Jugular Venous and Brain Tissue Oxygen Tension Monitoring

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W19 Jugular Venous and Brain Tissue Oxygen Tension Monitoring

Lucido Ponce, Jovany Cruz, Santhosh Sadasivan, Shankar Gopinath, Bartley Mitchell, Claudia Robertson

image Ultrasound-Guided Internal Jugular Vein Oxygen Saturation (Sjvo2) Catheter Placement: Before Procedure

Indications

• Severe traumatic brain injury
• Subarachnoid hemorrhage
• During neurosurgical and cardiovascular procedures where cerebral blood flow may be reduced
• Detection of arteriovenous fistulas
• To titrate hyperventilation in patients with increased intracranial pressure

Contraindications

• Absolute:

• Infection of the placement site
• Suspected pathologic conditions affecting the internal jugular vein or superior vena cava
• Severe coagulopathy

• Relative:

• Cervical spine injury
• Tracheostomy
• Recurrent sepsis
• Hypercoagulable state
• Sensitivity to heparin if heparin-coated catheter is used
• Distorted anatomic landmarks

Equipment

• Sterile gowns
• Sterile gloves
• Mask
• Betadine or chlorhexidine solution
• Commercially packaged catheterization kits are available; kits may include:

• Drapes
• Disinfectant sponges
• Gauze pads
• Sutures with needles
• Guidewire
• Scalpel
• Vein dilator
• Penetration syringe, guide syringe, anesthetic syringe, and 1% or 2% lidocaine anesthetic solution

• Ultrasound machines with high-resolution vascular transducers are preferred for this procedure.
• Sterile transduction gel, acoustically transparent sterile transducer sheath, and sterile rubber bands or clips to secure sheath around transducer
• 5.5F fiberoptic intravascular catheter (Opticath catheter)

• Catheter contains the fiberoptics for light transmission, a distal lumen for pressure reading, sampling, or infusion, and a thermistor for temperature measurement.

• Optical module (to connect to bedside monitor)
• Introducer kit

image Anatomy

The venous sinuses of the brain drain out of the skull through the jugular foramina and into the internal jugular veins. Immediately distal to the jugular foramen, the vein dilates, forming the jugular venous bulb. The cerebral and cerebellar veins and the veins of the brainstem all open into major sinuses (superior sagittal, inferior sagittal, straight, right, and left transverse, and occipital sinuses); these terminate in the right and left sigmoid sinuses, which curve downward in a deep groove on the mastoid part of the temporal bone and finally turn forward in the posterior aspect of the jugular foramen to become the jugular bulb of the internal jugular vein.

The trachea is in the midline going down to the sternal notch. The two heads of the sternocleidomastoid muscle and the clavicle form a triangle at the anterior neck. The internal jugular vein may be accessed through this triangle, approximately 2 to 3 cm above the clavicle. Performing venous puncture higher in the triangle reduces the risk of pneumothorax and allows for better compression of the carotid artery in case of inadvertent carotid puncture.

image Procedure

• Continuous electrocardiography (ECG) and pulse oximetry
• Place the patient in Trendelenburg position to increase jugular filling and reduce possibility of air embolism.

• Avoid this position in patients with increased intracranial pressure (ICP) or congestive heart failure.

