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Background: Unlike the right internal jugular vein (RIJV), there is a paucity of data regarding the effect of the Tren delenburg position on the left internal jugular vein (LIJV). The purpose of this study is to investigate the cross-sectional area (CSA) of the LIJV and RIJV and their response to the Trendelenburg position using two-dimensional ultrasound in adult subjects. Methods: This study enrolled fifty-eight patients with American Society of Anesthesiologists physical status class I -II who were undergoing general anesthesia. CSAs of both the RIJV and LIJV were measured with a two-dimensional ultrasound in the supine position and then in a 10 o Trendelenburg position. Results: In the supine position, the transverse diameter, anteroposterior diameter, and CSA of the RIJV were significantly larger than those of the LIJV (P < 0.001). Of 58 patients, the RIJV CSA was larger than the LIJV CSA in 43 patients (74.1%), and the LIJV CSA was larger than the RIJV CSA in 15 patients (25.9%). In the Trendelenburg position, CSAs of the RIJV and LIJV increased 39.4 and 25.5%, respectively, compared with the supine position. However, RIJV changed at a rate that was significantly greater than that of the LIJV (P < 0.05). Of 58 patients, the RIJV CSA was larger than the LIJV CSA in 48 patients (82.8%), and the LIJV CSA was larger than the RIJV CSA in 10 patients (17.2%). Conclusions: In supine position, the RIJV CSA was larger than the LIJV CSA. The increased CSA in the Trendelenburg position was greater in the RIJV than the LIJV. (Korean J Anesthesiol 2014; 67: 305-309)

Background: This 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. Methods: This 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 (ALUS distance). The patient’s head was then turned 30 o to the left; the same procedure was repeated and the AL-US distance was again measured. The changes in AL-US distance were calculated. Results: The AL-US distance increased significantly after 30 o 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. Conclusions: The 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. (Korean J Anesthesiol 2011; 61: 107-111)

Background: Percutaneous cannulation of internal jugular vein is difficult in pediatric patients because of its small size and anatomic variation. The aim of this study is to investigate cross-sectional area and relative anatomy of right internal jugular vein with respect to the carotid artery in two approaches and thereby to find ideal cannulation site in young children. Methods: The cross-sectional area of right internal jugular vein and the degree of the carotid artery overlap was evaluated in 47 children using ultrasound at two levels; 1) at the cricoid cartilage (high approach) and 2) at the junction of the two heads of the sternocleidomastoid muscle (low approach). Results: The cross-sectional area was significantly larger by about 28.8% in the low approach than that of the high approach (P ＜ 0.01). The internal jugular vein was partially overlapping the carotid artery in 48.9% and completely overlapping in 42.6% in the low approach and in 44.7% and 34.0% in the high approach respectively. The carotid artery overlap was significantly higher in the low approach when compared with the high approach (P ＜ 0.02). Conclusions: In terms of cross-sectional area, the low approach with larger size is optimal for internal jugular vein cannulation. Although the degree of the carotid artery overlap was higher at the low approach, the internal jugular vein was partially or completely covering the carotid artery in most patients in both approaches. When attempting to cannulate the internal jugular vein, clinicians should be aware of the large anatomic variations. (Korean J Anesthesiol 2009; 57: 455∼9)

Ultrasound-guided catheterization of the central vein is a precise, safe, and easy compared with the conventional landmark method. We incidentally detected thrombosis in the right internal jugular vein (IJV) during the ultrasound-guided cannulation (on) in a 22-month-old male patient. Cardiac operations had been performed 5 times previously and the right IJV was cannulated lastly 2 months ago. The thrombosis occluded right IJV near totally, so we cannulated the left IJV instead using the ultrasound. This case demonstrates that ultrasound-guided central vein catheterization approach is helpful not only in precise puncture but also in selection of appropriate vessel. (Korean J Anesthesiol 2008; 54: 214∼6)

Right internal jugular vein catheterization is performed frequently as central venous catheterization by the landmark method. This procedure, however, might prove difficulty due to anatomic variations or thrombosis of internal jugular vein. We failed to catheterize right internal jugular vein by the landmark method in 70-year-old female patient. And then, we detected right internal jugular vein thrombosis by ultrasound scan. Left internal jugular vein catheterization was performed by the ultrasound guided technique. Central venous catheterization has possibility to fail despite several attempts by the landmark method. Then, ultrasound guided approach is a good choice to aid central venous catheterization when difficulties or complications have been encountered.

