The airway device preference may affect the ... - Wiley Online Library

Pediatric Anesthesia ISSN 1155-5645

RESEARCH REPORT

The airway device preference may affect the overlapping of the common carotid artery by the internal jugular vein Menekse Ozcelik1, Cigdem Guclu1, Basak Meco1, Derya Oztuna2, Ahmet Kucuk3, Saban Yalcin3, Zekeriyya Alanoglu1 & Neslihan Alkis1 1 Department of Anesthesiology and Intensive Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey 2 Department of Biostatistics, Ankara University Faculty of Medicine, Ankara, Turkey 3 Department of Anesthesiology and Intensive Care Medicine, Harran University Faculty of Medicine, Sanlıurfa, Turkey

What is already known?

• There are conflicting results on the effects of laryngeal mask airway insertion on the anatomical relationship

between the internal jugular vein (IJV) and the common carotid artery (CCA). Up to our knowledge, there is no reported study comparing the sonoanatomic changes in the related vessels before and after the insertion of an endotracheal tube (ETT).

What this article adds?

• This observational study demonstrated that the overlap percentage of the CCA by the IJV was increased in

laryngeal mask airway with incremental head rotation, whereas it was decreased with ETT. We strongly recommend the evaluation of the impact of the airway devices on safety and success rate in IJV cannulation in pediatric patients.

Keywords jugular veins; carotid artery, common; ultrasonography; airway control Correspondence Dr. Menekse Ozcelik, Department of Anesthesiology and Intensive Care Medicine, Ankara University Faculty of Medicine, Ibn-i Sina Hastanesi, Kat:3 Sıhhiye/Ankara 06100, Turkey Email: [email protected] Section Editor: Adrian Bosenberg Accepted 1 August 2016 doi:10.1111/pan.13005

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Summary Background: Anatomical variation in the internal jugular vein (IJV), as well as its small size, tendency to collapse, and proximity to the common carotid artery (CCA) makes central venous cannulation via the IJV a technically challenging procedure, especially in pediatric patients. Aim: We evaluated the effects of laryngeal mask airway insertion and endotracheal intubation (ETT) on the anatomical relationship between the IJV and the CCA in neutral and 40° head away positions. Method: After parental consent 92 patients with ASA physical status I-II, aged 0–17, undergoing elective urological surgery were enrolled and divided into two groups according to the airway management device used for anesthesia: Group laryngeal mask airway (n = 63) and Group ETT (n = 29). An ultrasonographic evaluation was performed before and after airway instrumentation at neutral and 40° head rotation. The IJV position in relation to the CCA was noted, and the overlap percentage of the CCA was calculated as the ratio of the CCA length covering by the internal jugular vein to the transverse diameter of the CCA. Results: With no airway device insertion, the position of the IJV was found to be anterolateral to the CCA in the majority of patients (48.8% vs 35.3%, right vs left IJV) in the neutral head position. While there was no significant change in the overlap percentages of the CCA after laryngeal mask airway insertion in the neutral head position [48.71% vs 57.30% for the right IJV (difference in median: 21.20; 95% confidence interval (CI) of difference:

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The effect of airway devices on CCA overlapping

56.92 to 14.52; P = 0.133); 52.54% vs 60.36% for the left IJV (difference in median: 10.3; 95% CI of difference: 41.49 to 20.89; P = 0.128)], it increased significantly in the 40° head away position on both sides [50.11% vs 64.83% for the right IJV (difference in median: 55; 95% CI of difference: 84 to 25.24; P = 0.01); 53.82% vs 71.20% for the left IJV (difference in median: 46; 95% CI of difference: 86.85 to 5.15; P = 0.004)]. However, the overlap percentages of CCA decreased significantly on the right side with patients in a neutral head position (31.23% vs 6.27%, difference in median: 19; 95% CI of difference: 5.68 to 43.68; P = 0.002) and on both sides in the 40° head away position [29.50% vs 16.19%, difference in median: 26; 95% CI of difference: 2.84 to 49.16; P = 0.03 and 47% vs 31.94%, difference in median: 9.50; 95% CI of difference: 40.87 to 59.87; P = 0.03 for the right and left sides, respectively] after ETT insertion. Conclusions: Laryngeal mask airway with 40° head rotation increases, whereas ETT decreases, the overlap percentage of CCA by IJV. Both head position and airway management methods have an influence on the overlap of the CCA by the IJV in pediatric patients.

