Avaliação Ultra-Sonográfica Das Técnicas de Punção Da Veia Jugular Interna em Crianças
Avaliação Ultra-Sonográfica Das Técnicas de Punção Da Veia Jugular Interna em Crianças
Avaliação Ultra-Sonográfica Das Técnicas de Punção Da Veia Jugular Interna em Crianças
Sérgio Tomaz SchettiniI, Luiz Fernando Ybarra Martins de OliveiraII, Harold Ruiz HenaoIII, Henrique Manoel LedermanIV
I
Associate Professor, Division of Pediatric Surgery, Department of Surgery, UNIFESP, Brazil.
II
Medical student, Scientific Iniciation Program, Division of Pediatric Surgery, Department of Surgery, UNIFESP, Brazil.
III
Radiologist Member of the Division of Diagnostic Imaging in Pediatrics, Pediatric Institute of Oncology, UNIFESP, Brazil.
IV
Full Professor of Radiology, Department of Diagnostic Imaging, UNIFESP, Brazil.
ABSTRACT
Purpose: To determine by ultrasound which access and position the child must stay to obtain the best transversal section of the right
Internal Jugular Vein (RIJV) allowing a safer puncture. Methods: Three possible accesses to the RIJV, anterior, lateral and posterior,
from 57 healthy children, were analyzed through ultrasound images in a sequence of positions of the head, in supine position, with or
without a roll under the scapula: head centered in neutral position with and without a roll (NPP and NP); contra lateral rotation with and
without a roll (CLRP and CLR), neutral position and the patient raised in 30° in Trendelenburg position (TDG). To analyze the results it
was applied one statistic method, with variation analysis to the same individuals. Basic Procedures: Ultrasound evaluation in each one of
the proposed positions. Results: The statistical analysis of the results observed that the lateral puncture with the patient in the neutral
position, in Trendelemburg without a roll, offers a bigger area in comparison to all the other options of puncture and positioning of the
patient (p<0, 0001). Conclusion: The safer way for the puncture of RIJV in children is obtained in neutral position in Trendelemburg by
lateral puncture, without a shoulder roll.
Key words: Jugular Veins. Ultrasonics. Child.
RESUMO
Objetivo: Determinar pelo ultra-som qual o melhor acesso e posicionamento da criança com o intuito de se obter a melhor secção
transversal da veia jugular interna direita (VJID), permitindo uma punção com maior segurança. Métodos: Três possíveis acessos a
VJID, anterior, lateral e posterior foram analisados pela ultrassonografia em uma sequência de diferentes posições da cabeça, estando o
paciente em posição supina com ou sem um coxim sob a escápula; cabeça na posição neutra; (NPP E NP); rotação lateral da cabeça
(CLRP e CLR), posição neutra com o paciente em posição de Trendlemburg a 300 (TDG). Para analisar os resultados foi aplicado um
método estatístico com análise variada sobre os mesmos indivíduos. Procedimentos básicos: Avaliação ultrassonográfica em cada uma
das posições propostas. Resultados: Pela análise estatística dos resultados observou-se que a punção lateral estando o paciente em
posição neutra, em Trendlemburg sem a colocação de coxim sob a escápula oferece uma área maior em comparação a todas as outras
opções de punção e posicionamento do paciente (p<0,0001). Conclusão: A melhor técnica para a punção da VJID em crianças foi a
posição neutra em Trendlemburg, por punção lateral , sem a colocação de um coxim sob a escápula.
Descritores: Veias Jugulares. Ultra-som, Criança.
