Right Internal Jugular Research Articles

Evaluation of Right-Side Filling Pressure in Patients With Obesity With Heart Failure Using Handheld Ultrasound Score

The goal of this investigation is to evaluate the accuracy of handheld ultrasound score in assessing right atrial (RA) pressure in patients with obesity with heart failure. We prospectively studied 123 patients with heart failure referred for right-sided cardiac catheterization. Handheld ultrasound was performed before catheterization to evaluate volume status by estimating RA pressure using end-expiratory inferior vena cava (IVC) dimension, IVC respiratory collapsibility, and right internal jugular (RIJ) vein respiratory collapsibility. A 3-point simple score was created using multiple logistic regression. The patients were divided into 2 groups based on body mass index. The performance of this score was assessed using the receiver operating characteristics curve in each subgroup and was compared with the performance of the 2-point score (expiratory IVC dimension, IVC respiratory collapsibility). Median age was 58years (interquartile range 48 to 65), and 37% were women. The 3-point score including RIJ performed better than did the 2-point score in patients with obesity (area under the curve 0.84 [0.74 to 0.95]vs 0.69 [0.58 to 0.81], p=0.001). The performance of the scores did not differ in patients without obesity (area under the curve 0.85 [0.74 to 0.95]vs 0.82 [0.71 to 0.93], p=0.49). In patients with obesity, the 3-point score had a specificity of 100% and sensitivity of 21% (11% to 31%) for elevated RA pressure ≥10mm Hg. In conclusion, a 3-point score including both RIJ and IVC assessment performed better in patients with obesity with heart failure and highlights the importance of comprehensive evaluation in patients with obesity to achieve an accurate, noninvasive assessment of volume status.

PULM14: Long-haul ECMO as Bridge to Transplant in COVID-19 ARDS

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT) is an established treatment modality for refractory acute respiratory distress syndrome (ARDS). Per the Scientific Registry of Transplant Recipients (SRTR) database, 215 patients supported on ECMO due to the Coronavirus disease of 2019 (COVID-19) related ARDS underwent LT between August 2020 and June 2022. The COVID-19 pandemic limited donor availability and increased duration of ECMO support in ECMO-dependent patients listed for LT. Outcomes of long-term ECMO as bridge to transplant (BTT) in this population remain unclear, and no cases of VV ECMO greater than 200 days has been documented in the literature. Methods: A single-center review was conducted to identify patients cannulated for VV-ECMO to treat COVID-19 associated ARDS between January 1, 2021 and January 1, 2022. Patients were selected who were supported by VV-ECMO for ARDS secondary to COVID-19 for greater than 200 days before receiving a lung transplant. Detailed analysis was performed for the outcomes and characteristics of all patients who received a lung transplant for post-COVID-19 ARDS after >200 days of VV-ECMO support. Results: Three patients were identified as long-term ECMO as BTT recipients (>200 days) for COVID-19-associated ARDS. Average age was 38 years (22,52), BMI 32.9 (31.6,34) and no patients had any known relevant respiratory medical history. One patient had a history of daily e-cigarette use. All patients were unvaccinated at the time of first positive COVID-19 test. All were successfully bridged to bilateral lung transplant (BLT) off of VV-ECMO. None required VV-ECMO post-operatively. One patient required VA-ECMO post-operatively for elevated pulmonary arterial pressures related to incidentally discovered septal defects. Average ECMO duration was 278 days (250, 324). Two patients were cannulated as bridge to recovery, and one as bridge to decision. Patients remained ambulant on ECMO support until they were able to undergo the transplant procedure. Cannulation strategies included double lumen right internal jugular (RIJ), RIJ to right femoral vein, and bifemoral venous cannulation. Complications on ECMO included sepsis, hemorrhage, stroke, reconfiguration, and atrial fibrillation. Two were discharged to home and one to inpatient rehabilitation. Average length of stay after transplant was 27 days (16,37). All 3 patients have continued to do well. Conclusion: We present three patients with the longest documented VV-ECMO support for COVID-19 ARDS a bridge to lung transplant. Our findings suggest long-term VV-ECMO support is a feasible bridge to LT for patients with COVID-19-related ARDS when used in the long-term (>200 days). The duration of ECMO support remains associated with known ECMO-related complications. Post-transplant survival to-date suggests that survival in long-term ECMO support as a BTT may be comparable to short-term ECMO in patients with COVID-19-related ARDS.