Introduction Internal jugular venous catheterization is generally considered a technically challenging procedure in pediatric patients due to anatomical variations, small size, and the tendency of the vessel to collapse (1,2). Overlapping of the common carotid artery (CCA) by the internal jugular vein (IJV) especially jeopardizes success and increases the complication rate in catheterization mainly by facilitating the puncture of CCA with inadvertent needle advancement (3). The use of ultrasound assistance is accepted to be helpful to identify the relationship between the IJV and the CCA (4,5). Cannulation is generally performed under general anesthesia in Trendelenburg position with some degree of head rotation. Rotation of the head to the contralateral side by over 45° has been shown to increase the magnitude of CCA overlap (6,7). However, Roth et al. (4) showed that 40° contralateral head rotation increased the IJV cross-section with less resulting CCA overlap in both infants and children. In practice, endotracheal intubation and insertion of a laryngeal mask airway are two common options for airway management during general anesthesia for IJV cannulation (8,9). For cannulation in patients undergoing major surgery and those in intensive care, an endotracheal tube (ETT) is usually preferred for secure airway management. Laryngeal mask airway, on the other hand, is commonly the first choice for patients receiving anesthesia to insert a central venous catheter for treatments such as chemotherapy, apheresis, or hemodialysis. There are conflicting results as to whether the placement of laryngeal mask airway changes the anatomical relationship between the IJV and CCA in pediatric populations © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1148–1156

(1,10). For instance, Nagaraja et al. (1) revealed that anatomical changes were present in only 8.3% of healthy pediatric population after laryngeal mask airway insertion without knowing the direction of these changes. To our knowledge, no reported study has compared sonoanatomic changes in the related vessels before and after the insertion of an ETT in this group. In this study, we aimed to examine the impact of the laryngeal mask insertion and endotracheal intubation and the role of 40° head rotation on the overlap percentage of the CCA by IJV in pediatric patients with the aid of ultrasound device. Methods This prospective, observational study was approved by the ethics committee of our university (Prof. Melli, Ankara University Faculty of Medicine Ethical Committee, May 23, 2011, #32-662). The study was recorded on clinicaltrials.gov, with a registration number of NCT02217176. After informed parental consent was obtained, 92 infants and children with ASA physical status I–II and aged 0–17 years who were scheduled for elective urological surgery between May and August 2011 were enrolled in the study regardless of whether central venous cannulation was planned. Exclusion criteria included refusal of consent, history of central venous cannulation via the left IJV (LIJV) or right IJV (RIJV), the presence of cardiovascular anomalies, and thrombosis of the LIJV or RIJV. The patients were assigned into two groups according to their airway management devices, as decided by the anesthesiologist responsible for the procedure according 1149

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to the type of surgery (Group laryngeal mask airway or Group ETT). After standard monitoring, inhalational or intravenous anesthesia induction was initiated, and the patients were manually ventilated using a facemask. The patients under controlled mask ventilation were then positioned in a 15° Trendelenburg position with a pillow under the shoulder to allow the head to be extended slightly. Sequential ultrasonographic images for each patient were recorded bilaterally with an 8– 12 MHz linear probe (Venue 40 GE, USA) at the cricoid cartilage level, perpendicular to the skin, and parallel to the mandible in the neutral and 40° head away positions while they were under face mask ventilation. Afterwards, the airway was secured with cuffed ETT (Group ETT, n = 29, age range 0–15 years) or classical laryngeal mask airway (Group laryngeal mask airway, n = 63, age range 0–17 years). The cuffs of both ETT and laryngeal mask airway were inflated until no air leak was determined around the mouth by auscultation. In addition to this, the size of ETT and laryngeal mask airway was selected according to the traditional formula [age (in years)/4 + 3] and manufacturers’ recommendations, respectively. Following establishment of a patent airway, ultrasonographic images were re-recorded in patients with under controlled mask ventilation. We were careful to centralize the IJV on the recorded images without pressure on the neck. The timeline of these procedures was presented in Figure S1. All assessments were performed by two researchers blinded to the inserted airway device (MO, BM). The investigators studied the printouts of the recorded images mentioned above. They were blinded as to the airway management device used. Outcome measurements included the positions of the RIJV and LIJV in relation to the CCA and the overlap percentage of the CCA before and after airway device placement. The classification developed by Maecken et al. (11) based on the relationship between the CCA and the center of the IJV was used to determine the IJV position. According to this classification, the sonoanatomical position of the IJV was assessed to be anterior (A), anterolateral (AL), lateral (L), posterolateral (PL), posterior (P), posteromedial (PM), medial (M), or anteromedial (AM). The overlap percentage of the CCA was calculated according to the following formula as the ratio of the overlapping length of the CCA by the IJV to the transverse diameter of the CCA (Figure 1). The ultimate overlap percentage was identified according to the arithmetic means of two measurements. As this ratio increases, the overlap percentage also increases. Overlap percentage = overlap of CCA by IJV [in mm]/transverse diameter of CCA [in mm] 9 100 (Figure S2) (10). 1150