1
Research performed at the Department of Diagnostic Imaging, Federal University of São Paulo (UNIFESP), Brazil.
malposition of the catheter with hydrothorax, hemothorax, venous Concerning the puncture of the internal jugular vein is
thrombosis, pseudo aneurysm, arteriovenous fistula. The incidence preferable the right side because we have a straight way from the
of these complications are directly related to the skill and the vein, the brachiocephalic trunchus and the superior vena cava,
physician’s experience whereas the incapacity of obtaining the lowering the risks and improving the chance to reach the right
catheterization of IJV through puncture is referred in 19, 4%2. atrium, whereas on the left IJV, there is an acute angle between the
The success rate in the catheterization of IJV is lower vein and the brachiocephalic trunchus.
and the number of complications is higher in children than among The purpose of this study, using the ultrasound, is to
adults due to the smaller size of the vein, the close proximity of determine which would be the best way and patient position in
the common carotid artery and the variation of the vein position order to obtain the larger transversal section of the right IJV (RIJV)
related to the artery and to the cervical muscles not fully for catheterization, allowing a safer and precise access.
developed, which makes difficult the characterization of anatomical
landmarks in order to due a precise puncture. We must also Methods
consider the lack of cooperation from the small patients, and the
risks related to their sedation. The study was held at the Department of Diagnostic
Therefore the larger the diameter of the IJV the easier will Imaging, UNIFESP, from January of 2004 to June of 2006, with
be to obtain catheterization, because there is a significant relation volunteer patients from the outpatient clinic of the Division of
between the increase diameter of the IJV and the success rate at the Pediatric Surgery, in healthy condition, almost all of them bearers
first attempt to catheterization3. of phimosis, inguinal or umbilical hernia or cryptorchidic testes.
There are three sites or ways to access the IJV for puncture. Informed consent was provided by the parents or responsible tutor.
The landmarks are the margins of the sternocleidomastoid muscle: All procedures were done without sedation.
(A) anterior, (B) lateral and (C) posterior (Figure 1). 57 healthy children were selected, 21 girls and 36 boys
with ages between 8 months and 16 years-old (average age of 5,9
A) The puncture is done in the anterior margin of years-old). The criteria of exclusion were the existence of previous
sternocleidomastoid muscle (ECM), at the middle from the access of IJV or primary or secondary affections in the cervical
mastoid process and the clavicle. region which could change the anatomy of the IJV.
B) The puncture is done in the apex of the triangle formed The three possible ways to access the RIJV, anterior,
between the clavicle and the ECM margins. lateral and posterior, were analyzed through ultrasound images
C) The puncture is done in the posterior margin of ECM obtained with a linear transductor (10mHz) in a perpendicular
towards the jugular sternal incisure. section to the vessel, applied with the minimum pressure in order
to obtain a good image4.
These options are illustrated bellow: The ultrasound equipment that was used in all patients
was a SiemensR Sonoline Antares, Sie Scape, 3 Scape.
The sequence of examination was:
1) Supine position with the head in neutral position
without the use of a roll under the scapula (NP);
2) Supine position with contra lateral rotation of the head
without the use of a roll under the scapula (CLR);
3) Supine position with the head in neutral position with
the use of a roll under the scapula (NPP);
4) Supine position with contra lateral rotation of the head
with the use of a roll under the scapula (CLRP);
5) Supine position with the head in the neutral position
with the patient in Trendelenburg (patient raised 30° related to the
floor) without the use of a roll under the scapula (TDG).
The study was limited to the right internal jugular vein
due to aforementioned reasons.
The rolls were standardized for all patients according
to their weight and height. The head was positioned with the
auricular pavilion below the shoulder level and the chin at 90
degrees in relationship to the floor.
Images were performed in each position, in three different
locations, in relation to the ECM muscle, anterior, lateral and
posterior (Figure 1).
During the examination the carotid artery and jugular vein
were identified by their anatomical locations, ultrasound
characteristics and patterns of pulsation. Measurements of the
transverse section of RIJV were obtained during the examination,
FIGURE 1 from a frozen image on the monitor screen, using calipers. Also,
measurements of the average distance from the skin to the center
of the RIJV were obtained in each different acquisition.
dist
dist
dist
dist
dist
dist
dist
dist
dist
dist
dist
dist
dist
dist
diam
diam
diam
diam
diam
diam
diam
diam
diam
diam
diam
diam
diam
diam
diam
1,0 to 1,3 cm or 3,0 mm. (Figure 2).