PO-05-014 SUCCESSFUL IMPLANTATION OF A MICRA LEADLESS PACEMAKER THROUGH THE LEFT SUBCLAVIAN VEIN IN A PATIENT WITH SITUS AMBIGUOUS

Primary ciliary dyskinesia patients often have situs ambiguous, a congenital condition with abnormal arrangement of visceral organs in the abdomen and chest. It is associated with an increased risk of congenital heart defects and anomalous venous connections. As a result, placement of the leadless pacemaker through the femoral approach may not be viable in these patients. Herein we describe a successful placement of a leadless pacemaker through the left subclavian approach in a patient with primary ciliary dyskinesia with associated interrupted IVC, right internal jugular (RIJ) thrombus, failed epicardial pacers, and extraction of infected transvenous pacer. N/A A 36-year-old female with primary ciliary dyskinesia, situs ambiguous, RIJ thrombus, and azygous venous connection presents with paroxysmal atrial fibrillation, sinus node dysfunction and syncope (A); History of multiple pacemakers, including failed epicardial pacer, substance abuse and recurrent bacteremia with multiple transvenous pacer infections requiring extractions. Ultrasound access was gained in the left subclavian vein via the modified Seldinger technique. Access was serially dilated until a 23Fr dilator. A manual curve was applied to the tip of the Micra-introducer sheath and the long 27Fr hydrophilic micra-introducer sheath was advanced over a Lunderquist wire, using a stiff rail, into middle of the right atrium (B). The 105 cm Micra delivery catheter was inserted into the sheath, and advanced with fluoroscopic guidance into the right atrium. The introducer sheath was pulled back into the SVC and the delivery catheter was counter-clocked, flexed downward and advanced across the tricuspid valve. The pacemaker was directed to the midseptal position. Contrast was injected to verify positioning against the myocardium (C). The device was deployed with satisfactory parameters noting R waves of 12mV and threshold less than 1V at 0.24 msec pulse with. The pacer was then released with tugging testing confirming adequate deployment. (D). The patient was discharged safely home 2 days later. The left subclavian vein is a viable and safe approach for placing the Micra leadless pacemaker.

Central catheter tip migration in critically ill patients.

Chest X-ray (CXR) is routinely required for assessing Central Venous Catheter (CVC) tip position after insertion, but there is limited data as to the movement of the tip location during hospitalization. We aimed to assess the migration of Central Venous Catheter (CVC) position, as a significant movement of catheter tip location may challenge some of the daily practice after insertion. Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units in Tel Aviv Sourasky Medical Center 'Ichilov', Israel, between January and June 2019. We identified 101 patients with a CVC in the Right Internal Jugular (RIJ) with at least two CXRs during hospitalization. For each patient, we measured the CVC tip position below the carina level in the first and all consecutive CXRs. The average initial tip position was 1.52 (±1.9) cm (mean±SD) below the carina. The maximal migration distance from the initial insertion position was 1.9 (±1) cm (mean±SD). During follow-up of 2 to 5 days, 92% of all subject's CVCs remained within the range of the Superior Vena Cava to the top of the right atrium, regardless of the initial positioning. CVC tip position can migrate significantly during a patient's early hospitalization period regardless of primary location, although for most patients it will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned.

How to Do It: A Safe Bedside Protocol for Dual-Lumen Right Internal Jugular Cannulation for Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients With Severe Acute Respiratory Distress Syndrome.