Figure 1 Ultrasonographic image of transverse section of the RIJV and the CCA. Overlap percentage of CCA by IJV = a/b 9 100. RIJV, right internal jugular vein; CCA, common carotid artery.

Statistical analysis A preliminary estimate of a sample size of 22 patients per group, with Type I error of 0.05 and Type II of 0.20, was based on expected 20% difference in overlap percentage of CCA by IJV before and after airway device insertion within each group. The pilot overlap percentage was derived from a previous study by Matsuda et al. (10). Frequency (percent) for categorical variables, and mean standard deviation [median (minimum–maximum)] for metric variables were given as descriptive statistics. The chi-square test was used to compare two independent groups for categorical variables, and Student’s t-test was used for metric variables. Dependent groups were analyzed with Wilcoxon/Friedman test for metric variables, and marginal homogeneity test for categorical variables. The confidence intervals (CI) with the level of 95% for difference between two medians were calculated based on the method by Bonett and Price (12). All statistical analyses were computed by SPSS version 15.0 software (SPSS Inc, Chicago, Il, USA). A P value of < 0.05 was considered significant. Results In total, 92 patients were included in the study; however, the images obtained from six could not be evaluated due to poor echogenity that resulted in imprecise margins of the IJV and CCA. Accordingly, the investigators evaluated the images obtained from 60 patients in Group laryngeal mask airway and 26 patients in Group ETT. There was no interobserver discrepancy by means of © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1148–1156

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sonoanatomical position for all printed images. The demographics of the patients are provided in Table 1. Significant differences were observed between Group laryngeal mask airway and Group ETT in all demographic characteristics, including age, gender distribution, height, weight, and ASA grade. Assessments before airway device insertion Table 2 summarizes the distribution of the IJV positions in all patients with neutral and 40° head away rotation with no airway device insertion. The most frequent position of the IJV was AL in both the RIJV and LIJV in patients with neutral head (48.8% for RIJV, 35.3% for LIJV; Table 2). Similarly, the AL position was predominant in the right side of the patients with 40° head away rotation. However, the A and the AL positions were found similar in the left side of patients with 40° head away rotation. The overlap percentages of the CCA by the IJV did not show significant difference between neutral and 40° head rotation positions on either side (43.42% vs 43.88%; difference in median: 0.5; 95% CI of difference: 18.07 to 19.07; P: 0.067 for RIJV and 49.33% vs 51.73%; difference in median: 2; 95% CI of difference: 29.82 to 33.82; P: 0.060 for LIJV) (Table 2). The directions of position changes achieved by head rotation are shown in Table 3. The majority of relationships between IJV and CCA did not change with head rotation. Assessments after airway device insertion In Group laryngeal mask airway, there was no statistically significant difference in the RIJV and LIJV localizations between pre- and postimplementation of the airway device in the neutral head position. Although there was no significant change in the overlap percentages of the CCA after laryngeal mask airway insertion

Table 1 Demographic characteristics of the patients

Age (years, mean SD) Gender (n, %) Female Male Height (cm, mean SD) Weight (kg, mean SD) ASA PS classification (n, %) I II

laryngeal mask airway (n = 60)

Group ETT (n = 26)

