|Year : 2018 | Volume
| Issue : 2 | Page : 45-49
Effect of head pillow and shoulder roll on diameter of the right internal jugular vein
A Shivanandan1, S Chitra2, Reka Karuppusami3
1 Department of Emergency, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
3 Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
|Date of Submission||07-Sep-2018|
|Date of Acceptance||16-Sep-2018|
|Date of Web Publication||15-Nov-2018|
Dr. S Chitra
Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Right internal jugular vein (RIJV) is the most commonly used site for central venous cannulation. Ultrasound guidance has increased success rate and reduced complications of central venous cannulation. The main aim before cannulation is to increase the size of the vein by optimal positioning. We used ultrasound to assess changes in right internal jugular diameter with use of a head pillow and shoulder roll and their effect on the degree of overlap between RIJV and carotid.
Methodology: 106 patients were recruited in the study. After intubation the patients were placed in the following 3 positions (i) P1 -without head pillow or shoulder roll, (ii) P2 - with head pillow and (iii) P3- with shoulder roll. All measurements were made in 15 degree Trendelenberg tilt and head turned to the left by 30 degree. The following measurements were recorded in all 3 positions. (a) Transverse and Antero-Posterior diameter of the RIJV. (b) Transverse diameter of the right carotid. (c) Overlap between RIJV and carotid.
Results: In our study the mean transverse diameter of RIJV was 1.87cm in P1 and P2 and 1.72 cm in P3respectively. The mean antero-posterior diameter was 1.39cm, 1.37cm and 1.13 cm in P1, P2 and P3 respectively. The increase in diameter in P1 was statistically significant (P < 0.001). The mean overlap percentage between right carotid and RIJV was 49.41%, 50.97% and 35.7% in P1, P2 and P3 respectively. This difference between P3 and other two position was also statistically significant (P < 0.00).
Conclusion: We conclude that placing the patient supine in 15 degree Trendelenberg tilt and a30 degree head rotation to the opposite side with or without use of a head pillow would lead to greater chance of first pass success during R IJV cannulation as the diameter was found to be maximum in this position. We do not recommend use of a shoulder roll as there was significant reduction in diameter though the overlap between RIJV and carotid was found to be minimal. Use of ultrasound and proper positioning of the patient will reduce the possible catastrophic complications associated with RIJV cannulation.
Keywords: Carotid overlap, head pillow, right carotid artery, right internal jugular vein, shoulder roll, ultrasound
|How to cite this article:|
Shivanandan A, Chitra S, Karuppusami R. Effect of head pillow and shoulder roll on diameter of the right internal jugular vein. Indian Anaesth Forum 2018;19:45-9
|How to cite this URL:|
Shivanandan A, Chitra S, Karuppusami R. Effect of head pillow and shoulder roll on diameter of the right internal jugular vein. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:45-9. Available from: http://www.theiaforum.org/text.asp?2018/19/2/45/245553
| Introduction|| |
Central venous catheters (CVC) are used intraoperatively in the intensive care unit for a wide number of indications. The right internal jugular vein (RIJV) is one of the most commonly used sites for central venous access. It has a predictable location, ease of access during surgery, and enters the right atrium directly. Moreover, it is associated with low rate of mechanical complications compared to the subclavian central line.,,
Central venous cannulation can be done using either anatomical landmarks or by ultrasound guidance. Real-time ultrasound imaging has become the standard of care. Use of ultrasound has been associated with faster access time and lesser chance of arterial puncture.,,, In centers where ultrasound machine is not available, traditional landmark techniques need to be employed. Optimal positioning to maximize the size of the vein is a requirement to facilitate successful first-pass cannulation and minimize carotid artery puncture.
The success rate of IJV cannulation has been found to be directly related to its diameter. Several maneuvers such as Trendelenburg tilt, Valsalva manoeuver, head pillow, head rotation, neck extension, shoulder roll, passive leg raise, hepatic compression, and positive end expiratory pressure on the ventilator have been evaluated to increase the diameter of the IJV.,,,, Trendelenburg tilt has been well established as a method to increase the IJV diameter and is recommended in practice guidelines published by the American Society of Anesthesiologists (ASA).,,,,,,
Among the above-mentioned maneuvers, there are varied opinions regarding the use of a head pillow. Some feel that use of a head pillow can cause flexion, thereby restricting access to cannulation. Studies had shown that use of a head pillow is associated with significant increase in the RIJV diameter.,, A shoulder roll is used to increase exposure, especially in obese patients with a short neck where extension of the neck is required. While use of a shoulder roll decreases the overlap between the carotid and IJV, it also decreases the anteroposterior diameter of the IJV., The head is turned to the opposite side to improve exposure of the IJV.
