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

Abstract

Most guidelines fail to specify patient positioning during central venous catheterization. The objective was to determine the effects of head‐down tilt (Trendelenburg position) and head rotation on the internal jugular vein (IJV). A prospective, observational, longitudinal, and descriptive study using healthy adult volunteers, of both sexes, was performed. The change in position and cross‐sectional areas (CSA) of the right IJV and common carotid artery (CA) were measured by ultrasonography during Trendelenburg position (TP) (0°, 5°, 10°, and 15°) and contralateral head‐rotation (HR) (0°, 45°, and 90°) for a total of 12 positions. The neutral supine position was first, randomizing the other 11 positions, with 5‐min rest intervals in between. Vital signs and symptoms were recorded. A total of 54 volunteers were recruited between the ages of 21 and 32, of which 30 were men. Any degree of TP or HR significantly increased the CSA. The largest area obtained was 1.78 cm2 with a TP15HR90 which did not have a statistical difference with TP10HR45 1.59 cm2. A HR90 tended to displace the IJV medially, overlaying the CA. Any degree of TP or HR will significantly increase CSA or the right IJV. A 5° to 10° TP is recommended when the patient's condition allows it, with a 45° HR, without significantly displacing the IJV anterior to the CCA.

Use of Jugular Venous Pressure to Optimize Outcomes of Vestibular Schwannoma Resection: A Review of the Literature and Proof of Concept

“…In summarizing this literature, a consistent observation emerges: head rotation leads to occlusion of the IJV on the ipsilateral side, while leaving the contralateral IJV unaffected or possibly more patent. Watson et al (1974) 5 2022) 12 all independently found contralateral IJV diameter, patency, or cross-sectional area to increase following head rotation using ultrasound. Regarding neck flexion, little work has been done to investigate the impacts it may have on IJV occlusion.…”

Anatomical review of internal jugular vein cannulation

“…Many studies have identified an increase in IJV CSA with contralateral head rotation, making this a useful maneuver during cannulation [19,49,87,97]. An USG-based study found that the right IJV CSA decreased from 14.2 mm 2 to 8.7 mm 2 when transitioning from a >30° contralateral rotation to <30° ipsilateral rotation [87].…”

“…Increased tilt over 15° increases CSA further but has been shown to increase intracranial pressure [32]. Therefore, IJV cannulation is recommended to be performed at a Trendelenburg position of 5° to 10° with 45° contralateral head rotation, allowing a significant increase in IJV CSA without a significant displacement of the IJV location [49].…”

“…The CSA is significant since a low CSA may indicate stenosis or an underlying pathology [63]. Variations in CSA at different cervical levels, head rotations, and positions provide options that are most favorable for successful IJV cannulation [19,49,66,95].…”

Effect of passive leg raising on the cross-sectional area of the right internal jugular vein in patients with obesity: a randomised controlled trial protocol

“…The placement of central venous catheters can be particularly difficult in patients with obesity due to the obscured neck landmarks; furthermore, a high body mass index (BMI) is one of the most significant risk factors for complications during IJV cannulation in the surgical period 5 6. The success rate of central venous cannulation correlates with the venous cross-sectional area (CSA) 7–10. Techniques such as positive end-expiratory pressure, the Trendelenburg position, passive leg raising (PLR): a technique to elevate the patient’s legs to increase the venous return, and the Valsalva manoeuvre have been shown to increase the CSA of the IJV in anaesthetised patients 11–15.…”