4.9 3.7

7.3 4.6

(11, 18%) (49, 72%) 108.4 23.5 20.6 14.1

(12, 46%) (14, 54%) 122.0 29.9 25.9 14.2

(55, 92%) (5, 8%)

(17, 65%) (9, 35%)

ETT, endotracheal tube; SD, standard deviation; ASA PS, American Society of Anesthesiology Physical Status Classification. © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1148–1156

in the neutral head position [48.71% vs 57.30% for the RIJV (difference in median: 21.20; 95% CI of difference: 56.92 to 14.52; P = 0.133); 52.54% vs 60.36% for the LIJV (difference in median: 10.3; 95% CI of difference: 41.49 to 20.89; P = 0.128)], it increased significantly in the 40° head away position on both sides [50.11% vs 64.83% for the RIJV (difference in median: 55; 95% CI of difference: 84 to 25.24; P = 0.01); 53.82% vs 71.20% for the LIJV (difference in median: 46; 95% CI of difference: 86.85 to 5.15; P = 0.004)] (Table 4). In Group ETT, the most frequent positions were AL (42.3%) and L (42.3%) in the RIJV before airway device placement, but there was a significant change to the L position (80.8%) after airway instrumentation in patients in a neutral head position (P = 0.002; Table 4). Likewise, there was a statistically significant change in the RIJV and LIJV positions in the direction of L in the 40° head away position (P < 0.05; Table 4). The percentages of CCA overlap decreased significantly on the right side with a neutral head position (31.23% vs 6.27%; difference in median: 19; 95% CI of difference: 5.68 to 43.68; P = 0.002) and on both sides with a 40° head away position [29.50% vs 16.19%, difference in median: 26; 95% CI of difference: 2.84–49.16; P = 0.03 and 47% vs 31.94%, difference in median: 9.50; 95% CI of difference: 40.87 to 59.87; P = 0.03 for the right and left sides, respectively] (Table 4). Table 5 summarizes the distribution of right and left IJV positions in groups laryngeal mask airway and ETT in neutral and 40° head rotation positions after airway device insertion. Discussion In this observational study, the major aim was to evaluate the impact of airway device, the laryngeal mask airway or ETT, and the effect of 40° head rotation on the overlap of CCA by IJV with the use of ultrasound imaging. The use of laryngeal mask airway leads to an increase in the overlap percentage of the CCA bilaterally in pediatric patients with 40° head rotation. However, endotracheal tube placement caused a significant decrease in the overlap percentage of the CCA in all patients with neutral and 40° head away position. To our knowledge, this is the first study to evaluate the overlap percentage before and after the airway device insertion (laryngeal mask airway or ETT), and also evaluate the impact of head rotation in pediatric patients. Few studies have evaluated the effect of laryngeal mask airway insertion on the overlap percentage of the CCA by the IJV. Takeyama et al. (13) demonstrated that the overlap percentage clearly increased after classic 1151

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Table 2 Relationship between the IJV and the CCA before airway device insertion

Right IJV (n = 86)

Left IJV (n = 86)

Position of IJV

Neutral head position

40° head away position

Difference (95% CI)

P value

Anterior (n, %) Anterolateral (n, %) Lateral (n, %) Overlap percentage (mean [median (min–max)] Anterior (n, %) Anterolateral (n, %) Lateral (n, %) Overlap percentage (mean [median (min–max)]

SD),

19 (22.1) 42 (48.8) 25 (29.1) 43.42 38.74, [35.5 (0–100)]

16 (18.6) 48 (55.8) 22 (25.6) 43.88 37.50, [35 (0–100)]

0.5 ( 18.07 to 19.07)

0.067

SD),

27 (31.8) 30 (35.3) 28 (32.9) 49.33 41.78, [53 (0–100)]

30 (35.3) 29 (34.1) 26 (30.6) 51.73 43.34, [51 (0–100)]

2 ( 29.82 to 33.82)

0.060

IJV, internal jugular vein; CCA, common carotid artery; CI, confidence interval Overlap percentage = overlap of CCA by IJV [in mm]/horizontal length of CCA (diameter) [in mm]) 9 100.