In appropriately selected patients with COVID-19 acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV ECMO) may offer a promising bridge to lung recovery or lung transplantation if lung recovery fails. Although the cannulation technique for VV ECMO via a right internal jugular (RIJ) dual-lumen catheter (DLC) requires expertise and guidance by either fluoroscopy or transesophageal echocardiography (TEE), it offers theoretical circulatory support advantages by using bicaval venous drainage to deliver oxygenated blood systemically with minimal recirculation as compared with the femoral vein and RIJ dual-site cannula configuration. In addition, patients are often too unstable to transport safely to an operating room or catheterization laboratory, and fluoroscopy is not always readily available to guide RIJ DLC placement. Here, we provide a comprehensive description of a safe, bedside protocol for VV ECMO cannulation via a RIJ DLC under TEE guidance. We will report our center's experience (March 30, 2020 to November 21, 2021) and discuss important hemodynamic, safety, and infection control considerations.

Accurate Estimation of Right-Filling Pressure Using Handheld Ultrasound Score in Patients with Heart Failure

IntroductionThis study aims to evaluate the accuracy of bedside assessment of inferior vena cava (IVC) and right internal jugular (RIJ) vein in predicting right atrial (RA) pressure in heart failure patients. MethodsWe prospectively studied 124 heart failure patients who were referred to our catheterization laboratory for right heart catheterizations to assess hemodynamics and to guide heart failure management. Just prior to the procedure, a handheld ultrasound examination was performed in each patient. The volume status was assessed by estimating RA pressure using end-expiratory IVC dimension, IVC respiratory collapsibility, and RIJ respiratory collapsibility. Patients were divided into 2 groups based on invasive RA pressure value. Multiple logistic regression models were used to identify factors associated with RA ≥10 mm Hg; a 3-point simple score was then created. The performance of this score was assessed using the receiver operating characteristics curve. ResultsIn this study 124 heart failure patients were included; median age was 59 years (interquartile range 48-65), and 40% were female. RIJ respiratory collapsibility <50%, end-expiratory IVC dimension ≥21 mm, and respiratory collapsibility <50% were significantly associated with elevated RA pressure, and were used to build the score. The area under the receiver operating characteristics curve (AUC) for the 3-point score was 0.84 (0.77-0.92), and it performed better than 2-point score using IVC characteristics alone (AUC 0.84 [0.77-0.92] vs 0.75 [0.67-0.83]; P = .003). Of 124 patients, 90 patients (72.5%) had concordant RA pressure and pulmonary capillary wedge pressure. ConclusionConcomitant ultrasound assessment of RIJ and IVC correlated better with RA pressure than IVC alone. A simple 3-point score can provide a useful and easily accessible tool to estimate volume status, and further guide management of heart failure patients.

Internal jugular vein ultrasound in patients with chronic congestive heart failure

Abstract Background Bedside assessment of intravascular volume in patients with chronic congestive heart failure (CHF) is often difficult. Under- and over-diuresis are common causes of morbidity and readmissions in these patients. Purpose We hypothesized that ultrasound assessment of the internal jugular vein would be easier and more reproducible than clinically assessing jugular venous pressure (JVP). Our goal was to create a bedside test that would be simpler to learn than inferior vena cava (IVC) assessment and easier to perform in obese patients. Methods Adults with HF (n=53, 52% men, mean age 65 years, mean BMI 29.6 kg/m2, mean LVEF 44%) scheduled for right heart catheterization (RHC) had an ultrasound of their right internal jugular (RIJ) vein performed immediately prior. Cross-sectional area of RIJ was measured during normal breathing with patients at 90 and 45 degrees recumbency and was indexed by height (RIJI). JVP was also assessed clinically. Results were compared to right atrial pressure (RAP) measured by RHC. Operators were blinded to RHC results and vice versa. Results JVP was correctly assessed clinically in only 43%. RIJI at 90 and 45 degrees were significantly larger in patients with elevated RAP compared to euvolemic patients (Table). At 90 degrees, RIJI of &amp;gt;15 predicted a RAP of &amp;gt;10 mmHg with 68% sensitivity and 72% specificity. At 45 degrees, RIJI of &amp;gt;10 predicted a RAP of &amp;gt;10 mmHg with 94% sensitivity and a negative predictive value of 80% (Table). Simply being able to see the RIJ at 90 degrees (n=34) had an 82.4% positive predictive value for elevated RAP. IVC data could not be obtained on 23% of patients due to body habitus or inability to lay flat. Conclusion Ultrasonographic RIJI is more accurate than clinical assessment in patients with CHF and can be accurately performed even in obese patients. It requires only a basic linear ultrasound probe and was easily performed by clinicians at various stages of training with reproducible results. With the increased availability of bedside ultrasound in clinical practice, it is a feasible method of evaluating chronic CHF patients. Funding Acknowledgement Type of funding sources: None.