This difference was considered without lat post ant lat post ant lat post ant lat post ant lat post ant
significance.
np clr npp clrp tdg
Discussion FIGURE 2 - Average of the transversal section (diameter in cm) of the RIJV and the distance of
the center of the vein to the skin (in cm) obtained at the ultrasound in 57 children
The easy access, the superficial
localization related to the skin (1,0 to
1,3 cm in this study) and the low
incidence of pneumothorax in comparison to the puncture of accidental puncture of the artery8. The extreme rotation has the
the subclavia vein, make the IJV one excellent option to obtain a inconvenience of making difficult the IJV puncture9 and also
central venous access1. It is well established the puncture on the interfere in the ventilation, increasing the risk in critical patients.
right side it is easier to reach the vena cava due to better anatomical The use of ultrasound for puncture the RIJV is an easy
conditions, practically a straight way. That was the reason we have procedure10,11. Adequate transverse diameter is necessary for small
limited this study on the right internal jugular vein. children.
There is a straight correlation between the diameters In patients suspected to have injury in the cervical column
of IJV with the success in the first attempt of catheterization or in the initial treatment of the infantile trauma that needs the
by puncture 3. central venous access we can use the NP position, which becomes
The position of the TDG increases the venous return and very important despite reducing the vision field and presenting
consequently the transversal section of IJV, increasing the success smaller average diameter in comparison to the TDG position.
of the puncture. Also minimize the chance of gas embolism1,5,6. On the contrary, as the referred by Parry10, the use of a
Nevertheless, is not recommended in the cardiac pulmonary edema roll under the scapula which is a very common practice among
and in situation of reduced brain perfusion7. several professionals, did not determined any benefit, in any of the
In these conditions we can try CLR, which give the positions studied.
second largest diameter. On the other hand it may superimpose the Lukish et al.12 have the same conclusion in regard to
RIJV to the common carotid artery, which increases the chance of the subclavian vein in children. Their conclusion are against the
recommended maneuvers of turning the head or turning the head 4. Defalque RJ. Percutaneous catheterization of the internal jugular vein.
and placing a posterior shoulder roll. According to the authors these Anesth Analg. 1974;53:116-21.
procedures significantly reduce the cross-sectional area of the 5. Lobato EB, Florete OG, Paige GB, Morey TE. Cross-sectional area and
subclavian vein and maintaining the head in a normal position with intravascular pressure of the right internal jugular vein during anesthesia:
effects of Trendelenburg position, positive intrathoracic pressure and
the chin midline without a shoulder roll optimizes subclavian vein
hepatic compression. J Clin Anesth. 1998;10:1-5.
size. These recommendations may serve to reduce the morbidity 6. Botero M, White SN, Younginer JG. Effects of Trendelenburg position
associated with percutaneous subclavian vein cannulation. and positive intrathoracic pressure on internal jugular vein cross-sectional
In a similar study performed in adults, concerning the area in anesthitized children. J Clin Anesth. 2001;13:90-3.
puncture of the IJV, Suarez et al.13 went to the same conclusion, 7. Mallory DL, Shawker T, Evans RG, McGee WT, Brenner M, Parker M,
like the present study in children. Morrison G, Veremakis L, Parillo JE. Effects of clinical maneuvers on
sonographicallly determined internal jugular vein size during venous
Conclusion cannulation. Crit Care Med. 1990;11:1269-73.
8. Sulek CA, Gravenstein N, Blackshear RH, Weiis L. Head rotation
during internal jugular vein cannulation and the risk of carotid artery
The best and precise way for the catheterization of RIJV
puncture. Anesth Analg. 1996;82:125-8.
in pediatric patients is obtained in Trendelemburg, with lateral 9. Bazaral M, Harlan S Ultrassonographic anatomy of the internal jugular
access without the use of a roll under the scapula. vein relevant to percutaneous cannulation. Crit Care Med. 1981; 9:307-10.
10. Parry, G Trendelenburg position, head elevation and a midline position
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11. Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM.
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Correspondence:
Rua Butirapoã, 111
05050-030 Sao Paulo – SP Brazil
Phone/Fax: (55 11)5539-4621
stschettini@uol.com.br
Received: March 28, 2008
Review: May 29, 2008
Accepted: June 30, 2008