Table 3 Direction of IJV position changes relative to CCA, evaluated in all patients after 40° head rotation IJV positions after 40° head away (n, %) Right IJV (n = 86) Left IJV (n = 86)

A?A (11, 57.9)a A?AL (7, 36.8) A?L (1, 5.3) A?A (23, 85.2)a A?AL (4, 14.8) A?L (0, 0)

AL?A (5, 11.9) AL?AL (30, 71.4)a AL?L (7, 16.7) AL?A (6, 20) AL?AL (18, 60)a AL?L (6, 20)

L?A (0, 0) L?AL (11, 44) L?L (14, 56)a L?A (1, 3.6) L?AL (7, 25) L?L (20, 71.4)a

IJV, internal jugular vein; A, anterior; AL, anterolateral; L, lateral; PL, posterolateral; P, posterior; PM, posteromedial; M, medial; AM, anteromedial; A?A, anterior to anterior; no change; A?AL, anterior to anterolateral change; A?L, anterior to lateral change; AL?A, anterolateral to anterior change; AL?AL, anterolateral to anterolateral; no change; AL?L, anterolateral to lateral change; L?A, lateral to anterior change; L?AL, lateral to anterolateral change; L?L, lateral to lateral; no change, from neutral to 40° head away position. a No change in sonoanatomical position of the IJV in the majority of patients with 40° head away position.

laryngeal mask airway placement, as compared with before airway instrumentation, in adults with 30° head rotation. They evaluated the overlap percentage at three different measurement points on the neck. The measurement point in our study corresponds to their middle point, identified as the intersection of the clavicular head and sternal head of the sternocleidomastoid muscle. They found that the CCA became susceptible to extrinsic compression from the inflated cuff as a result of head rotation after laryngeal mask airway insertion. This finding for the adult patients was confirmed by the results of our study, despite its being performed in pediatric patients with a larger degree of head rotation. Matsuda and Arai (10) studied the degree of overlap of the CCA before and after laryngeal mask airway placement in 160 infants and children with 30° head rotation. In contrast to our study, they observed no 1152

significant change in the degree of overlap of the right CCA after laryngeal mask airway placement. Although the method of collecting images of the neck vascular anatomy by ultrasound was the same in these two studies, there was a difference in the degree of patients’ head rotation. Matsuda and Arai (10) turned the patient’s head 30° to the contralateral side, unlike our 40° head rotation. Thus, the increase in the degree of head rotation might have caused an increase in the overlap percentage in pediatric patients after insertion of laryngeal mask airway. In their study with 11 infants and 51 children, Arai et al. (6) showed that contralateral 45° head rotation significantly increased the overlap of the CCA by the IJV, which was further confirmed in a study of 88 pediatric patients (14). However, there is still a debate about the effect of head rotation and airway device type on overlap of the CCA. The summary of the effects of these variables on overlap of CCA, derived from the previous literatures in pediatric population, is presented in Table S1 (1,4,6,7,10,14,15). None of these studies evaluated the combined effect of airway device and head rotation on anatomic relationship of IJV or CCA or overlap percentage of CCA by IJV. The present study showed that the combination of these two variables has substantially different effects on sonoanatomical placement of IJV related to CCA and overlap percentage of CCA by IJV. The difference resulted from the type of airway device used for the maintenance of anesthesia. One recent report compared the overlap of the CCA by the IJV after laryngeal mask airway and ETT placement in 100 adult patients under 15°, 30°, and 45° head rotation (16). They found a higher overlap percentage and lower success rate of the simulated IJV cannulation after laryngeal mask airway vs ETT insertion. The cannulation of right IJV was considered to be more difficult after laryngeal mask airway insertion and Kim et al. (16) explained this finding due to the displacement of © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1148–1156


21 (35) 27 (45) 12 (20) 57.30 40.29, [59 (0–100)] 24 (40.7) 20 (33.9) 15 (25.4) 60.36 41.64, [65 (0–100)]

0 (0) 5 (19.2) 21 (80.8) 6.27 12.43, [0 (0–46)] 3 (11.5) 10 (38.5) 13 (50) 29.5 34.92, [12.5 (0–100)]

20 (33.9) 23 (39) 16 (27.1) 52.54 40.92, [54.7 (0–100)]

