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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.58 no.4 Campinas July/Aug. 2008
Ultrasound-guided central venous puncture in an obese patient with cervical adenomegaly*
Uso del ultrasonido para punción venosa central en paciente obeso con adenomegalia cervical
Jaderson WollmeisterI; Diogo Bruggemann da Conceição, TSAII; Pablo Escovedo Helayel, TSAII; Ricardo Kotlinsky dos SantosI
do CET Integrado de Anestesiologia da SES-SC
IIAnestesiologista do Hospital Governador Celso Ramos; Membro do Núcleo de Ensino e Pesquisa em Anestesia Regional (NEPAR)
OBJECTIVES: Classical central venous techniques are based on superficial
anatomical references and the knowledge of the vascular anatomy of the area
to be punctured. The ultrasound allows direct vision of vascular and perivascular
structures, and the needle during the procedure. The objective of this report
was to describe an ultrasound-guided central venous catheter placement in an
obese patient with adenomegaly.
CASE REPORT: This is a 28 years old white male patient, with 1.70 m, weighing 120 kg, with the diagnosis of nodular sclerosis Hodgkin's lymphoma. An ultrasound-guided internal jugular vein catheter placement was requested to the Anesthesiology Department of the Hospital Governador Celso Ramos due to the presence of a supraclavicular node that would hinder the anatomical reference for the puncture in an obese patient. After obtaining the best image, the left internal jugular vein was punctured and a triple lumen catheter was introduced. It was necessary only a single puncture and the catheter was easily introduced; no complications developed during the procedure.
CONCLUSIONS: Ultrasound-guided central venous puncture can prevent complications, increasing the safety of the procedure.
Key Words: EQUIPMENT: ultrasound; VEINS: central venous access.
Y OBJETIVOS: Las técnicas clásicas para la punción
venosa central se realizan con base en referencias anatómicas de superficie
y con conocimiento de la anatomía vascular de la región en que
se realizará la punción. El uso del Ultrasonido permite la realización
de la punción bajo la visión directa de las estructuras vasculares,
peri-vasculares y de la aguja de punción. El objetivo de este relato
fue el de describir el uso del Ultrasonido en el auxilio de acceso venoso central
en paciente obeso y con adenomegalias.
RELATO DEL CASO: Paciente del sexo masculino, blanco, de 28 años, 1,70 m, 120 kg, con diagnóstico de linfoma de Hodgkin esclerosis nodular. Solicitado al Servicio de Anestesiología del Hospital Governador Celso Ramos, punción de vena yugular interna derecha guiada por Ultrasonido debido a la presencia de ganglio supraclavicular que le perjudicaba la referencia anatómica de punción y obesidad del paciente. Después de la obtención de la mejor imagen, la vena yugular interna izquierda se puncionó y se le puso un catéter venoso de triple lumen. La punción fue única, con progresión fácil del catéter y realizado sin complicaciones.
CONCLUSIONES: El uso del ultrasonido para la punción venosa central puede evitar complicaciones haciendo el procedimiento más seguro para el paciente.
Classical techniques for central venous access are based on superficial anatomic references and knowledge of the area's vascular anatomy. The rate of technical complications can reach 15% 1.
The use of the ultrasound to facilitate the placement of catheters in the internal jugular vein was first described in 1978 by Ullman et al. 1 It allows the direct visualization of vascular and perivascular structures, as well as the needle.
The objective of this report was to describe the use of the ultrasound to guide a central venous access in an obese patient with adenomegaly.
A 28 years old white male, with 1.70 m, weighing 120 kg, was admitted in September 2006 with a history of dry cough, pruritus, nocturnal diaphoresis, and the presence of a right supraclavicular node.
A diagnosis of nodular sclerosis Hodgkin's lymphoma was made and the patient was treated with chemotherapy.
In October 2007, the patient had a relapse of the disease, with progression of the adenopathy and an increase in size of the right supraclavicular node, which measured 10 × 5 cm, several lymphonodes in the upper mediastinum, right pretracheal, retrocaval, and subcarinal areas. The disease was classified as primarily refractory, a rescue protocol was instituted, the stage of the disease was reevaluated, and the patient was included in the bone marrow transplant protocol.
Ultrasound-guided catheter placement in the right internal jugular vein was requested to the Anesthesiology Department due to the presence of the right supraclavicular node that hindered the anatomical reference points for the puncture in an obese patient (Figures 1 and 2).