Internal jugular vein cannulation is commonly used for the anesthetic management of patients undergoing a major operation. Complications associated with internal jugular vein cannulation such as a carotid artery puncture, pneumothorax and hemothorax, have been reported; however, thrombotic complications of arteries due to accidental arterial punctures are rare. We report a case of thrombotic obstruction of the subclavian artery associated with inadvertent arterial puncture following an attempted internal jugular vein cannulation. (Korean J Anesthesiol 2008; 55: 95～8)

Background: Measuring the distance between internal jugular vein (IJV) and external jugular vein (EJV) on ultrasound image can give the information of the whereabouts of the IJV. We compared the success rate between carotid artery (CA)-guided and EJV-guided cannulation based on the information gathered from ultrasound. Methods: We studied 152 patients requiring central venous cannulation during anesthesia. Ultrasound images were obtained with 7.5 MHz probe on the right neck at 0, 30, and maximum rotation of the head in flat and 15o Trendelenberg (T) position. The horizontal diameter of the RIJV and % overlap of the CA with the RIJV at each position, and the horizontal distance of RIJV-REJV at 30o were measured on ultrasound images. In EJV group, the distance of RIJV-REJV was drawn along the cricoid level and the point of IJV was marked as the needle insertion site. Cannulation was performed with palpation of the CA in CA group and performed at the marked point in EJV group without palpation of CA. Results: Overall RIJV diameter was increased in T-position compared to flat position. Following head rotation, RIJV diameter was decreased and % overlap of CA was increased (P ＜ 0.05). In 26.8% of patients at 30 in T position, CA overlapped 26-50% of RIJV. The success rate of cannulation at the first trial was 97.4% in CA group and 96.1% in REJV group. Conclusions: With the IJV identified on ultrasound image, the distance between the IJV and the EJV can be used as another landmark for RIJV cannulation provided the EJV is visualized with the naked eye.

Central venous cannulation via an internal jugular vein has become a common procedure in the management and monitoring of severely ill patients. Although complications such as carotid artery puncture or pneumothorax have been reported, hemothorax is relatively uncommon. We describe a case of hydrohemothorax and subclavian artery laceration which occurred during right internal jugular vein cannulation. A 44-year-old female patient was admitted for laparoscopic adrenalectomy under general anesthesia. For central venous pressure monitoring, central venous cannulation performed. However, dilator overinsertion injured the right subclavian artery. This led to a massive ipsilateral hydrohemothorax requiring thoracotomy for subclavian artery repair. This case suggests that central venous cannulation should be done carefully and improves awareness of the potential for dilator induced injury.

Transesophageal echocardiography (TEE) in addition to the conventional pressure tracing method may enhance a proper insertion of pulmonary artery (PA) catheter by providing information about the real-time location of catheter. We report a case of abrupt air leakage from the balloon of PA catheter during its advancement that was immediately diagnosed by TEE in 54-year-old male with moderate tricuspid regurgitation for elective CABG. Introducer and sheath of PA catheter were inserted in right internal jugular vein. After checking balloon function, connecting distal port to a previously zeroed transducer and confirming the location in right atrium, PA catheter was advanced under direct the visual surveillance by TEE images as well as pressure tracing. During the third trial of catheter advancement through tricuspid valve, multiple air shadows, which convincing balloon leakage, were appeared in right atrium in the view of TEE after inflation of air. We withdrew catheter immediately without any further effort of balloon inflation or advancement, then, balloon leakage and the incapability of balloon expansion were confirmed by saline injection, instead of air, into the balloon port. We replaced the injured PA catheter to new one, and advanced it successfully to the wedged position by the aid of TEE and pressure tracing. We assumed that TEE image might be a beneficial aid to enhancing PA catheter placement in a proper position and preventing possible complications or side effects produced by advancing it with unawareness or delayed recognition of its dysfunction.