JOURNAL HOME CME HOME THIS MONTH PAST ISSUES ETOC COLLECTIONS
AUTHORS REVIEWERS EDITORIAL BOARD FEEDBACK RSS HELP
A&A International Anesthesia Research Society
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a colleague
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (12)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Verghese, S. T.
Right arrow Articles by Patel, K. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Verghese, S. T.
Right arrow Articles by Patel, K. M.
Related Collections
Right arrow Monitoring (Cardiac)
Right arrow Pediatrics
Anesth Analg 2002;94:250-254
© 2002 International Anesthesia Research Society

PEDIATRIC ANESTHESIA

The Effects of the Simulated Valsalva Maneuver, Liver Compression, and/or Trendelenburg Position on the Cross-Sectional Area of the Internal Jugular Vein in Infants and Young Children

Susan T. Verghese, MD, Ajay Nath, MD, David Zenger, MD, Ramesh I. Patel, MD, Richard F. Kaplan, MD, and Kantilal M. Patel, PhD

Department of Anesthesiology, Children’s National Medical Center and George Washington University Medical Center, Washington, DC

Address correspondence and reprint requests to Susan T. Verghese, MD, Department of Anesthesiology, Children’s National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010. Address e-mail to sverghes{at}cnmc.org


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
We calculated the effects of the simulated Valsalva (V), liver (L) compression, and Trendelenburg (T) position on the cross-sectional area (CSA) of the right internal jugular vein by using planimetry (Aloka® ultrasound machine) in 84 infants and young children. Eight combinations of positions and interventions were studied for each patient, with the patient supine, in the T position, during the simulated V maneuver, with L compression and a combination of maneuvers. Data were analyzed by using Friedman’s {chi}2 test and Wilcoxon’s signed rank test. An increase of >25% in the CSA of the internal jugular vein was considered significant. In infants, the maximal mean increase achieved with the combination of all 3 maneuvers was only 17.4% ± 16.1%. As a single maneuver, the simulated V was the most effective (11.6% ± 11.5%). In children, the combination of all 3 maneuvers performed simultaneously produced a mean 65.9% (SD ± 44.7%) increase in the CSA, which was larger than the increase by all other maneuvers alone or in a single combination (Friedman’s test, P < 0.001 and Wilcoxon’s test, P < 0.002). As a single maneuver, V produced the most increase (40.4% ± 32.2%) compared with L compression (14.3% ± 18.9%) or T position (24.3% ± 27.1%).

IMPLICATIONS: The combinations of simulated Valsalva, liver compression, and Trendelenburg maneuvers produce the maximal mean increase in the size of the internal jugular vein in infants and young children, with the Valsalva maneuver being the most effective single maneuver. This increase is significant in young children, but negligible in infants.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Technically, internal jugular vein (IJV) cannulation is more difficult in infants and children than in adults (1). The smaller target vessel, the variable position of the IJV with respect to the carotid artery, and its close proximity to the carotid artery are some of the reasons for this difficulty. Studies with surface ultrasonography have shown that Valsalva (V) and liver (L) compression are more effective in maximizing the cross-sectional area (CSA) of the right IJV (RIJV) in healthy anesthetized, intubated adult patients than the Trendelenburg (T) position (2). The T position and L compression are used during IJV cannulation in infants and children, even in the absence of studies showing their effectiveness in this population. We compared the effect of these routinely used maneuvers, as well as the simulated V maneuver on the CSA of the RIJV in infants and children with the help of surface ultrasonography.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
The protocol was approved by the IRB of Children’s National Medical Center, and parental consent was obtained for each patient. Eighty-four infants and young children between the ages of 1 mo to 6 yr, ASA physical status I and II, scheduled to undergo routine surgery under general endotracheal anesthesia, were studied. Because IJV cannulation has a smaller success rate in infants compared with older children (1), we stratified the patients into 2 groups: the Infant group (<1 yr of age) and the Children group (1–6 yr). Patients with abdominal distension caused by masses, L enlargement, or ascites, those with increased intracranial pressure (hydrocephalus with or without shunts), and those with any lung pathology, were excluded. Patients who had undergone any previous neck surgery or IJV cannulation were also excluded.