The patient was placed in dorsal decubitus and an ultrasound (8000SE SonoAce, Medison) of the right cervical area was performed. It showed a large adenomegaly and the right internal jugular vein compressed by the increased lymphonode (Figure 3). Ultrasound of the left cervical region showed normal venous anatomy (Figure 4). It was, then, decided to place the venous access on the left internal jugular vein.
The head of the patient was rotated to the right at approximately a 30° angle and the ultrasound-guided puncture of the left internal jugular vein was done. A 4-cm high-frequency (7-12 MHz, Medison) linear transducer was used. After cleaning the area with alcohol chlorhexidine and a sterile cover was placed over the transducer, it was placed transversal to the left internal jugular vein (Figure 5). After obtaining the best image, the left internal jugular vein was punctured and a triple lumen catheter was introduced. A single puncture was done and the catheter was easily introduced; the procedure was done without any complications.
Approximately 5 million central venous punctures are performed every year in the United States, with a 15% incidence of complications 1. Complications include arterial puncture, hematoma, pneumothorax, and even death. Lesions of the stellate ganglion and phrenic nerve are possible 2,3.
Physicians should have prior knowledge of the anatomical references, vascular anatomy of the cervical region, and experience to introduce a catheter in the internal jugular vein. However, anatomical variations are frequent, which hinder puncture and can lead to the development of complications.
In 1978, Ullman et al. described the use of the Doppler to locate and facilitate catheterization of the right jugular vein. From 1984 on, the recommendation to use the ultrasound to guide and optimize vascular catheterization with a low incidence of complications increased 2,4.
The ultrasound-guided procedure can be done in three ways: marking with an "X" the location of the carotid artery and internal jugular vein with the ultrasound, in which the place is identified and the needle is introduced without ultrasound visualization; the "one way" technique, which identifies the internal jugular vein and the needle is introduced with real-time visualization; and the "three-way" technique that requires two people: one handles the transducer while the other performs the puncture and catheterization of the vein 1. As for the orientation of the transducer in relation to the vein, the puncture can be performed with the transducer placed transversal or longitudinal to the vein. In the present case, the transducer was transversal to the vein because the patient had a short neck, which does not provide enough space to place the transducer longitudinally to the vein.
A metanalysis by Randolph et al. 5 in 1996 demonstrated that Doppler ultrasound decreased the failure rate of the catheterization of the internal jugular and subclavian veins when compared with the traditional method, as well as the number of attempts and complications.
Despite the high cost of the ultrasound equipment, studies suggest that its use increases patient safety, the speed of the procedure, and decreases the rate of catheterization failure with clear evidence of cost-effectiveness 6.
To conclude, ultrasound-guided central venous catheterization can avoid complications, making the procedure safer for the patient.
01. Kopmann D - Ultrasound-guided central venous catheter placement: the new standard of care? Crit Care Med, 2005;33:1875-1877. [ Links ]
02. Maecken T, Grau T - Ultrasound imaging in vascular access. Crit Care Med, 2007;35:179-185. [ Links ]
03. Domino K, Bowdle T, Posner K et al. - Injuries and liability related to central vascular catheters: A closed claims analysis. Anesthesiology, 2004;100:1411-1418. [ Links ]
04. Legler D, Nugent M - Doppler localization of the internal jugular vein facilitates central venous cannulation. Anesthesiology, 1984; 60:481-482. [ Links ]
05. Randolph A, Cook D, Gonzales C et al. - Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature, Crit Care Med, 1996;24:2053-2058. [ Links ]
06. Calvert N, Hind D, McWilliams R et al. - Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anesthesia, 2004;59:1116-1120. [ Links ]
Correspondence to: Submitted em 22
de dezembro de 2007 *
Received froms CET/SBA Integrado de Anestesiologia da Secretaria de Estado de
Saúde de Santa Catarina (SES-SC) do Hospital Governador Celso Ramos,
Dr. Diogo Brüggemann da Conceição
Rua Bocaiúva, 1659/1103
88015-000 Florianópolis, SC
Accepted para publicação 2 de abril de 2008
Submitted em 22
de dezembro de 2007
* Received froms CET/SBA Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina (SES-SC) do Hospital Governador Celso Ramos, Florianópolis, SC