Studies show that head rotation to opposite side to <45° improves exposure with less overlap between IJV and carotid artery as compared to greater degrees of rotation.,,,,
The present study was done to observe the effect of a head pillow and shoulder roll on the diameter of the RIJV and its overlap with the carotid artery using ultrasound.
| Materials and Methods|| |
The study was done after approval from the Institutional Review Board and informed consent was obtained prior to the surgery.
- ASA I and II patients posted under general anesthesia
- Patients of both genders
- Age >18 years.
- ASA III or higher
- Diseases involving the cervical spine
- Neck scars or burns and swelling
- Patient refusal to participate in the study
- Patients with limitation of neck movement or pain
- Previous neck or vascular surgery involving the RIJV
- Recent RIJV cannulation.
All patients recruited were advised standard preoperative fasting orders with clear fluids up to 2 h prior to surgery. The induction of anesthesia was based on standard protocol using Propofol 2mg/kg, fentanyl 2 microgm/kg and intubation achieved with 0.1mg/kg of vecuronium. All patients were ventilated using pressure-controlled mode with a standard setting of a tidal volume of 8 ml/kg, a respiratory rate of 15, and a positive end-expiratory pressure 5 to avoid the effects of positive pressure ventilation on the caliber of the IJV., The measurements were done in the anesthetized patients with the aid of an ultrasound linear probe of 5–13 Hz (Fuji film Sonosite).
A 15° Trendelenburg tilt and head rotation to the left by 30° were done in all patients.,,, The angle of head rotation was based on the position of the tip of nose to neutral position and measured using a protractor and a scale. The head pillow and shoulder roll used were of a fixed height of 4 cm and 5 cm, respectively. The patients were placed in the following three positions for measuring the diameter:
- Position 1 (P1): Without head pillow or shoulder roll
- Position 2 (P2): Head placed on a small pillow of 4-cm height
- Position 3 (P3): Use of a shoulder roll of 5-cm height.
The study design is depicted in the consort flowchart [Figure 1]. A mark was made at the level of cricoid in the triangle formed by the sternal and clavicular head of the right sternocleidomastoid with medial third of the clavicle inferiorly. The ultrasound probe was placed perpendicular to the axis of the neck at this point. It was placed gently on the site to avoid compression of the vein. All measurements were taken at end expiration to maintain uniformity. The patients were placed for 30 s in each position before the measurements were taken. All observations were done by the principal investigator. The following measurements were made in all the three positions:
- RIJV transverse and anteroposterior diameter
- Right carotid artery transverse diameter
- Percentage of overlap between both vein and artery.
RIJV overlap of carotid/carotid artery diameter × 100
Based on an alpha error of 5% with the power of 80% and two-sided tests, the calculated sample size was 106 patients. The sample size was calculated using n Master soft ware version 2.0 (cmc-biostatistics.ac.in/n master).
For continuous data such as age, descriptive statistics such as n, mean, and standard deviation (SD) were used.
For categorical data, number and percentage were used. Based on the normality of data, the parametric paired t-test was used for the transverse and anteroposterior diameters to see the difference between P1 and P2 and P1 and P3. Pearson's correlation coefficient was used to find the relationship between height, weight, and body mass index (BMI) with transverse and anteroposterior diameters of RIJV.
All tests were two sided at α = 0.05 level of significance. The analyses were done using Statistical Package for the Social Sciences software, Version 21.0 (IBM Corp., Armonk, NY, USA).
| Results|| |
In our study of 106 patients, 57 were males and 49 were females. The demographic data are presented in [Table 1].
The mean transverse and anteroposterior diameters of the RIJV and the overlap percentage in patients placed in the three different positions P1, P2, and P3 and the comparative analysis among the positions are summarized in [Table 2].
|Table 2: Comparison between positions, anteroposterior diameter, transverse diameter, and carotid right internal jugular vein overlap|
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On comparative analysis of the transverse diameter between P1 and P3, there was a statistically significant difference of 0.15 cm (P < 0.00).