4 (15.4) 11 (42.3) 11 (42.3) 31.23 34.59, [19 (0–100)] 7 (26.9) 7 (26.9) 12 (46.2) 42.04 43.60, [37.5 (0–100)]

After insertion

15 (25) 31 (51.7) 14 (23.3) 48.71 39.51, [37.8 (0–100)]

Before insertion

25 ( 12.87 to 62.87) 0.090

0.197

19 ( 5.68 to 43.68) 0.001

0.002

10.3 ( -41.49 to 20.89) 0.128

21.20 ( 56.92 to 14.52) 0.133 0.369

0.217

Difference (95% CI) P value

9 (34.6) 9 (34.6) 8 (30.8) 47 43.09, [33 (0–100)]

3 (11.5) 14 (53.8) 9 (34.6) 29.50 30.83, [26 (0–100)]

21 (35.6) 20 (33.9) 18 (30.5) 53.82 43.65, [54 (0–100)]

13 (21.7) 34 (56.7) 13 (21.7) 50.11 38.64, [45 (0–100)]

Before insertion


3 (11.5) 11 (42.3) 12 (46.2) 31.94 35.38, [23.5 (0–100)]

0 (0) 11 (42.3) 15 (57.7) 16.19 21.90, [0 (0–67)]

34 (57.6) 17 (28.8) 8 (13.6) 71.20 38.24, [100 (0–100)]

29 (48.3) 19 (31.7) 12 (20) 64.83 41.52, [100 (0–100)]

After insertion

9.50 ( 40.87 to 59.87) 0.030

0.008

26 (2.84–49.16) 0.033

0.013

5.15)

25.24)

46 ( 86.85 to 0.004

0.002

55 ( 84 to 0.014

0.010

Difference (95% CI) P value

IJV, internal jugular vein; ETT, endotracheal tube; CCA, common carotid artery; CI, confidence interval; overlap percentage = overlap of CCA by IJV [in mm]/horizontal length of CCA (diameter) [in mm]) 9 100. a No change in overlap percentage after laryngeal mask airway insertion in neutral head position and increased overlap percentage after laryngeal mask airway insertion with 40° head away position b Decreased overlap percentage after ETT insertion with both neutral and 40° head away position c Decreased overlap percentage after ETT insertion with 40° head away position. Bold italic values in indicate P value < 0.05

Group laryngeal mask airway (n = 60) Right I Anterior (n, %) JVa Anterolateral (n, %) Lateral (n, %) Overlap percentage (mean SD), [median (min–max)] Left I Anterior (n, %) JVa Anterolateral (n, %) Lateral (n, %) Overlap percentage (mean SD), [median (min–max)] Group ETT (n = 26) Right Anterior (n, %) IJVb Anterolateral (n, %) Lateral (n, %) Overlap percentage (mean SD), [median (min–max)] Left Anterior (n, %) IJVc Anterolateral (n, %) Lateral (n, %) Overlap percentage (mean SD), [median (min–max)]

Relationship of IJV and CCA

Neutral head position

Table 4 The effect of airway device insertion on the relationship between the IJV and the CCA

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Table 5 Direction of IJV position changes relative to CCA in the study groups after airway device insertion, classified according to Maecken et al. (10) IJV positions after 40° head away (n, %) Group laryngeal mask airway (n = 60) Right IJV Neutral position


Left IJV

Neutral position


Group ETT (n = 26) Right IJV

Neutral position


Left IJV

Neutral position


A?A (8, 53.3)a A?AL (6, 40) A?L (1, 6.7) A?A (11, 84.6)b A?AL (2, 15.4) A?L (0, 0) A?A (14, 70)a A?AL (5, 25) A?L (1, 5) A?A (15, 71.4)b A?AL (4, 19) A?L (2, 9.5)

AL?A (9, 29) AL?AL (18, 58.1)a AL?L (4, 12.9) AL?A (14, 41.2)b AL?AL (13, 38.2) AL?L (7, 20.6) AL?A (9, 39.1) AL?AL (10, 43.5)a AL?L (4, 17.4) AL?A (14, 70)b AL?AL (4, 20) AL?L (2, 10)

