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The Effect of Passive Leg Elevation and/or Trendelenburg Position on the Cross-Sectional Area of the Internal Jugular Vein in Infants and Young Children Undergoing Surgery for Congenital Heart Disease

Kim, Won Ho MD; Lee, Jong Hwan MD, PhD; Lee, Sangmin M. MD, PhD; Kim, Chung Su MD, PhD; Kang, Ryunga MD; Yoo, Chan Seon MD; Cho, Hyun Sung MD, PhD

doi: 10.1213/ANE.0b013e31826d2a89
Pediatric Anesthesiology: Research Reports
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BACKGROUND: In this study we evaluated the effect of passive leg elevation (LE) and Trendelenburg (T) position on the cross-sectional area (CSA) of the internal jugular vein (IJV) in infants and young children undergoing surgery for congenital heart disease. A secondary aim was to compare the CSA of the IJV between subjects with right-to-left (RL) shunt and left-to-right (LR) shunt.

METHODS: Ninety infants and small children from 10 days to 31 months old weighing from 1.5 to 9.7 kg were assigned to group RL (n = 48) or LR (n = 42). In both groups, the CSA, transverse, and vertical diameters of the IJV on both sides of the neck were measured using a 2-dimensional ultrasound transducer in the following positions: supine position, 15° of T position, supine position with 50° of LE, and 15° of Trendelenburg position with 50° of LE (TLE). A more than 25% increase in mean CSA of the IJV was considered clinically significant.

RESULTS: In group LR, T, LE, and TLE significantly increased CSA of both right (at least 12.3%, 10.3%, and 18.3%, respectively, “at least” refers to the lower 95% confidence limits) and left (at least 15.8%, 15.0%, and 18.9%, respectively) IJVs, whereas only TLE increased the CSA of both IJVs significantly in group RL (at least 8.2% and 7.7% in the right and left, respectively). The increase in the CSA of the right IJV related to T and TLE was larger in group LR than in group RL (at least 12.3% vs 1.2% for T and at least 18.3% vs 8.2% for TLE, respectively). A clinically significant increase in CSA was achieved in both right and left IJVs with TLE in group LR (mean 28.6% and 26.3%, respectively). The CSA of the right IJV was larger than that of the left IJV in most (at least 69.2%) patients.

CONCLUSIONS: Passive LE was as effective as T position to increase the CSA of the IJV, but there was no clinically significant increase in the CSA with any single maneuver. Only T position with passive LE achieved a clinically significant increase in the CSA of both IJVs in infants and young children with LR shunt, but not in the same age group with RL shunt.

Published ahead of print December 7, 2012 Supplemental Digital Content is available in the text.

From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Accepted for publication July 25, 2012.

Published ahead of print December 7, 2012

Funding: None.

The authors declare no conflict of interest.

Reprints will not be available from the authors.

This report was presented at the annual meeting of the Society of Cardiovascular Anesthesiologists, Boston, MA, April 2012.

Address correspondence to Chung Su Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-Dong, Gangnam-Gu, Seoul, 135-710, Republic of Korea. Address e-mail to chungsukim.ane@gmail.com

Internal jugular venous (IJV) catheterization is routinely performed in infants undergoing surgery for congenital heart disease to monitor central venous pressure (CVP) and to infuse vasoactive drugs.1,2 However, IJV catheterization is technically more difficult in infants and children than in adults for both blind3–5 and ultrasonography-guided techniques,6 predominantly due to small vein size,7,8 variability of its relationship to the carotid artery,9 and difficulty retaining the needle inside the IJV while threading the guidewire.7 Moreover, central venous catheterization in infants and children is associated with frequent morbidity and mortality.10

Generally, Trendelenburg (T) position, Valsalva maneuver, liver compression, or passive leg elevation (LE) have been recommended to increase the cross-sectional area (CSA) of the IJV in adults.11–13 However, studies that have evaluated some of these maneuvers in infants or young children reported few clinically significant increases in the CSA, especially in infants,14,15 although the effect of passive LE on the CSA of the IJV in infants or young children has not been evaluated. Because IJV catheterization would be easier on a large IJV, it is necessary for evaluating the maneuver to increase in the CSA of IJV in infants and small children. Passive LE can be performed easily in infants or small children, avoids increase of intracranial pressure, and does not require a tilt table to place the head in the down position.