The difference in mean transverse diameter between P1 (1.87 cm) and P2 (1.87 cm) was not statistically significant. Similarly, with respect to the anteroposterior diameter at P1 and P3, there was a statistically significant difference of 0.26 cm (P < 0.00). There was no statistically significant difference in the anteroposterior diameter between P1 and P2.
The mean overlap percentage between the RIJV and right carotid between P1 and P3 showed that there was a statistically significant difference of 13.71% (P < 0.00). There was no statistically significant difference in the overlap percentage between P1 and P2. The ultrasound image taken in one of the patients is shown in [Figure 2].
|Figure 2: Ultrasound of right internal jugular vein. A – transverse diameter of the right internal jugular vein, B – anteroposterior diameter of the right internal jugular vein, C – transverse diameter of the carotid, F – overlap between right carotid and right internal jugular vein|
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Further analysis to look for correlation between the diameter of the right IJV and the height, weight, and BMI of the patient is summarized in [Table 3].
|Table 3: Correlation of height, weight, and body mass index with transverse and anteroposterior diameters of right internal jugular vein|
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Our analysis showed a significant correlation between the weight (P = 0.0013 and correlation factor 0.308), BMI (P = 0.0009 and correlation factor = 0.318), and anteroposterior diameter of the RIJV. There seemed to be a significant correlation between the weight and BMI with the anteroposterior diameter. There was an increase in RIJV anteroposterior diameter with increase in BMI.
We found no significant correlation between height, weight, and BMI with transverse diameter of the RIJV and the percentage of right carotid overlap with RIJV.
| Discussion|| |
The main aim in securing a central venous access using a landmark technique is first-pass success and avoiding injury to the surrounding structures, especially carotid artery puncture. The larger the diameter of the RIJV, greater would be the success of first-pass cannulation. Our study was done to observe the effect of use of a head pillow and shoulder roll on the diameter of the RIJV and find the position in which RIJV diameter was largest. There was no significant difference in the mean transverse and anteroposterior diameters between P1and P2 (with head pillow). This is in contrast to previous studies which have shown that use of head pillow increased the RIJV diameter.,,
There was a statistically significant reduction in mean transverse and anteroposterior diameters when a shoulder roll was used (P3). This was in accordance with previous studies which showed that use of a shoulder roll decreased the RIJV diameter.,
The overlap between the RIJV and carotid plays an important role in inadvertent arterial puncture. It has been shown that neck rotation to <45° improves exposure and causes less overlap between the IJV and carotid as compared to greater degrees of rotation.,,,,, In our study, we chose to keep all our patients at 30° head rotation in order to minimize the carotid overlap.
There was a 49% and 50% overlap in P1 and P2, respectively, and it reduced to 35% in P3. However, the diameter of the RIJV was also reduced in P3 compared to the other two positions. This may be attributed to the shoulder roll causing neck extension and stretching of the neck musculature, resulting in compression of the RIJV. The findings are in agreement with previous studies.,
A shoulder roll is useful in patients who have a very short neck as it gives more space to access the vein by providing extension of the neck. The height of the shoulder roll also affects the diameter of the vein and it is better to avoid using larger shoulder rolls which cause more extension of the neck, which in turn may lead to further compression of the vein.
| Conclusion|| |
There was no significant change in the diameter of the vein with the use of a head pillow. Based on our observations, we felt that there was no added advantage in the use of a head pillow, but it may be useful to relax the neck musculature. There was a significant decrease in diameter with the use of a shoulder roll, but it was also associated with a decrease in overlap between vein and artery.
Even though the IJV was not cannulated in our study, from our observations, we recommend against the use of a shoulder roll. Adopting a 15° Trendelenburg tilt, with head rotation to opposite side of <30°, will further aid in increasing the diameter of the vein and decreasing overlap. Proper patient positioning and use of ultrasound in anticipated difficult external anatomy can improve first-pass success and avoid possible catastrophic complications.
All the authors express their sincere gratitude to all respondents whose honest attention helped, supported, and led the research project to worthful outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]