All patients underwent an inhaled induction of anesthesia with O2, N2O, and sevoflurane, and intubation was facilitated by using rocuronium. All maneuvers were performed at the same anesthetic (inspired and end-tidal) concentration. After placement of routine monitors and IV lines, patients were positioned supine (S) with their heads in the midline position and their shoulders above three folded towels to provide moderate extension (3). Baseline CSA measurement of the RIJV image during mechanical ventilation was obtained. A 2-dimensional 5-MHz transducer (Aloka® Ultrasound System SSD-650 CL; ALOKA, Tokyo, Japan) was used. This device is used routinely in the operating room by neurosurgeons to measure the diameter and size of intracranial cysts or cavities.

In each patient, the primary investigator held the ultrasound probe in an identical position perpendicular to the skin over the IJV immediately cephalad to the clavicle to visualize the vein. RIJV was imaged in the center of the screen during each single or combination of maneuvers, each of which was held for at least 10 s. The circumference of the RIJV was delineated by the electronic marker at end-expiration by using the Aloka ultrasound machine. The images were printed out for subsequent review by an independent blinded investigator who calculated the CSA of the RIJV with each maneuver (Fig. 1).



View larger version (115K):
[in this window]
[in a new window]
  		Figure 1. Ultrasound images of the right internal jugular vein in a child showing the increase in size with the Valsalva maneuver (B) from the baseline (A).

 
To simulate the V maneuver, a positive inspiratory pressure of 25 mm Hg was applied for 10 s. The L compression maneuver was achieved by placing an inflatable pressure cuff with a manometer and an inflation bulb with the bladder enclosed within a thin abdominal binder. This pressure device was positioned with the inflatable portion snug against the right upper quadrant of the abdomen to provide sustained measurable compression force to the undersurface of the L. In each case, the cuff was inflated to a pressure of 40 mm of Hg and maintained for 10 s during the assessment of the vein size (SL).

For the T maneuver, the operating room table was tilted down to a 15° angle by following the movement of an air bubble placed inside a marked leveler and measurements were made alone and in combinations (TV, TL, and TVL) at the end of the first two maneuvers (V and L compression).

With the probe held in the same position, eight measurements of the CSA of RIJV were therefore made as follows (Table 1): 1) baseline in the S position, 2) V maneuver in the S position, 3) L compression in the S position, 4) V maneuver and L pressure together in the S position, 5) T position, 6) V maneuver in the T position (TV), 7) L compression in the T position (TL), and 8) L compression and V maneuver in the T position (TVL).


View this table:
[in this window]
[in a new window]
  		Table 1. Combination of Positions and Maneuvers
 
Data were analyzed by using Friedman’s {chi}2 test (4) and Wilcoxon’s signed rank test (5). Each P value for Wilcoxon’s test was adjusted by the Bonferroni method and a P value < 0.002 is significant at an overall significance level <0.05. Based on our prior clinical experience, a mean increase of 25% in the CSA of the IJV from the baseline value was considered significant.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
There were 38 infants (1 mo to <1 yr) and 46 children (1–6 yr) enrolled in the study. Complete data were collected for all patients. The percentages of increase in the CSA of the RIJV from baseline (S) are presented separately for infants and children in Figure 2.



View larger version (21K):
[in this window]
[in a new window]
  		Figure 2. Changes in the cross-sectional area of the right internal jugular vein in infants and children from baseline (S) with different maneuvers alone or in combination. S = supine or baseline, V = Valsalva, L = liver compression, T = Trendelenburg position.

 
Infants (1 Month to Less than 1 Year)
The mean age of the infants was 5.8 ± 2.9 mo and the mean weight 6.95 ± 2.04 kg. The mean baseline size of the CSA of the RIJV was 0.37 ± 0.17 cm2. The maximal mean increase of 17.4% ± 16.1% from baseline (S) occurred with the combination of all 3 maneuvers (TVL) (P < 0.0001). There was no significant difference in the CSA of the RIJV when the combination of V maneuver and L pressure (SVL) was compared with either the combination of T and V or with that of V alone (14.2% ± 14.6%, 12.6% ± 13.3%, and 11.6% ± 11.5%, respectively). The effect of T alone and L pressure alone on the RIJV size increase was 5.3% ± 11.1% and 6.8% ± 7.4%, respectively, less than their combined effect of 10.0% ± 12.5%. The significant mean increase of 25% in the CSA of the RIJV in the infants was not attained by any of these maneuvers alone or in combination.