L?A (4, 28.6) L?AL (3, 21.4) L?L (7, 50)a L?A (4, 30.8)b L?AL (4, 30.8)b L?L (5, 38.5) L?A (1, 6.3) L?AL (5, 31.3) L?L (10, 62.5)a L?A (5, 27.8)b L?AL (9, 50)b L?L (4, 22.2)

A?A (1, 25) A?AL (0, 0) A?L (3, 75)c A?A (0, 0) A?AL (3, 100)c A?L (0, 0) A?A (2, 28.6) A?AL (3, 42.9)c A?L (2, 28.6) A?A (2, 22.2) A?AL (6, 66.7)c A?L (1, 11.1)

AL?A (0, 0) AL?AL (4, 36.4) AL?L (7, 63.6)c AL?A (0, 0) AL?AL (6, 42.9) AL?L (8, 57.1)c AL?A (1, 14.3) AL?AL (5, 71.4)c AL?L (1, 14.3) AL?A (1, 11.1) AL?AL (5, 55.6)c AL?L (3, 33.3)

L?A (0, 0) L?AL (0, 0) L?L (11, 100)c L?A (0, 0) L?AL (2, 22.2) L?L (7, 77.8)c L?A (0, 0) L?AL (2, 16.7) L?L (10, 83.3)c L?A (0, 0) L?AL (0, 0) L?L (8, 100)c

CCA, Common carotid artery; IJV, internal jugular vein; ETT, endotracheal tube; A, anterior; AL, anterolateral; L, lateral; PL, posterolateral; P, posterior; PM, posteromedial; M, medial; AM, anteromedial; A?A, anterior to anterior; no change; A?AL, anterior to anterolateral change; A?L, anterior to lateral change; AL?A, anterolateral to anterior change; AL?AL, anterolateral to anterolateral; no change; AL?L, anterolateral to lateral change; L?A, lateral to anterior change; L?AL, lateral to anterolateral change; L?L, lateral to lateral; no change, from neutral to 40° head away position. a No change in the majority of patients with neutral head position after laryngeal mask airway insertion. b More A or AL localizations with head rotation after laryngeal mask airway insertion. c More AL or L localizations with both neutral and head away positions after ETT insertion.

the sternocleidomastoid muscle that makes the central landmark less valuable for IJV puncture and palpating the CCA more difficult. The results of our study also reveals similar results but in pediatric population. We may speculate that laryngeal mask airway insertion with 40° head rotation might cause displacement of the ipsilateral IJV at the supraglottic level, being above the thyroid cartilage. However, the ultrasonographic images of the IJV and CCA were recorded at the level of cricoid cartilage in our study. Accordingly, we might obtain the reflected result of this displacement arised above the cricoid cartilage. In another report, Nagaraja et al. (1) studied the anatomical relationship between the IJV and the CCA after laryngeal mask airway insertion in a neutral head position in 60 healthy subjects aged 2–16, and showed 1154

anatomical changes in only 8.3% of the study subjects after laryngeal mask airway insertion. Similarly, we also found no difference in the neutral head position after laryngeal mask airway insertion compared to before insertion. The authors of this study published a correspondence regarding the findings of the study of Nagaraja et al. (17). Although Nagaraja et al. (1) clearly demonstrated a 8.3% change in the position of IJV after laryngeal mask airway insertion, they did not clarify the number of patients with no position change in IJV and also the number of patients with IJV position changes between different locations such as anterolateral to anterior or just the opposite. Therefore, in the present study, we aimed to study the effect of laryngeal mask airway and ETT insertion and the impact of head rotation on IJV location change (Table 5). We determined that the © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1148–1156

