Head Rotation During Internal
and the Risk of Carotid Artery
Cheri A. Sulek,
Lee
Weiss,
Departments
MD*,
Nikolaus
Gravenstein,
Jugular Vein Cannulation
Puncture
MD*t,
of *Anesthesiology
and tNeurosurgery,
University
We undertook
a prospective
laboratory
study to examine the effect of head position on the relative positions of the carotid artery and the internal jugular
vein (IJV). Volunteers
(n = 12) from departmental
staff, 18-60 yr of age, who had never undergone
cannulation of the IJV underwent
imaging of their IJV
and carotid artery. With the subject in a 15” Trendelenburg position, two-dimensional
ultrasound
images of the IJV and the carotid artery were obtained
on the left and right sides of the neck at 2 and 4 cm
from the clavicle along the lateral border of the sternal head of the sternocleidomastoid
muscle at 0”, 40”,
and 80” of head rotation from the midline. The percent overlap of the carotid artery and IJV increased
significantly
at 40” and 80” head rotation to both the
right and left (P < 0.05). Data from 2 and 4 cm above
C
ompared with the subclavian approach, percutaneous cannulation of the internal jugular vein
(IJV)
Robert H. Blackshear,
MD*,
and
MD”
has a lower
incidence
of complications.
The most common of these is carotid artery puncture,
the incidence of which ranges from 3% to 10% (l-4).
Although usually benign, for example, when an inconsequential hematoma results, accidental carotid artery
puncture can be life-threatening when it results in
accidental intraarterial cannulation, cerebrovascular
accident, hemothorax, IJV-carotid artery fistula, or
airway compromise secondary to hematoma (5-7).
Although the incidence of accidental puncture of the
carotid artery decreases with practitioner experience, the risk of this complication is never eliminated (4).
When the IJV requires cannulation, its exposure is
commonly facilitated by rotating the head away
from the side being cannulated. The recommended
Presented in part at the Twenty-second
Educational
and Scientific
Symposium
of the Society of Critical Care Medicine,
New York, NY,
June 1993.
Accepted
for publication
August
17, 1995.
Address correspondence
to Nikolaus
Gravenstein,
MD, Attn: Editorial Office, Department
of Anesthesiology,
University
of Florida
College of Medicine,
PO Box 100254, Gainesville,
FL 32610-0254.
01995 by the International
0003.2999/96/$5.00
Anesthesia
Research
of Florida
College
of Medicine,
the clavicle did not differ and
cent overlap was larger on the
with 80” of head rotation (P
overlap of carotid artery and
Gainesville,
Florida
were pooled. The perleft than the right only
< 0.05). The increased
IJV with head rotation
>40” increasesthe risk of inadvertent puncture of the
carotid artery associated with the common occurrence of transfixion
of the IJV before it is identified
during needle withdrawal. The IJV frequently collapseswith needle insertion. This may result in puncture of the posterior wall of the vessel,and thus of the
carotid artery when the two vesselsoverlap. To decreasethis risk, the head should be kept in asneutral
a position as possible, that is ~40” rotation, during
IJV cannulation.
(Anesth Analg 1996;82:125-8)
amount of rotation from midline ranges from 30” to
90” (S-11). This practice presumes that rotation either enhances, or does not significantly affect, the
relative position of the IJV and the carotid artery. If
this presumption is wrong, and the technique results in new overlap or increasing overlap, this
would increase the risk of accidental puncture. During IJV cannulation, venous blood return may not be
achieved until the needle is withdrawn because the
pressure of the advancing needle can cause the IJV
to collapse, the incidence of which is reported to be
50% (12). This, in turn, causes the needle to puncture
the posterior wall of the IJV and the carotid artery,
if it is lying behind the IJV.
The anatomic position of the IJV is generally lateral
and anterior to the carotid artery (Fig. 1). Variations in
the relative positions of the IJV and carotid artery that
could result in accidental puncture of the carotid artery have been documented by ultrasound (13-15). In
one series of 77 ultrasonographically visualized IJVs,
in three cases, the IJV overlapped the carotid artery;
head position, however, was not specified (14). Therefore, we designed a study to examine, by ultrasound
imaging, the influence of head position on the relative
positions of the IJV and the carotid artery.
Society
Anesth
Analg
1996;82:125-8
125
126
SULEK ET AL.
HEAD ROTATION
DURING
JUGULAR
ANESTH ANALG
1996;82:125%?
VEIN CANNULATION
1. Percent Overlap of Carotid Artery by Internal
Jugular Vein at Three Different Degreesof Head Rotation
Table
Overlap of vesselswith different degrees
of head rotation (%)
Side of
neck
0”
40"
Right
1.5 rt 0.8
Left
(O-17.4)
5.2 2 2.9
(O-54)
6.5 t 2.8
(O-48)
11.5 t 4.9
(O-76.5)
Values
*P <
t P <
$P <
Figure
1. Typical anatomic
relationship
(a) and the internal
jugular
vein (b)
weighted
magnetic
resonance
imaging
with neutral head position.
between
the carotid artery
demonstrated
by axial T-l
at the cervical
level of 5-6
Methods
The research protocol was approved by our institutional review board, and informed consent was obtained from subjects who were volunteers recruited
from departmental staff. The subjects (n = 12) ranged
in age from 18 to 60 yr, and had never undergone IJV
cannulation. For testing, each subject was placed supine in a 15” Trendelenburg position. Images were
made of the right and left sides of the neck at 2 and 4
cm from the clavicle along the lateral border of the
sternal head of the sternocleidomastoid muscle and at
0”, 40”, and 80” rotation of the head from midline. The
same, experienced, vascular laboratory technician obtained all images by ultrasound (Ultramark@ 9 HDI;
Advanced Technology Laboratories, Inc., Bothell,
WA) with a 38mm-linear-array
(LlO-51, 7.5-MHz
transducer, which was held perpendicular to the long
axis of the body and applied gently, so as not to distort
the underlying low-pressure venous structure. Images
were displayed on a B-mode scan with color flow, and
color prints were developed for off-line analysis. The
diameter of both the IJV and the carotid artery and the
percent overlap between the two vessels were measured from the prints by two independent observers.
