Trendelenburg position for internal jugular vein catheterization: A systematic review and meta-analysis

Abstract

To determine the effect of Trendelenburg position on the diameter or cross-section area of the internal jugular vein (IJV) a systematic review and metanalysis was performed. Studies that evaluated the cross-sectional area (CSA) and anteroposterior (AP) diameter of the right internal jugular vein (RIJV) with ultrasonography in supine and any degree of head-down tilt (Trendelenburg position) were analyzed. A total of 22 articles (613 study subjects) were included. A >5° Trendelenburg position statistically increases RIJV CSA and AP diameter. Further inclination from 10° does not statistically benefit IJV size. This position should be recommended for CVC placement, when patient conditions allow it, and US-guided cannulation is not available.

Trendelenburg (Head‐Down tilt) and head rotation: Ultrasonographic effects on the internal jugular vein for catheterization safety

“…The right IJV is the recommended vessel for CVC. Although risks are lowered using real‐time US‐guided cannulation, even in expert hands, complications may still occur (Garcia‐Leal et al, 2021; Srinivasan et al, 2017). Patient positioning may provide a more comfortable approach for the physician with partial HR, and lower complication rates regarding posterior wall puncture and arterial cannulation when patient conditions allow it.…”

“…Contrary to this, a recent metaanalysis concluded any TP ≥5 increased the CSA and anteriorposterior diameter of the right IJV, and TP above 10 did not further benefit size, similar to our results. However, no significant changes were exhibited with HR in their analysis (Garcia-Leal et al, 2021). In the absence of contraindications, the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists currently recommend patients should be placed in a TP to increase IJV diameter and reduce the risk of air embolisms (Troianos et al, 2011).…”

“…The internal jugular vein (IJV) is frequently the first option for CVC due to its safety and accessibility, with lower complication rates. However, the femoral, axillary, brachiocephalic, and subclavian veins are also viable options, when the IJV is not (Garcia‐Leal et al, 2021; Hoffman et al, 2017; Lalu et al, 2015; Smith & Nolan, 2013; Spencer & Pittiruti, 2019).…”

“…Several techniques such as the Valsalva maneuver and liver compression have been proposed to increase IJV size and diameter, facilitating its cannulation (Armstrong et al, 1994; Beddy et al, 2006; Dincyurek et al, 2015; Javeri et al, 2020; Troianos et al, 2011). The most controversial topic still being the applicability and safety of a head‐down tilt (Trendelenburg) position and contralateral head rotation (HR) (Garcia‐Leal et al, 2021; Hoffman et al, 2017; Lamperti, Subert, et al, 2012; Wang et al, 2006; Zingg et al, 2011).…”

“…The Trendelenburg position (TP), originally described at a 45° inclination, favors venous blood return to increase the veins' cross‐sectional area (CSA), although the position has been modified to make it feasible in current clinical scenarios, and many times this is referred to as head‐down tilt (Bellazzini et al, 2009; Bernstein et al, 1999; Bos et al, 2016; Marcus et al, 2010; Nayman et al, 2015). Contralateral HR does not exhibit changes on the CSA of the IJV and allows better exposure (Garcia‐Leal et al, 2021; Quiroga‐Garza et al, 2021; Suarez et al, 2002; Wang et al, 2006). Yet, these positions are still debated due to lack of evidence between degrees of position, symptomatic effects in patients, such as the tolerance of the position, difficulty breathing, distress, possible increase of intracranial o intraocular pressures, worsening of heart problems, and anatomical changes such as IJV CSA changes, and positioning in relation to the carotid artery (CA).…”