Moreover, in patients with congenital heart disease, the effect of T position or LE on the CSA of the IJV might be different between subjects with left-to-right (LR) shunt and right-to-left (RL) shunt, because the shunt flow direction may influence the vena caval blood drainage into right atrium by impeding central venous bloodflow into the right atrium. Therefore, we evaluated the effect of passive LE on the CSA of the IJV in infants and young children undergoing heart surgery for congenital disease. We also compared the effect of passive LE with that of the T position, or both maneuvers combined. Second, we compared the effect of T position or LE on the CSA of the IJV in subjects who have congenital heart disease with RL or LR intracardiac shunt.

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METHODS

Design and Materials

This study was approved by the Samsung Medical Center IRB (2011-05-093) and written parental informed consent was obtained for each subject. The study was registered at www.clinicaltrials.org with the registration number NCT01401920. Ninety infants and young children with body weight <10 kg who were scheduled to undergo surgery for congenital heart disease were enrolled prospectively between July and December 2011. The patients were divided into 2 groups on the basis of the type of intracardiac shunt: group RL or group LR. Patients with atrial septal defect (ASD), ventricular septal defect (VSD), atrioventricular septal defect, or ASD with VSD were assigned to group LR. Those with tetralogy of Fallot, pulmonary atresia with VSD, or Ebstein anomaly with ASD were assigned to group RL. Those with an obstructive or mixing lesion were excluded from the comparison of RL versus LR intracardiac shunt.

Patients with previous IJV catheterization, previous neck surgery, concurrent pulmonary disease that might influence the hemodynamics of the right heart, increased intracranial pressure, or preoperative hemodynamic instability were excluded from the present study. Patients with a history of bidirectional cavopulmonary shunt were also excluded because a previous study reported that the size of the right IJV did not change with T position in such patients.16

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Study Protocol and Measurements

Anesthesia was induced with pentothal sodium (5 mg/kg) and fentanyl (1 μg/kg), and endotracheal intubation was facilitated using rocuronium. After induction, pressure-controlled mechanical ventilation (tidal volume adjusted to 10 mL/kg with no application of positive end expiratory pressure) was initiated, and a radial arterial catheter was inserted. Anesthesia was maintained with sevoflurane and remifentanil. After placing a rolled towel under the shoulder to extend the neck, an 8-MHz 2-dimensional linear surface transducer (15L8 linear array, Siemens Acuson Sequoia C256, Mountain View, CA) was applied perpendicularly over the skin at the level of the cricoid cartilage with the head rotated 30° to the contralateral side. The size of the roll was adjusted for each subject so that it was not larger than the size of the neck. The transducer was applied with minimal pressure to ensure that the vein was not compressed. The IJV was imaged in the center of the screen during each single or combination maneuver, each of which was held for at least 30 s. For the T position, the operating table was tilted down to 15°. Passive LE was performed by raising the legs 50°, as measured with a protractor, for 30 seconds. All maneuvers were performed at the same anesthetic (inspired and end-tidal) concentration. Two investigators (W.H. Kim and C.S. Kim) with more than 2 years experience handling the ultrasound machine captured all the images. To eliminate the respiratory effect, the investigator selected the image showing the largest CSA at the end of inspiration after freezing the image on the screen. All ultrasonography images were stored, and measurements were performed later by different blinded investigators (J.H. Lee and S.M. Lee). The mean values measured by 2 investigators were used in the analysis. The CSA was calculated by the planimetry method. The circumference of the IJV was delineated using an electronic tracing tool (Siemens Acuson Sequoia C256, Mountain View, CA). The horizontal and transverse diameter and depth of the IJV from the skin on both sides was measured (Fig. 1). All measurements were performed for supine position (S), T position, supine position with passive LE, and T position with passive LE. The measurement side and the sequence of positioning and LE were assessed according to a randomized assignment number generated by an Internet-based computer program (www.randomizer.org). After measurements, central venous catheterization was performed through the IJV by the Seldinger technique with ultrasound guidance. We used a 4-Fr double-lumen or 5.5-Fr triple-lumen central venous catheter kit (Arrow, Reading, PA) and determined the depth of the catheter tip according to guidelines of a previous study.17 The initial CVP was measured and recorded for comparison between groups.