Evolution of Vascular Access and Anticoagulation.

Continuous renal replacement therapy (CRRT) is an important and widely used adjuvant treatment in critically ill patients. However, any CRRT protocol can be adhered to only when the technique is correctly installed and functioning properly. Within this context, an appropriate vascular access and a safe and effective circuit anticoagulation method are key requisites. The right internal jugular (RIJ) vein is the preferred route for insertion with the tip of the catheter placed in the right atrium. Both femoral veins offer a valuable alternative access, but catheters must be longer to avoid recirculation and circuit blood flow is lower as compared with that of the RIJ approach. The location of the catheter is not associated with differences in bacterial colonization/infection rate or filter/circuit lifespan. Adequate anticoagulation is imperative to avoid a system "shutdown" due to the early clotting of the filter. For a long time, unfractionated heparin (UFH) was the anticoagulant of choice. UFH is associated with an increased bleeding risk and requires the use of high circuit blood flows. The introduction of regional citrate anticoagulation (RCA) created a paradigm change in CRRT anticoagulation. RCA can be applied safely in patients with increased bleeding risk and may enhance filter and circuit survival as compared with UFH. RCA requires close monitoring for potentially serious metabolic side effects. Future perspectives include improved catheter technology and development of novel citrate solutions with less severe metabolic impact.

Implantation of a MICRA Leadless Pacemaker Via Right Internal Jugular Vein.

The MICRA leadless pacing system (Medtronic, Inc, Minneapolis, Minnesota) delivers VVI pacing implanted through a 23-F sheath via a femoral approach. We present feasibility of MICRA implantation via a right internal jugular (RIJ) vein approach in a patient with an inferior vena cava (IVC) filter,

Incidence of Cannula-Associated Deep Vein Thrombosis After Veno-Venous Extracorporeal Membrane Oxygenation.

Limited literature regarding the incidence of cannula-associated deep vein thrombosis (CaDVT) after veno-venous extracorporeal membrane oxygenation (VV ECMO) exists. The purpose of this study was to identify the incidence of post decannulation CaDVT and identify any associated risk factors. Forty-eight patients were admitted between August 2014 and January 2016 to the Lung Rescue Unit were included in the study. Protocolized anticoagulation levels (partial thromboplastin time [PTT] 45-55 seconds) and routine post decannulation DVT screening were in place during the study period. Forty-one (85.4%) patients had CaDVT. Of those with CaDVT, 31 (76%) patients were treated with full anti-coagulation therapy. Thirty-four (76%) patients with right internal jugular (RIJ) cannulation had CaDVT at cannula site. Twenty-five (61%) patients had CaDVT in the lower extremity (18 associated right femoral vein cannulation and 7 left femoral vein cannulation). Eighteen (44%) patients had both upper and lower extremity CaDVT. Overall, patients with CaDVT tended to be older, have a higher body mass index (BMI), and on ECMO longer (p = NS). Mean PTT during time on ECMO between patients that did and did not have CaDVT did not differ. No clinical evidence of pulmonary embolism (PE) was seen.

