Share this article on:

Positive End-Expiratory Pressure to Increase Internal Jugular Vein Size Is Poorly Tolerated in Obese Anesthetized Adults

Downey, Laura A. MD; Blaine, Kevin P. MD, MPH; Sliwa, Jan MD; Macario, Alex MD, MBA; Brock-Utne, John MD, PhD

doi: 10.1213/ANE.0000000000000347
Patient Safety: Brief Report

BACKGROUND: Central venous cannulation is technically challenging in obese patients. We hypothesized that positive end-expiratory pressure (PEEP) increases the size of the internal jugular vein (IJV) in obese adults.

METHODS: The circumference and cross-sectional area of the IJV were measured in obese patients under general anesthesia at PEEP 0, 5, and 10 cm H2O. Results are reported as means ± SE.

RESULTS: PEEP at 10 cm H2O was tolerated by 18 of 24 obese patients. Each 5 cm H2O of PEEP increased the cross-sectional area by 0.16 ± 0.02 cm2 (P < 0.0001) and the circumference by 0.23 ± 0.03 cm (P < 0.0001).

CONCLUSIONS: PEEP modestly increases the size of the IJV in obese adults but was poorly tolerated because of hypotension.

From the Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University Medical Center, Stanford, California.

Laura A. Downey, MD, is currently affiliated with the Department of Anesthesia, Boston Childrens Hospital Boston, Boston, Massachusetts.

Kevin P. Blaine, MD, MPH, is currently affiliated with the Critical Care Medicine Department of the National Institutes of Health Clinical Center, Bethesda, Maryland.

Accepted for publication May 9, 2014.

Funding: This study was supported solely with departmental funds.

The authors declare no conflicts of interest.

This report was previously presented, in part, at the IARS Annual Meeting 2013.

Reprints will not be available from the authors.

Address correspondence to Laura A. Downey, MD, Department of Anesthesia, Boston Childrens Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to

© 2014 International Anesthesia Research Society