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most frequent anatomical location of the IJV relative to the CCA was in the AL position on both sides of the neck (right, 48.8%; left, 35.3%). This finding is consistent with previous studies. Roth et al. (4) found that the IJV was in the AL position, partially covering the homolateral CCA, in 54.4% of 45 children aged 60 months and under. Moreover, Hong et al. (7) showed that RIJV and LIJV were in the AL position with ratios of 67.5% and 58.5%, respectively, in their studies with 200 pediatric patients 26.5 23.3 months of age. In addition to this, the results of our study revealed that both right and left IJV locations did not change in the majority of the patients with neutral head position after laryngeal mask airway insertion. The IJVs of patients with laryngeal mask airway had a tendency to become AL or A locations under head rotation. In contrast to this, ETT insertion caused further change to AL or L locations of both RIJV and LIJV. These findings may suggest that the practitioner should be aware of the high risk of having anterior positioned IJV after laryngeal mask airway insertion compared with ETT placement in 40° head away position; especially conventional landmarks are preferred for traditional palpation techniques. We acknowledge the limitations of this study. The main limitation is the statistically significant differences in patient number and demographics, between Group laryngeal mask airway and Group ETT, caused by the allocation of the pediatric patients included in the study by the anesthesiologist responsible for the procedure. Although there was no selection bias to jeopardize the results of the study, as the diameter of IJV is correlated with the age, height, and weight in children (18–20), the outcomes of this study should be confirmed in a larger pediatric subpopulation in a randomized controlled trial. These differences in demographics might also have an effect on main findings of the study with respect to ETT insertion. In addition to this, uncontrolled cuff pressures in both groups and levels of cuffs of either two devices variable according to patient age and size of device used might have an impact on the overlap percentages of the CCA by the IJV. The level of laryngeal mask airway cuff is above the level of ETT cuff. We already know that the cartilaginous portions of the airway are soft and compliant in pediatrics. Calcification of the larynx and trachea typically does not occur until the teenage years (21). Therefore, we may only speculate that the IJV might be more susceptible to pressure changes at this level of the neck due to compliant and soft trachea. Although this finding is more likely multifactorial, this may explain why the overlap percentage of CCA by IJV was decreased in patients with ETT in contrast to laryngeal mask airway. The results of the present study should be supported by other studies © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1148–1156


aiming to evaluate the impacts of ETT on neck vessel anatomy due to the lacking argument to explain why ETT insertion decreases the overlap percentage of CCA in contrast to laryngeal mask airway. The sample size, especially the number of pediatric patients in Group ETT, was too small, and we evaluated the effects of head rotation in a single position (40° away position). Due to the nature of the study, a double-blind design was not possible, and the ultrasound operator who recorded the ultrasonic images was not blinded to the head position. However, the results were evaluated by examiners who were unaware of the technique used for airway management and head position. Defining a preset cutoff value for the overlap percentage of the CCA by the IJV may be a priceless predicting parameter of the successful cannulation of IJV from the clinical point of view. However, there was no minimum percentage of transverse overlap that was required to define the presence of overlap prior to the horizontal calculation in the present study. This might be a subject for an upcoming study that will evaluate the successful IJV cannulation rate and the overlap percentage with head rotation using different airway devices. Additionally, as the measurements of diameters were all done at the cricoid level, the operator did not try to find the place of maximum overlap percentage of the two vessels. This may be a criticized for a study trying to find the maximum overlap percentage affected by different airway devices inserted into different anatomical locations in the neck. Finally, there were some other limitations attributed to the procedure, mainly focusing on nonstandard degree of head extension and unmeasured air leak around the airway device cuff. Conclusions Special attention to head rotation should be considered in pediatric patients during IJV catheterization to prevent CCA puncture. The results of this study further show the effects of the airway management methods on the overlap percentage of the CCA by the IJV. In conclusion, in pediatric patients, we recommend the use of ultrasound for the identification of the actual location of the IJV, especially when laryngeal mask airway is the preferred airway management device. The practitioner should also be aware of the high risk of having anteriorpositioned IJV which leads to overlapping after laryngeal mask airway insertion compared with ETT in neutral and 40° head away position. Funding This research was carried out without funding. 1155

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contribution of Dr. Menekse Ozcelik as the primary investigator and the author of this study was addressed by the other authors of this study with a declaration letter to the editor of this journal.

Conflict of interest No conflicts of interest declared. Acknowledgments This research was represented as an e-poster in American Society of Anesthesiologist 2012 Annual Meeting in Washington, DC. Considering the application requirements, the presenter of the poster, Professor Dr Zekeriyya Alanoglu, DESA, registered as the first author of this e-poster. However, Dr. Menekse Ozcelik is the primary investigator and the first author of this study. The

Supporting information Additional Supporting Information may be found in the online version of this article: Figure S1 Timeline of the study. Figure S2 Overlap percentage of CCA by IJV. Table S1 The summary of the previous literatures.

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