Children (1 to 6 Years)
The mean age of the children was 34.5 ± 18.3 mo and the mean weight 14.78 ± 4.63 kg. The mean size of the CSA of the RIJV was 0.58 ± 0.22 cm2. The combination of the three maneuvers (TVL) produced a mean 65.9% ± 44.7% increase in the CSA of the RIJV from the baseline (P < 0.0001). The effect of the combination of V and L pressure (SVL) was similar to the effect of the combination of TV (52.6% ± 38.1% and 51.7% ± 36.0%, respectively). The V maneuver alone (SV) increased the CSA of the RIJV by 40.4% ± 32.2%, which is larger than the 31.7% ± 23.4% increase obtained by combining the other two maneuvers (TL). The effect of T alone and L pressure alone on the RIJV size increase was 24.3% ± 27.1% and 14.3% ± 18.9%, respectively, less than their combined effect (TL) of 31.7% ± 23.4%.

The significant increase of 25% in the CSA of the RIJV was attained by all maneuvers in combinations (TVL, SVL, TL, TV) and by V alone in this group. As a single maneuver, L pressure produced the least mean increase of 14.3% in children compared with that produced by T position alone (24.3%).

The increase in the size of the RIJV from the baseline with the different maneuvers was more pronounced in children older than 1 yr of age when compared with infants.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
IJV cannulation is often used in children to monitor central venous pressure and to infuse vasoactive drugs. Cannulation of the RIJV is reported to have a more frequent success rate with a less frequent incidence of complications than cannulation of the LIJV (6). Ultrasound-guided cannulation has become particularly popular in children after its superiority in facilitating cannulation had been proven by randomized clinical studies (7). Several maneuvers have been described to increase the size of IJV in adults (8). Studies in healthy adult patients comparing the effect of T, application of L pressure, and the V maneuver showed the largest increase in the CSA of the IJV with the V maneuver (9). The V maneuver was more efficient than the T position in another study of awake adult volunteers (2). Some of these maneuvers have also been used in infants and children, although there is no evidence to support their efficacy.

The effect of abdominal compression on filling of the neck veins was first observed by Pasteur in 1885 (10). Abdominal or L compression increases the right atrial pressure by increasing venous return via the inferior vena cava. An increase in central venous pressure is believed to be caused by the "transfusion" of blood from the compressed L and abdominal veins (11).

In the awake subject, the V maneuver consists of a forceful expiration made against a closed glottis resulting in an increase in the intrathoracic pressure and a decrease in the venous return to the heart (12). To simulate the effect of the V maneuver in anesthetized children, a sustained application of increased airway pressure up to 25 cm H2O is made by inflating the bag of the anesthesia machine for 10 seconds.

The changes in the area and circumference as well as the flow velocities of the superior vena cava (SVC) (an intrathoracic vein) and the IJV (an extrathoracic vein) with the V maneuver have been studied in awake adult patients by using an intravascular ultrasound probe and doppler echocardiography (13,14). Attubato et al. (13) found that the increase in intrathoracic pressure during the V maneuver significantly decreased the size of the SVC, an intrathoracic vein, whereas significantly increasing the size of the IJV, an extrathoracic vein. The decrease in size of the SVC was found to be secondary to direct external compression from acutely increased intrathoracic pressure, which in turn obstructed the venous flow from the IJV to the SVC (14). The venous pressure in both the SVC and the IJV, however, increased during this maneuver. Lobato et al. (15) found that in healthy adult volunteers the LIJV was significantly smaller compared with the RIJV, and the CSA of both veins increased in size with the V maneuver and the T position.

The T position is used during IJV cannulation to distend the veins by an increase in the blood volume in the jugular vessels and thus the CSA (16,17). By increasing the height between the right atrium and the RIJV, there is a decrease in the venous return to the heart via the SVC.

