Optimal head rotation and puncture site for internal jugular vein cannulation after laryngeal mask airway insertion

Abstract

INTRODUCTIONRecently, the laryngeal mask airway (LMA) is frequently used for patients under general anaesthesia.(1-7) Occasionally, a clinical situation that requires internal jugular vein (IJV) cannulation after LMA insertion is encountered, especially for difficult airways in patients undergoing major surgery. (8,9) However, the anatomic relationship of the IJV and the common carotid artery (CCA) has been reported to change significantly in patients after LMA insertion.(10) The degree of overlap between the right IJV and the right CCA was found to be greater after LMA insertion.(10) In our experience, there are many cases of complete overlap between the right IJV and the right CCA after LMA insertion. This means that there is a higher risk of puncturing the CCA and a lower rate of successful IJV cannulation, when IJV cannulation is performed after LMA insertion. Lieberman et al reported that an increase in head rotation was associated with a higher probability of CCA contact; (11) we postulated that the effect of head rotation would be similar in patients with LMA insertion. If the degree of overlap between the right IJV and the right CCA varies according to the degree of head rotation after LMA insertion, the degree of head rotation with the least amount of overlap can be determined and the risk of CCA puncture can therefore be reduced.The central landmark approach, which is commonly used for IJV cannulation, was shown to have a low success rate in patients with LMA insertion.(12) Takeyama et al recommended the use of a lower puncture point -near the area where the clavicular head of the sternocleidomastoid muscle (SCM) attaches to the clavicle; the CCA was not observed to be in the vicinity of the IJV when the patient was in that position even after LMA insertion.(10) Although the authors performed test punctures at the supraclavicular lower puncture point in 20 patients without any complications, Kim et al (13) opined that the supraclavicular puncture could still be associated with pneumothorax, hydrothorax or cardiac tamponade. Takeyama et al evaluated the puncture point using only a 30° head rotation, (10) without evaluating the effect of different degrees of head rotation. Another commonly used landmark approach for IJV cannulation is the skin point 1.5 cm or 2.5 cm medial to the external jugular vein (EJV). (14) The use of this landmark has not been evaluated in patients with LMA insertion.In the present study, we compared the degrees of overlap between the right IJV and the right CCA as well as the success rates of simulated right IJV cannulation between patients with LMA insertion and patients with endotracheal intubation (E-tube) using ultrasonography. We aimed to find: (a) the optimal degree of head rotation for right IJV cannulation; and (b) a suitable skin landmark for right IJV cannulation after LMA insertion. To achieve these goals, we compared the success rates of simulated right IJV cannulation at different degrees of head rotation and used different skin landmarks for right IJV cannulation.

The airway device preference may affect the overlapping of the common carotid artery by the internal jugular vein

“…They found a higher overlap percentage and lower success rate of the simulated IJV cannulation after laryngeal mask airway vs ETT insertion. The cannulation of right IJV was considered to be more difficult after laryngeal mask airway insertion and Kim et al (16) explained this finding due to the displacement of the sternocleidomastoid muscle that makes the central landmark less valuable for IJV puncture and palpating the CCA more difficult. The results of our study also reveals similar results but in pediatric population.…”

“…One recent report compared the overlap of the CCA by the IJV after laryngeal mask airway and ETT placement in 100 adult patients under 15°, 30°, and 45° head rotation . They found a higher overlap percentage and lower success rate of the simulated IJV cannulation after laryngeal mask airway vs ETT insertion.…”

“…The percentages of CCA overlap decreased significantly on the right side with a neutral head position (31.23% vs 6.27%; difference in median: 19; 95% CI of difference: À5.68 to 43.68; P = 0.002) and on both sides with a 40°h ead away position [29.50% vs 16.19%, difference in median: 26; 95% CI of difference: 2.84-49. 16; P = 0.03 and 47% vs 31.94%, difference in median: 9.50; 95% CI of difference: À40.87 to 59.87; P = 0.03 for the right and left sides, respectively] ( Table 4). Table 5 summarizes the distribution of right and left IJV positions in groups laryngeal mask airway and ETT in neutral and 40°head rotation positions after airway device insertion.…”

Ultrasonographic Assessment of Anatomic Relationship Between the Internal Jugular Vein and the Common Carotid Artery in Infants and Children After ETT or LMA Insertion: A Prospective Observational Study

“…In a previous study, Takeyama et al ( 7) reported a similar result in adults; one possible reason is that when the head rotated after LMA insertion, the CCA tends to be subject to external pressure from the inflated cuff, causing it to lean toward the dorsal side of the IJV. Furthermore, the LMA insertion may displace the sternocleidomastoid muscle, which makes palpating the CCA difficult (20). So, the usual attempts to catheterize the IJV just lateral to the CCA may result in failure.…”

Difficult Central Venous Cannulation under Laryngeal Mask Airway Anesthesia in Adolescent

“…4 Although, studies have also proven the LMA insertion instigated the overlapping of IJV over CCA and distortion of anatomical land marks. 5 We present a case of difficult right sided IJV access under LMA anesthesia, which triggered the surgical morbidity like prolonged surgical duration and excessive blood loss.…”