Central Venous Catheters and Venous Thrombotic Events in Pediatric Oncology Patients: A Multicenter Case Control Study

AbstractAbstract 3400 Background:Central venous catheters (CVCs) have greatly improved the delivery of systemic chemotherapy to pediatric oncology patients and have significantly improved their quality of life. However, CVCs can cause serious venous thrombotic events (VTE), necessitating anticoagulation, CVC removal and reinsertion. There is paucity of data on clinical manifestations and impact of CVC associated VTE in pediatric cancer patients. In this study we describe the clinical presentation and impact of VTE on CVCs. Methods:We performed a multi-center case-control study in childhood cancer survivors. Survivors who experienced a symptomatic VTE during their therapy, and survivors who did not experience VTE (controls) were recruited. Additionally, controls in whom an asymptomatic VTE was detected were assessed separately. Data on location and number of CVCs and of VTE was analyzed. CVCs were categorized by method of insertion and included totally implanted devices (TID) such as ports, tunneled lines (TL) and peripherally insertion central catheters (PICC). Results:Seventy-seven survivors with a history of symptomatic VTE, 10 with asymptomatic VTE, and 178 controls were recruited (Table 1). The mean number of CVCs per individual cases and controls was 1.64±0.91 and 1.12±0.55, respectively (p=0.0001). In cases and controls, 44% and 12.3%, respectively, had >1 CVC (p=0.0001). In patients with asymptomatic VTE the mean number of CVCs per individual was 1.8±1.03 (p=0.069, tending towards significance as compared to controls); 50% had >1 CVC.Among cases with symptomatic VTE, right subclavian (RSCV) (35.1%), left subclavian (LSCV) (16.9%) and right internal jugular (RIJ) (14.3%) veins were the most common CVC sites. In controls, corresponding percentages were 32.6%, 20.8% and 9.6%, respectively. In patients with asymptomatic VTE, RIJ (40%) and RSCV (20%) were the most frequent CVC sites.TID, TL and PICC were used in 60.7%, 22.5% and 2.3% of the controls, respectively. The corresponding numbers in symptomatic VTE cases were 52%, 22.1% and 11.7%, respectively. The difference in distribution of CVCs in the 2 groups was statistically significant (p=0.017). TID were used more frequently in controls (60.7%) as compared to symptomatic VTE (52%) patients. Central venous catheters were inserted into the right-sided veins in 57.9%, 65% and 80% of the controls, symptomatic and asymptomatic VTE cases, respectively.Forty-nine patients had central venous VTE (CVVTE). CVC dysfunction (46.9%), swelling (34.7%) and pain (14.3%) were the most common symptoms of CVVTE. TID, TL and PICC were used in 50%, 34.8% and 6.5%, respectively, of the patients with CVVTE. Concordance in the location of CVC and CVVTE was seen in 27 (55.1%) cases. The most common sites of CVCs in these 27 patients were RIJ (25.9%), RSCV (25.9%) and LSCV (18.5%). Conclusions:In this cohort of pediatric cancer survivors, we made several novel observations indicating significant clinical impact of both symptomatic and asymptomatic VTE. The type of CVC used varied significantly between cases and controls. Use of TID appears protective, plausibly due to relatively shorter length of the central line (compared to other CVCs), non-exposed parts, and use of only non-coring needles to access the device.A concordance of over 50% in the location of CVCs and that of CVVTE was observed and has not previously been reported. These observations are of importance in identification of pediatric oncology patients at higher risk of CVC related complications. These observations can inform the design of appropriate preventive and therapeutic interventions in pediatric oncology patients who will continue to require CVCs.Table 1Characteristics of the study patientsParametersSymptomatic VTE (77)Controls (178)p value*Asymptomatic VTE (10)CVC (mean)1.64±0.911.12±0.550.00011.8±1.03 (p**=0.069)Patients with >1 CVC42.8% (33)11.8% (21)0.000150% (5)Location of CVCRIJ14.3% (11)9.6% (17)–40%LIJ2.6% (2)2.3% (4)0RSCV35.1% (27)32.6% (58)20%LSCV16.9% (13)20.8% (37)0Others31.2% (24)34.8% (62)40%Type of CVCPICC11.7% (9)2.3% (4)0.01710%TL22.1% (17)22.5% (40)40%TID52% (40)60.7% (108)40%Others7.8% (6)6.2% (11)10%Side of CVCRight65% (50)57.9% (103)0.22380%Left23.4% (18)25.8% (46)–Central7.8% (6)2.8% (5)10%Numbers in parenthesis indicate patient numbers,*for comparison between symptomatic VTE and controls,**comparison with controls. Disclosures:No relevant conflicts of interest to declare.

