Central Venous Access - PEARLS
PEARLS
Knowledge of the little nuances goes a long way to improve the success rates of central venous cannulation - particularly for IJV:
1. Anatomical Variation - Cervical Vasculature's Relative Position
2. Head Positioning and Cervical Vasculature's Relative Position
3. Caliber of the Vessel
Knowledge of the little nuances goes a long way to improve the success rates of central venous cannulation - particularly for IJV:
1. Anatomical Variation - Cervical Vasculature's Relative Position
2. Head Positioning and Cervical Vasculature's Relative Position
3. Caliber of the Vessel
1. Anatomical Variation - Cervical Vasculture's Relative Position
In this study, 104's cervical triangles were examined bilaterally.
The variation in the relative positions between the IJV and CCA are as illustrated. The pattern bracketed in Red (IJV is lateral to CCV) is the classically described relative positioning of the two vessels - ~75% in this study.
In this study, 104's cervical triangles were examined bilaterally.
The variation in the relative positions between the IJV and CCA are as illustrated. The pattern bracketed in Red (IJV is lateral to CCV) is the classically described relative positioning of the two vessels - ~75% in this study.
To briefly summarize other findings from this study:
- 18%: anatomical variation on the right
- 16%: anatomical variation on the left
- 17%: unilateral variation only
- 9%: bilateral variation
- 26%: anatomical variations that may contributed to difficulty with IJV cannulation
2. Head Positioning and Cervical Vasculature's Relative Position
The head is usually rotated during the central venous catherization procedure to expose the cervical triangle. However, this maneuver can cause the IJV to overlap the CCA.
In this study, 100 patients for cardiac surgery had their IJV and CCA assessed. Dimensions of the vessels, relative positions, and a simulation cannulation pathway were assessed at 6 different head positions. The study found that the overlap was least in neutral position though progressively increased with further rotation.
The head is usually rotated during the central venous catherization procedure to expose the cervical triangle. However, this maneuver can cause the IJV to overlap the CCA.
In this study, 100 patients for cardiac surgery had their IJV and CCA assessed. Dimensions of the vessels, relative positions, and a simulation cannulation pathway were assessed at 6 different head positions. The study found that the overlap was least in neutral position though progressively increased with further rotation.
3. Caliber of the Vessel
The diameter of the IJV does affect the success rates of the procedure.
This study evaluated the failure and complication rates of US guided technique for central venous access via the IJV in 493 patients. It showed that the failures rates substantially increase in the subcentimeter range
The diameter of the IJV does affect the success rates of the procedure.
This study evaluated the failure and complication rates of US guided technique for central venous access via the IJV in 493 patients. It showed that the failures rates substantially increase in the subcentimeter range
Take Home Messages:
- If the anatomy is not favourable on one side, evaluate the contralateral side
- Minimize the overlap between IJV and CCV with head rotation
- Choose a central vein that has larger caliber: >1cm in diameter