The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children

Abstract

INTRODUCTIONWe compared the effects of various surgical positions, with and without the Valsalva manoeuvre, on the diameter of the right internal jugular vein (RIJV). METHODSWe recruited 100 American Society of Anesthesiologists physical status class I patients aged 2-12 years. The patients' heart rate, blood pressure, peripheral oxygen saturation and end-tidal CO 2 pressure were monitored. Induction of anaesthesia was done using 1% propofol 10 mg/mL and fentanyl 2 μg/kg, while maintenance was achieved with 2% sevoflurane in a mixture of 50/50 oxygen and air (administered via a laryngeal mask airway). The RIJV diameter was measured using ultrasonography when the patient was in the supine position. Thereafter, it was measured when the patient was in the supine position + Valsalva, followed by the Trendelenburg, Trendelenburg + Valsalva, reverse Trendelenburg, and reverse Trendelenburg + Valsalva positions. A 15° depression or elevation was applied for the Trendelenburg position, and an airway pressure of 20 cmH 2 O was applied in the Valsalva manoeuvre. During ultrasonography, the patient's head was tilted 20° to the left. CONCLUSION In paediatric patients, the application of the Trendelenburg position with the Valsalva manoeuvre gave the greatest increase in RIJV diameter. The reverse Trendelenburg position had no significant effect on RIJV diameter. RESULTS

Comparison of the Trendelenburg position versus upper-limb tourniquet on internal jugular vein diameter

“… 17 It also reduces the risk of air embolism. 1 , 5 , 8 Apart from this, the Valsalva manoeuvre and hepatic compression are used to increase the venous return and IJV diameters. 5 , 9 , 14 We found no studies showing the effect of taking advantage of upper-extremity venous drainage on IJV diameter and cross-sectional area.…”

“…Complications of IJV cannulation include carotid puncture, nerve damage, hydrothorax, haemothorax, pseudoaneurysm and arteriovenous fistula. 1 , 2 Internal jugular vein (IJV) cannulation is routinely performed with USG in our clinic.…”

Ultrasonographic assessment of internal jugular vein diameter and its relationship with the carotid artery at the apex, middle, and base of the triangle formed by two heads of sternocleidomastoid muscle: A pilot study in healthy volunteers

“…One recent study in children showed that Trendelenburg position and Valsalva maneuver increases IJV diameter significantly. [ 6 ] In another study,[ 7 ] Trendelenburg alone increased IJV cross-sectional area by 96% with simulated venipuncture and 40% without simulated venipuncture. Schreiber et al .…”

Practice Guidelines for Central Venous Access 2020

“…Although observational studies report that Trendelenburg positioning (i.e., head down from supine) increases the right internal jugular vein diameter or cross-sectional area in adult volunteers (Category B2-B evidence), [157][158][159][160][161] findings are equivocal for studies enrolling adult patients (Category B2-E evidence). 158,[162][163][164] Observational studies comparing the Trendelenburg position and supine position in pediatric patients report increased right internal jugular vein diameter or cross-sectional area (Category B2-B evidence), [165][166][167] and one observational study of newborns reported similar findings (Category B2-B evidence). 168 The literature is insufficient to evaluate whether Trendelenburg positioning improves insertion success rates or decreases the risk of mechanical complications.…”