A Comparison between Blood Flow Outcomes of Tunneled External Jugular and Internal Jugular Hemodialysis Catheters

The right internal jugular (RIJ) vein is preferred for placement of long-term venous catheters (CVC) for hemodialysis (HD). Use of left IJ vein potentially depletes the access site for arteriovenous fistula (AVF) or arteriovenous graft (AVF) placement because of the high rates of central venous stenosis. The right external jugular (EJ) vein is a viable alternative to the LIJ. The purpose of this study is to compare blood flow outcomes in a series of percutaneously placed external jugular (EJ), LIJ and RIJ HD catheters. Using a prospectively collected database, we identified 46 hemodialysis patients who received a tunneled catheter during a 4-year period. Blood flow outcomes of RIJ, LIJ, and EJ catheters that were date-matched over the study period were compared. Using ANOVA, the blood flow outcomes of the 3 tunneled catheter techniques at 30-d and 90-d were compared. The 90-d blood flow outcomes of the 3 groups did not differ significantly. The 30-d blood flow was found to be 348.5± 56.62, 341± 22.42, and 365.7± 71.76 mL/min for RIJ, LIJ, and EJ respectively (P<.05). Using multiple regression analysis, no covariates (age, sex, race, diabetes) were found to be associated with blood flow outcomes at 30-d or 90-d. No identifiable factors were found to be associated with the difference in blood flow between 30-d and 90-d either. EJ blood flow outcomes at 30-d and 90-d were comparable to both LIJ and RIJ historic data. Further prospective investigation is required to define the role of EJ CVC placement as another potential long-term access modality.

Central Venous Catheter-Induced Cardiac Tamponade

Editori have read with great interest the review (1)written by Pittiruti et.al. followed by their multicenter study (2) regarding the use of EKG for central venous catheter (CVC) positioning.Late cardiac tamponade is a fatal complication that might arise if the CVC tip is left within the pericardial reflection by continuously eroding the atrial wall over time (3). it is there-fore that i do not understand why the authors in their study (2) aimed to position the CVCs so low. only procedures that require free blood flow (dialysis, hemofiltration, plasmapher-esis, etc.) are indications for a very low CVC position. in the review the authors claim that the EKG assisted CVC positioning technique is superior to fluoroscopy. Since EKG will position the CVC at the cava-atrial junction it will leave its tip within the pericardial reflection. Additional positioning as well as chest x-ray (CXR) is therefore required. Since CXR is needed to preclude other pathologies (such as pneumotho-rax) the use of expensive EKG catheters did not add any safety to the patients.The recommendations by Pittiruti in his review and study will expose patients to the danger of incorrect (deep) CVC position while using unnecessary expensive equipment. it is my recommendation to use the CVC lengths cited by Kim et. al. (4)and verify the position by CXR.

Changes in the relationship between the right internal jugular vein and an anatomical landmark after head rotation

BackgroundThis study was performed to ultrasonographically demonstrate the changes in relationship between the right internal jugular vein (IJV) and an anatomical landmark in two different head positions: neutral and rotated.MethodsThis was a randomized clinical trial. One hundred patients scheduled for elective surgery under general anesthesia with endotracheal intubation were enrolled in this study. The patients were placed in the supine position with a neutral head position and without a pillow. The apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and clavicle was marked (AL point : anatomical landmark point). Ultrasonography of the neck anatomy was performed and the skin was marked at the central point of the IJV (US point: ultrasonography point). The other investigator measured the distance from the AL point to the US point (AL-US distance). The patient's head was then turned 30° to the left; the same procedure was repeated and the AL-US distance was again measured. The changes in AL-US distance were calculated.ResultsThe AL-US distance increased significantly after 30° head rotation compared with that in a head neutral position. The mean ± SD of the AL-US distance was 0.28 ± 0.78 cm in the neutral head position and 0.83 ± 1.03 cm in the head rotated position.ConclusionsThe anatomical landmark point becomes more distant from the actual right IJV point and moves more medially after head rotation. We suggest minimizing the angle of head rotation and taking this distance into consideration when using the landmark-guided method.