Figure 1

Figure 1

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Statistical Analysis

To ensure that the sample sizes of the study groups would support a valid comparison, a power analysis was performed (α = 0.05, β = 0.20), which indicated that at least 40 subjects should be recruited for each group. For this calculation, we used the mean (10.3 mm3) and SD (4.53) of the right jugular vein CSA with S position in that study8 and assumed a 25% increase of CSA from the baseline value to be clinically significant.15

SPSS software (version 18.0; SPSS Inc., Chicago, IL) was used for statistical analysis. Continuous data with a normal distribution were expressed as means with standard deviations, and nonparametric data were presented as medians with their interquartile ranges. Some variables such as transverse diameter or CSA of the right IJV were highly nonnormally distributed because of skewness. Normality of data distribution was checked with Lilliefors test, and by visual inspection of histogram and Q-Q plot. A P value > 0.05 was treated as normal. The test of within-subject effects for diameters, depth, and CSA according to the position (S, T, LE, TLE) and test of interaction between groups and IJV CSA were performed using repeated-measures analysis of variance. For this comparison, Mauchly test of sphericity revealed that the condition of sphericity was met. The comparison between groups (LR and RL shunt) at individual measurements (S, T, LE, TLE) was performed by Bonferroni corrected unpaired t test or Mann–Whitney test. Bonferroni correction was performed to reduce the false-positive results by multiple comparisons. The comparison between right and left side was performed by paired t test or Wilcoxon signed-ranks test according to the normality of data. The statistical tests for individual outcome variables are presented again in detail in Tables 14. A P value <0.05 was considered to be statistically significant.

Table 4

Table 4

Table 1

Table 1

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RESULTS

Table 1 shows patient characteristics and perioperative values. There were no differences in demographic factors or age distributions between the 2 groups. The initial CVP was not different between groups. The incidence of tricuspid regurgitation (TR) of more than mild grade and tricuspid annuloplasty was significantly higher in group LR than group RL. The hemoglobin and hematocrit levels and the incidence of major aortopulmonary collateral arteries or persistent left superior vena cava (SVC) were significantly higher in group RL. The CSA of the right IJV was larger than that of the left IJV in most (>69.2%) patients.

The changes in IJV according to positioning are presented in Tables 2 and 3. The mean vertical diameter, transverse diameter, and CSA of the right IJV were significantly larger than those of the left IJV in group LR for all positions. There was a significant difference in CSA between the right and left IJV in group RL with T or LE positioning.

Table 3

Table 3

Table 2

Table 2

T, LE, and TLE positions significantly increased the CSA of both the right and left IJV in group LR (at least 12.3%, 10.3%, and 18.3%, respectively, in right IJV; at least 15.8%, 15.0%, and 18.9%, respectively, in left IJV; “at least” refers to the lower 95% confidence limits). However, in group RL, T or LE positions alone did not increase the CSA of the IJVs: only TLE significantly increased the CSA of both IJVs (at least 8.2% and 7.7% in the right and left, respectively). In group LR the CSA of the right IJV with TLE position was significantly larger than that with T or LE alone. A clinically significant increase in CSA (greater than or equal to mean of 25%) was achieved in both IJVs only with TLE position in group LR, but not in group RL. In the comparison between groups (Fig. 2), the increase of CSA of the right IJV with T position or TLE was significantly larger in group LR than in group RL (at least 12.3% vs 1.2% for T and at least 18.3% vs 8.2% for TLE, respectively).

Figure 2

Figure 2

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DISCUSSION

This prospective observational study demonstrated that the increase in IJV CSA was larger in group LR than group RL, when we compared the effect of the T position, passive LE, or their combination. This increase was largest, with clinical significance (≥25%), in both IJVs of group LR patients when T position was performed together with passive LE. However, there was no difference in the CSA of the IJV in the S position between group LR and group RL. Additionally, regardless of positional changes, the right IJV size was larger than the left in a large portion of infants and young children with congenital heart disease.

To explain the difference between group LR and group RL in our study, we focused on several possible mechanisms. First, the incidence of more than mild-grade TR was significantly more frequent in group LR. When TR developed, the inflow of vena caval blood into the right atrium could be impeded. Previous studies in subjects with TR have shown that the flow of SVC drainage into the right atrium during ventricular systole was reversed or decreased,18–20 secondary to the presence of 2 opposite streams, one from the right ventricle to the right atrium or SVC and the other from the SVC towards the right atrium.19 In addition, the SVC flow in patients with ASD was reported to be reversed or zero, which is explained by the disturbance caused by shunt flow.20,21 Theoretically, both right ventricular volume overload caused by LR shunt except VSD and pressure overload caused by RL shunt can cause TR to develop. However, in our study, the incidence of right ventricular hypertrophy or dilation was very low, and there was no difference in the incidence of preoperative right ventricular hypertrophy or dilation between group LR and RL. We performed a comparison of IJV CSA between those with more than mild TR and those with less than mild TR regardless of the shunt direction, and found that there were significant differences in CSA change in the right IJV in all positions (Table 4). This also supports the hypothesis that the presence of TR significantly influences CSA change. We also performed a comparison of IJV CSA between those with and without ASD to evaluate the influence of ASD on IJV CSA change. However, there was no significant difference, and this may have been due to small sample size or the difference confounded by the mixed effect of TR.