Percent overlap was calculated as follows:
% overlap =
[overlap (mm)/carotid artery diameter (mm)1 X 100.
are
0.05
0.05
0.05
80"
27.5 I 7.4"t
(O-100)
44.7 t 7.2*+$
(O-100)
means t SEM; range given in parentheses.
compared with 0” rotation to same side of the neck.
compared with 40” rotation to same side of the neck
compared with 80” rot&Ion to the right.
The difference between percent overlap at the different degrees of head rotation were analyzed statistically by a multiple group comparison with a twoway repeated-measures analysis of variance followed
by Student-Newman-Keuls testing, where P < 0.05
was considered significant.
Results
Overlap of the carotid artery by the IJV did not differ
between 2 and 4 cm above the clavicle at the same
degree of head rotation, and did not differ between
the observers who analyzed the printed color images;
therefore those data were pooled. Of the 12 subjects,
11 had some degree of overlap between the vessels
with different degrees of rotation to either side. When
compared with rotation from 0” to 40”, when head
rotation to the same side was increased to 80”, percent
overlap of the carotid artery by the IJV increased
significantly (P < 0.05) (Table 1, Fig. 2). When overlap
occurred, it was always more on the left than the right
side, but this was significant only at 80” head rotation
(P < 0.05). No overlap at any time-that
is, a fixed
relationship between the two vessels, even with 80” of
head rotation-was observed in one subject on the left
side, three subjects on the right side, and one subject
on both sides, the relative positions of the two vessels
in these subjects being normal (Fig. 3).
Discussion
The IJV is routinely cannulated for central venous
access. Skin puncture and cannulation are facilitated
by exposure of the neck with contralateral head rotation. Our data demonstrate that this maneuver alters
the anatomic relationship of the IJV and the carotid
artery. This has not previously been documented.
Variation in the relative positions of these vessels,
including extreme lateral and even medial positions of
the IJV relative to the carotid artery, complicate cannulation when external landmarks are used as the sole
guide to cannula placement. Interestingly, in one
ANESTH
ANALG
1996;82:125-X
Figure
2. Ultrasound
images of the internal jugular vein (v) and the
carotid artery (a) 4 cm above the clavicle on the right with evidence
of substantial
overlap
at neutral
head position
(top) and even
greater overlap with head rotation
to 40” (middle)
and 80” (bottom).
study that used ultrasound
imaging, with head rotation of approximately
30” from midline, an aberrant
anatomic relationship
between IJV and carotid artery
was observed whereby, in 1% of patients, the IJV was
more than 1 cm lateral to the carotid artery, and in 2%
the IJV was medially positioned to the carotid artery
(13). Head rotation did not correlate with the relationshin between the two vessels (13). In an ultrasound
HEAD
ROTATION
DURING
JUGULAR
VEIN
SULEK
ET AL.
CANNULATION
127
Figure
3. Ultrasound
images of the internal jugular vein (v) and the
carotid
artery
(a) 4 cm above the clavicle
on the right without
evidence of overlap
with a neutral head position
(top) or with head
rotation
to 40” (middle)
and 80” (bottom).
study of pediatric cardiac patients, the carotid artery
coursed posteriorly
to the IJV in 10% of patients,
which would predispose
them to accidental carotid
artery puncture (15). In the present study, an aberrant
anatomic relation between the two vessels was not
noted, but overlap between them was significant in all
but one subject.
Cannulation of the IJV can be facilitated with ultrasound imagine. The use of ultrasound
imaging: has
128
SULEK
HEAD
ET AL.
ROTATION
DURING
JUGULAR
VEIN
ANESTH
ANALG
1996;82:125-8
CANNULATION
decreased not only the number of attempts and the
time needed to place the cannula but also the incidence of carotid artery puncture
(14,16-l@.
Ultrasound imaging is especially appealing in teaching situations,
and in situations
where
carotid
artery
puncture should be avoided or external or anatomic
landmarks
to guide needle placement are distorted.
Portable ultrasound
equipment or echocardiography,
however, are often not accessible.
Accidental
carotid artery puncture
is usually benign, but can result in serious complications
(5-7).
Therefore, we advocate neutral or near neutral head
position during IJV cannulation to reduce the risk of
carotid artery puncture. In spite of greater difficulty
because of associated change in mandible position,
and the more acute needle insertion angle required
with a neutral head position, this method has been
highly successful:
In patients with cervical spine injury, in whom maintenance of neutral head and neck
positions is mandatory,
cannulation of the IJV had a
98% success rate (19).
In addition to the customary guidelines for IJV cannulation, we would add the following
based on our
data: 1) The head should be kept in as near a neutral
position as possible to decrease the risk of carotid
artery puncture associated with overlap of the two
vessels caused or increased by head rotation. 2) The
right IJV should be preferred for cannulation because
this approach is associated with less overlap of carotid
artery and IJV and with fewer cannula malpositions
than cannulation on the left side (20).
We would like to thank
sound imaging
Sheila
Smith
for her assistance
with
ultra-
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