In the clinical situation, the application of L pressure and/or simulated V maneuver require the help of a knowledgeable assistant. For the V maneuver, the assistant should be capable of removing the patient from mechanical ventilation and manually holding the desired constant pressure on the anesthesia bag for 10 seconds. Applying L pressure is simpler than simulating the V maneuver and can be performed by properly trained nonanesthesia personnel. A single operator, however, can easily place the patient in the T position and perform central venous ultrasonography and/or cannulation without additional help.

The success rate in cannulating IJV in infants and younger children is less than that in teenagers and adults (18). The small size of the IJV and the variability of its relationship to the carotid artery in children may contribute to the decreased success rate and the increased incidence of carotid puncture. Mallinson et al. (19) reported the position of the IJV to be anterior to the carotid artery at the cricoid level in 24% of the children in their study. We perform our IJV cannulation with the head in the midline position because the IJV becomes more lateral to the carotid artery with rotation of the head to the opposite side (3).

Compared with older children, all three maneuvers have less effect on the infant’s IJV probably because the small-sized IJV does not have as much elasticity or compliance. The study by Alderson et al. (20) of IJV anatomy using ultrasonography showed the incidence of unusually small IJV diameter (defined as <5 mm) in 4% of infants. Our data showed that in infants the mean baseline size of the CSA of the RIJV was 0.37 ± 0.17 cm2. The small size and short stature of infants account for the negligible increase in blood flow to the neck vessels with the T position, making it an inefficient maneuver to increase the size of the IJV. Although the T position does not cause significant enlargement of the IJV, children are routinely placed in this position to decrease the chance of air embolism.

Because infants have a relatively larger L than older children, we had expected a significant increase in IJV size with the L compression. However, L compression did not produce the expected significant increase in IJV size in infants. The lack of increase in the CSA of the IJV with L pressure alone could be attributable to the inadequacy of the abdominal binder in producing the necessary compressive force solely directed to the undersurface of the L. However, the design of the abdominal binder was shown to simulate manual compression. Our study population was composed of healthy infants and children. Whether compression would be beneficial in increasing IJV size in cardiac patients with large L’s is not known.

In this study we did not examine the success rate of cannulation resulting from increasing the size of the IJV with these various maneuvers, and hence cannot make any conclusion regarding the facilitation of IJV cannulation by our study results. Further studies using ultrasonography are therefore needed to show the effectiveness of these maneuvers in increasing the success rate of IJV cannulation in infants and children.

In conclusion, the combination of the V, L pressure, and T maneuvers offer the maximal mean increase in the CSA of the RIJV in the combined population of infants and children <6 years of age. This increase is maximal (65.9%) in children and minimal and clinically negligible (17.4%) in infants. As a single maneuver, the simulated V is clearly the most effective in producing this enlargement compared with the other two maneuvers.


   Acknowledgments
 
The authors thank Raafat S. Hannallah, MD, Professor of Anesthesiology and Pediatrics, Children’s National Medical Center, for critically reviewing the manuscript, and Deirdre Savoy for technical assistance.


