV might have expanded somewhat because the contrast medium was flushed into this area.

In conclusion, we have demonstrated some anatomical information about the RIJV in children with congenital heart disease. Further studies examining the RIJV anatomy after previous cannulation may be useful.

We obtained venograms of the right internal jugular vein in infants and children with congenital heart disease. These venograms show anatomical information about the internal jugular vein and may be useful for performing percutaneous cannulation.

	References

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