Haemodialysis catheter‐related right transverse cervical artery pseudoaneurysm and treatment by coil embolization

In patients with end-stage renal disease, temporary placement of venous catheters for haemodialysis (HD) is often necessary, and the right internal jugular (RIJ) vein is the usual preferred site of HD catheter placement. We report here a patient who experienced complications because of the development of a pseudoaneurysm of the transverse cervical artery following an apparently uneventful RIJ vein cannulation for temporary HD, using the blind landmark-guided technique. This is a rare complication of RIJ vein cannulation and HD catheter placement. The pseudoaneurysm presented 3 weeks after the procedure and was diagnosed by using colour-Doppler ultrasound, followed by an angiogram, and it was successfully occluded using endovascular coil embolization.

Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter.

The right internal jugular (RIJ) is commonly used to provide central venous access, and success of cannulation shows a positive correlation with the vein's diameter. The purpose of this study is to establish the patient position resulting in the largest RIJ diameter. 2D ultrasound was used to measure RIJ diameter, in varying body positions, in 21 healthy volunteers. In the neutral position (table flat, head on the table in midline) the RIJ diameter was (mean +/- standard deviation) 9.2 +/- 2.18 mm. A small pillow under the head increased RIJ diameter (10.6 +/- 2.16 mm, P < 0.001). Trendelenburg tilt of 15 degrees increased RIJ diameter (12.1 +/- 2.34 mm, P < 0.001). In the Trendelenburg position (15 degrees of tilt), a small pillow under the head further increased RIJ diameter (13.3 +/- 2.26, mm P < 0.001), palpating for the carotid artery decreased RIJ diameter (8.2 +/- 1.98 mm, P < 0.001), and rotation of the head 45 degrees to the left did not reduce RIJ diameter significantly (11.7 +/- 2.52 mm, P = 0.12). The patient position to achieve maximal RIJ diameter cannulation is: 15 degrees of Trendelenburg tilt; a small pillow or head ring under the head; the head in or close to midline; and after palpation of the carotid artery, it should be released prior to vein cannulation.

Percutaneous bypass cannulae can interfere with rapid infusion during liver transplantation