   Footnotes
 
Presented in part at the annual meetings of the International Anesthesia Research Society, Los Angeles, CA, March 1999.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Verghese S, Patel RI, Hannallah RS. Central venous catheterization in infants and children: a comparison of internal and external jugular vein approaches. Paediatr Anaesth 1993; 3: 95–9.
  2. Lobato EB, Florete OG, Paige GB, Morey TE. Cross-sectional area and intravascular pressure of the right internal jugular vein during anesthesia: effects of Trendelenburg position, positive intrathoracic pressure, and hepatic compression. J Clin Anesth 1998; 10: 1–5.[ISI][Medline]
  3. Sulek CA, Gravenstein N, Blackshear RH, Weiss L. Head rotation during internal jugular cannulation and the risk of carotid artery puncture. Anesth Analg 1996; 82: 125–8.[Abstract]
  4. Friedman M. The use of ranks to avoid the assumption of normality implicit in the analysis of variance. J Am Stat Assoc 1937; 32: 675–701.[ISI]
  5. SAS procedures guide. Version 6, 3rd ed. Cary, NC: SAS Institute, 1990: 617–34.
  6. Muralidhar K. Left internal versus right internal jugular vein access to central venous circulation using the Seldinger technique. J Cardiothorac Vasc Anesth 1995; 9: 115–6.[ISI][Medline]
  7. Verghese ST, McGill WA, Patel RI, et al. Ultrasound-guided internal jugular vein cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999; 91: 71–7.[ISI][Medline]
  8. Mallory DL, Shawker T, Evans RG, et al. Effects of clinical maneuvers on sonographically determined internal jugular vein size during venous cannulation. Crit Care Med 1990; 18: 1269–73.[ISI][Medline]
  9. Armstrong PJ, Sutherland R, Scott DHT, et al. The effect of position and different maneuvers on internal jugular vein diameter size. Acta Anaesthesiol Scand 1994; 38: 229–31.[ISI][Medline]
  10. Pasteur W. Note on a new physical sign of tricuspid regurgitation. Lancet 1885; 2: 524.
  11. Ducas J, Magder S, McGregor M. Validity of the hepatojugular reflux as clinical test for congestive heart failure. Am J Cardiol 1983; 52: 299–303.[ISI][Medline]
  12. Nishimura RA, Tajik AJ. The Valsalva maneuver and response revisited. Mayo Clin Proc 1986; 61: 211–7.[ISI][Medline]
  13. Attubato MJ, Katz ES, Feit F, et al. Venous changes occurring during the Valsalva maneuver: evaluation by intravascular ultrasound. Am J Cardiol 1994; 74: 408–10.[ISI][Medline]
  14. Gindea AJ, Slater J, Krozon I. Doppler echocardiographic flow velocity measurements in the superior vena cava during the Valsalva maneuver in normal subjects. Am J Cardiol 1990; 65: 1387–91.[ISI][Medline]
  15. Lobato EB, Sulek CA, Moody RL, et al. Cross-sectional area of the right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999; 13: 136–8.[ISI][Medline]
  16. Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979; 7: 218–24.[ISI][Medline]
  17. Terai C, Anada H, Matsushima S, et al. Effects of mild Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. Am J Emerg Med 1995; 13: 255–8.[ISI][Medline]
  18. Denys BG, Uretsky BF, Reddy PS. Ultrasound assisted cannulation of the internal jugular vein: a prospective comparison to the external landmark guided technique. Circulation 1993; 87: 1557–62.[Abstract/Free Full Text]
  19. Mallinson C, Bennett J, Hodgson P, Petros AI. Position of the internal jugular vein in children: a study of the anatomy using ultrasonography. Paediatr Anaesth 1999; 9: 111–4.[ISI][Medline]
  20. Alderson PJ, Burrows FA, Stemp LI, et al. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Br J Anaesth 1993; 70: 145–8.[Abstract/Free Full Text]
Accepted for publication September 27, 2001.




This article has been cited by other articles:


Home page
 Anesth. Analg.Home page
K. Yuki, K. Chilson, K. C. Odegard, and J. A. DiNardo
Trendelenburg Position, Simulated Valsalva Maneuver, and Liver Compression Do Not Alter the Size of the Right Internal Jugular Vein in Patients with a Bidirectional Glenn Shunt
Anesth. Analg., August 1, 2007; 105(2): 365 - 368.
[Abstract] [Full Text] [PDF]

Home page
 Emerg. Med. J.Home page
S Clenaghan, R E McLaughlin, C Martyn, S McGovern, and J Bowra
Relationship between Trendelenburg tilt and internal jugular vein diameter
Emerg. Med. J., December 1, 2005; 22(12): 867 - 868.
[Abstract] [Full Text] [PDF]

Home page
 Br J AnaesthHome page
S. J. Schreiber, U. K. W. Lambert, F. Doepp, and J. M. Valdueza
Effects of prolonged head-down tilt on internal jugular vein cross-sectional area
Br. J. Anaesth., November 1, 2002; 89(5): 769 - 771.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a colleague
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (12)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Verghese, S. T.
Right arrow Articles by Patel, K. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Verghese, S. T.
Right arrow Articles by Patel, K. M.
Related Collections
Right arrow Monitoring (Cardiac)
Right arrow Pediatrics

Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press