Second, the incidence difference of persistent left SVC between the 2 groups (Table 1) might have been a possible cause of our results.22,23 The presence of bilateral SVC could divide venous return from the head and upper extremities, which may reduce the influence of increasing preload.

Additionally, the right IJV was larger than the left in a large portion (77.8%) of pediatric subjects with congenital heart disease. This result is consistent with previous data, showing the CSA of the right IJV was larger than the left IJV in 69% of patients.14 However, another study, in which 60 neonates or small infants weighing from 1.4 to 4.5 kg were enrolled, has reported no difference between the right and left IJV.8 Considering previous controversial results and the relatively small number of patients enrolled in the present study, it is difficult to conclude whether the size of the right IJV is larger than the left IJV in pediatric patients with congenital heart disease. Therefore, ultrasonographic examination of the IJV before cannulation would be a sensible approach to compare the size of both sides and reduce failure rates and complications.1,2,24–26

The increase in CSA of the IJV was significantly different between groups on the right side, but not significant in the left IJV, though the CSA increase of the left IJV appeared larger in group LR. This may have been due to the anatomical difference between the right and left IJV. While the right IJV forms a nearly straight line with the right innominate vein, SVC, and right atrium, the left IJV is longer and makes a wider angle with the left innominate vein. The response of the right IJV to T, LE, or TLE positions may be influenced more by the right heart, and subsequently the drainage of vena caval blood would be more decreased by TR flow or LR shunt flow. As such, the CSA of the IJV may be more influenced by T position or LE on the right side IJV than on the left.

The present study has several limitations. First, we enrolled patients of different ages from neonates to young children. Verghese et al.15 reported that preload-increasing maneuvers have less effect on the IJV of infants than with older children. They postulated that this is because the smaller IJV does not have as much elasticity or compliance. Salim et al.27 reported that the contribution of SVC return to cardiac output is different among neonates, infants, and young children. The mixed age groups included in the present study may have resulted in a selection bias in the intergroup difference. However, the age distribution was not different between groups, and separate analyses of neonates, infants, and young children also showed the intergroup difference. Second, we did not compare the success rate of cannulation with the maneuvers used in the present study. Thus, it is difficult to conclude whether the increased CSA of the IJV by T, LE, or TLE positions actually increases the success rate of IJV catheterization. Third, we did not evaluate the effect of positive intrathoracic pressure, which has proven to be effective in increasing the IJV in infants or small children.14,15 Fourth, we explained the difference between groups mainly by the different incidence of TR. The inclusion of Ebstein anomaly in group RL seems to have been inadequate due to the presence of severe TR in most of these patients. However, the group was initially chosen by the study hypothesis that different shunt direction may affect vena caval blood drainage into the right atrium.

In conclusion, passive LE was as effective as T position for increasing the CSA of the IJV; however, there was no clinically significant increase of the CSA with a single maneuver. Only simultaneous application of T position and passive LE produced a clinically significant increase of the IJV CSA in infants and young children with LR shunt, but not in the same age group with RL shunt. The increase in IJV CSA with the T position or TLE was larger in subjects with LR shunt than in those with RL shunt. The presence of TR seems to influence these differences.

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DISCLOSURES

Name: Won Ho Kim, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Won Ho Kim has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Jong Hwan Lee, MD, PhD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Jong Hwan Lee has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Sangmin M. Lee, MD, PhD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Sangmin M. Lee has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Chung Su Kim, MD, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Chung Su Kim has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Ryunga Kang, MD.

Contribution: This author helped conduct the study and analyze the data.

Attestation: Ryunga Kang has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Chan Seon Yoo, MD.

Contribution: This author helped conduct the study and analyze the data.

Attestation: Chan Seon Yoo has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Hyun Sung Cho, MD, PhD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Hyung Sung Cho has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

This manuscript was handled by: Peter J. Davis, MD.

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ACKNOWLEDGMENTS

The authors sincerely thank Ms. Joong Hyun Ahn and the Biostatistics team, Samsung Bioresearch Institute, for their valuable advice and help in statistical analysis of the results.

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