VENOVENOUS BYPASS (VVB) may be used during orthotopic liver transplantation (OLT) to maintain adequate preload when blood return to the heart is interrupted by cross-clamping of the inferior vena cava. Traditionally, when VVB is used, 1 drainage cannula is inserted via surgical cutdown into a femoral vein, and another is used to cannulate the portal vein directly. A centrifugal pump is used to aspirate venous blood from these sites and return it through a cannula inserted via surgical cutdown into an axillary vein. To avoid the complications of surgical cutdowns, percutaneous VVB has been used. 1 Tisone G Mercadante E Dauri M et al. Surgical versus percutaneous technique for veno-venous bypass during orthotopic liver transplantation: A prospective randomized study. Transplant Proc. 1999; 31: 3162-3163 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar , 2 Frenette L Cox J Singer D et al. Five years of experience with percutaneous cannula for establishing venous bypass access in orthotopic liver transplantation. Transplant Proc. 1996; 28: 2974-2977 PubMed Google Scholar , 3 Manas DM Gibbs P Talbot D et al. Use of percutaneously placed catheters for venovenous bypass in orthotopic liver transplantation. Transplantation. 1996; 62: 144-145 Crossref PubMed Scopus (3) Google Scholar , 4 Spiekermann BF Bogdonoff DL Hershey JE McLaughlin JD A method for percutaneous cannulation for veno-veno bypass during orthotopic liver transplantation. Anesth Analg. 1995; 80: 432-433 PubMed Google Scholar , 5 Scherer R Erhard J Giebler R et al. Percutaneous portofemoro-subclavian venovenous bypass during orthotopic liver transplantation. Transplantation. 1994; 57: 472-473 Crossref PubMed Google Scholar , 6 Scherer R Giebler R Schmutzler M et al. Effect of high shunt flows during portofemoro-subclavian venovenous bypass in human orthotopic liver transplantation. Transplant Proc. 1993; 25: 2591 PubMed Google Scholar , 7 Washburn WK Lewis WD Jenkins RL Percutaneous venovenous bypass in orthotopic liver transplantation. Liver Transpl Surg. 1995; 1: 377-382 Crossref PubMed Scopus (9) Google Scholar , 8 Ozaki CR Langnas AN Bynon JS et al. A percutaneous method for venovenous bypass in liver transplantation. Transplantation. 1994; 57: 472-473 Crossref PubMed Google Scholar , 9 Scherer R Giebler R Erhard J et al. A new method of veno-venous bypass during human orthotopic liver transplantation. Anaesthesia. 1994; 49: 398-402 Crossref PubMed Scopus (15) Google Scholar , 10 Johnson SR Marterre WF Alonso MH Hanto DW A percutaneous technique for venovenous bypass in orthotopic cadaver liver transplantation and comparison with the open technique. Liver Transpl Surg. 1996; 2: 354-361 Crossref PubMed Scopus (16) Google Scholar Although these reports all use at least 1 percutaneous cannula in the VVB circuit, they vary in their choice of cannulation sites, types and sizes of percutaneous cannulae, and VVB circuit configuration. The authors' VVB technique also varies from what has been reported. The authors routinely insert percutaneously a left femoral venous drainage cannula and a right internal jugular (RIJ) venous return cannula. The RIJ cannula serves a dual role as the major conduit for intravenous infusions from the rapid infusion system (RIS) (Haemonetics Corporation, Braintree, MA); this eliminates the need for additional large-bore intravenous access. In the following case, an unusually high VVB flow rate limited the maximal intravenous infusion rate of the RIS.

Percutaneous access for venovenous extracorporeal life support in neonates

Background: Although percutaneous cannulation has been previously described in adult and pediatric patients older than 3 years, its use in neonates for venovenous extracorporeal life support (ECLS) has not been previously described. Methods: Twenty neonates of weight 3.4 ± 0.6 kg (range, 2.3 to 4.9 kg.) with severe respiratory failure (meconium aspiration syndrome, persistent pulmonary hypertension of the newborn, sepsis) were managed with double-lumen venovenous ECLS. Percutaneous access via the right internal jugular (RIJ) vein with a 12F (n = 13) or 15F (n = 7) double-lumen ECLS cannula was obtained via a modified Seldinger technique. RIJ access was specifically obtained 2 to 3 cm above the clavicle with a 21-gauge needle and a 0.018-in guide wire followed by a technique that allowed insertion of the larger cannula guide wire. Decannulation simply involved removal of the cannula with hemostasis obtained by direct pressure. Results: Percutaneous cannulation was performed without difficulty in 11 infants. Conversion to an open technique for cannula placement was required in four patients early in our experience because percutaneous access to the RIJ with the 0.018-inch guide wire could not be achieved, and in one neonate because the 15F cannula could not be advanced into the RIJ and resulted in laceration of the vein. Inability to achieve RIJ access also led to use of an “exposure-assisted” percutaneous procedure in four patients later in our experience. Complications included a pneumothorax identified on chest radiograph 18 hours after cannulation in one infant and partial thrombotic occlusion of the cannula requiring a change over a guide wire in another. There were no problems associated with decannulation. Conclusions: This is the first description of percutaneous cannulation in neonates for venovenous ECLS. In the authors' early experience, percutaneous access using a 12F double lumen venovenous cannula may be efficiently performed especially in patients >3.0 kg in weight and has the potential for simplifying and reducing the cost of the ECLS technique.