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J Anaesthesiol Clin Pharmacol. 2017 Jan-Mar; 33(1): 124–125.
PMCID: PMC5374815

Obtaining external jugular venous access in the prone-positioned patient

Sir,

The anesthesiologist is more than occasionally confronted with having to obtain or “augment” intravenous (IV) access. This frequently occurs with changes in patient positioning. Moreover, “tucking” or adduction of the arms may create “resistance” and additionally interfere with the appropriate flow of IV fluids. Existing IV access may also “clot off” or infiltrate; despite previously working successfully.

Once in the prone position, the ability to obtain additional IV access can be challenging. The authors have utilized the external jugular vein (EJV) under these circumstances with relative ease Figure 1. On two occasions, EJV cannulation was achieved quickly. Furthermore, enough “backflow” was available to allow for venous blood gas assessment. Use of ultrasound guidance (USG) may also be beneficial to locate the vessel. In each of the two instances, the patients' arms were covered with padding and adducted. In addition, extensive hospitalization, obesity, and IV drug abuse made localization for peripheral venous access unobtainable; despite untucking of the patients' arms and employing USG and infrared-based optical devices.

Figure 1
The external jugular vein should be considered when vascular access is required in prone-positioned patients

It should be noted that EJV pressures, in supine-positioned patients, have been utilized for volume status measurement and have been documented to correlate with internal jugular venous pressures.[1] However, central venous pressure, measured from the internal jugular vein in the prone position, does not appear to correlate with measurements obtained using transesophageal echo.[2] Other devices, such as the esophageal Doppler monitor, have been reported for volume assessment and management in prone-positioned patients.[3,4] The anesthesiologist should be aware of the availability of the EJV should the need arise to obtain IV access in those patients who are in the prone position.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Abdullah MH, Soliman Hel D, Morad WS. External jugular venous pressure as an alternative to conventional central venous pressure in right lobe donor hepatectomies. Exp Clin Transplant. 2011;9:393–8. [PubMed]
2. Soliman DE, Maslow AD, Bokesch PM, Strafford M, Karlin L, Rhodes J, et al. Transoesophageal echocardiography during scoliosis repair: Comparison with CVP monitoring. Can J Anaesth. 1998;45:925–32. [PubMed]
3. Wang D, Atlas G. Abstract and poster presented at the New York State Society of Anesthesiologists Annual PGA. New York: 2009. [Last accessed on 2016 Jul 26]. Use of the esophageal Doppler monitor in prone-positioned patients. Available from: http://www.glenatlasmd.com/download/EDM-prone.pdf .
4. Yang SY, Shim JK, Song Y, Seo SJ, Kwak YL. Validation of pulse pressure variation and corrected flow time as predictors of fluid responsiveness in patients in the prone position. Br J Anaesth. 2013;110:713–20. [PubMed]

Articles from Journal of Anaesthesiology, Clinical Pharmacology are provided here courtesy of Wolters Kluwer -- Medknow Publications