• Rotate patient’s head slightly to the contralateral side of the chosen site.
• Perform an ultrasound survey to assess the location and patency of the jugular vein and to determine whether one side has dominant flow. Catheter placement is easier, and continuous oxygen saturation measurements will usually be better on the side with the greatest blood flow.
• The common carotid artery and the internal jugular vein should be easily identifiable. You will see the common carotid artery as a pulsating image, and it will be difficult to compress. The internal jugular vein is larger, easily compressible, and nonpulsating. Make sure the internal jugular vein is patent by gently compressing the vein with the transducer; slight pressure is sufficient to collapse the lumen of the internal jugular vein. Placing the transducer in a cross-sectional position during the ultrasound examination facilitates interpretation of the resulting images. Many probes have a marker on one side that corresponds to the same side of the image on the screen. This helps the operator identify the correct orientation of the image.
• After you have identified an acceptable site for cannulation, you will need an assistant.
• Follow Universal Precautions when placing a jugular venous line.
• Prepare skin using chlorhexidine-based antiseptic, and cover the area with a sterile fenestrated drape.
• To prepare the ultrasound probe, have the assistant dispense enough acoustic nonsterile gel into a sterile transducer sheath to cover the transducer surface inside the sheath.
• Have the assistant carefully feed the probe into the sheath and through the gel while extending the sterile sheath away from you over the length of the probe wire. Eliminate any wrinkles in the sheath and any air bubbles between the transducer and sheath. Place the rubber bands to secure the cover sheath in place. To complete acoustic coupling, apply a small amount of sterile ultrasound gel to the covered ultrasound probe or the patient’s skin.
• Identify a convenient sterile area on which the probe can be placed when not in use.
• Position the transducer perpendicular to the skin so that the internal jugular vein is centered in the resulting ultrasound image and between the two heads of the sternocleidomastoid muscle. The ultrasound probe should be held in your nondominant hand.
• Gently palpate the skin to confirm that the puncture will be between the muscle heads and not through one of the heads.
• Using an 18-gauge needle, puncture the skin just below the transducer, being careful not to damage the sterile sheath.
• Slowly advance the needle at a 45-degree angle in an upward direction while watching the ultrasound screen. As you advance the needle, maintain negative pressure in the syringe until the vein is punctured. The needle will appear as a hyperechogenic shadow.
• If you do not aspirate blood as the needle is advanced, slowly withdraw the needle while maintaining negative pressure. Venous puncture may become evident as you withdraw the needle. Occasionally, pressure from the ultrasound probe may compress the vein, making it difficult to enter the vessel.
• As soon as the blood is freely aspirated, place the probe in the predetermined sterile area, stabilize the needle, and disconnect the syringe.
• Confirm the blood flow is nonpulsatile.

Introducer Insertion

• Using the Seldinger technique, introduce a flexible guidewire through the needle and into the internal jugular vein. Direct the guidewire in an upward direction toward the jugular bulb.
• While holding the guidewire in place, remove the needle. The guidewire can be visualized in both cross-sectional and longitudinal views within the lumen of the internal jugular vein in the ultrasound screen.
• Use the scalpel to make a small incision in the skin to widen the opening.
• Thread the guidewire thorough the distal opening of the dilator until it exits through the proximal end of the dilator.
• Confirm that it has reached the proximal end of the dilator, hold the wire in place, and advance the dilator through the skin and into the vessel.
• Once proper placement is achieved, remove the guidewire and the green dilator.
• Hold the proximal end of the guidewire at all times when advancing the dilator or catheter. This avoids complications from unintended advancement of the guidewire.
• Bleeding frequently occurs after the dilator is withdrawn; minimize it by applying pressure until the bleeding subsides.

Opticath Intravascular Catheter Insertion

• Inspect the sterile package first; if damaged, DO NOT USE.
• Have an assistant remove outer wrap, and leave the catheter covered by inner covering.
• Pass the optical connector to the assistant, who will connect it to the optical module and proceed with the preinsertion calibration. PLEASE NOTE that only after verifying with your assistant that the preinsertion calibration was successful should you proceed to the next step. Failure to do so will result in inaccurate readings.
• After successful preinsertion calibration, the oximetry system is now ready for use. Prepare for catheter insertion.
• Pull off remaining inner catheter covering; pull the retainer red tab to release the catheter.
• Grasp catheter near the entrance of the black reference assembly and gently pull straight out. Care should be taken in removing the catheter, as the fiberoptics may be damaged if the catheter is withdrawn improperly.
• Flush the catheter with sterile solution, using the distal lumen, to remove the remaining air.
• Catheter tip should be illuminated with a red light emission before insertion.
• The catheter should then be advanced until resistance is felt; this distance is usually about 13 to 15 cm and indicates positioning in the jugular bulb.
• The catheter is then pulled back 0.5 to 1 cm to minimize cephalic vascular impact with head movement.
• Connect the distal lumen to a pressure monitoring line.
• When the catheter is in position and blood is flowing, the system will immediately provide SO2 readings.
• At this time, ask the assistant to perform a light intensity calibration.
• Verify the position of the catheter tip, and secure the catheter to the patient. The optical module should be secured to the patient or in close proximity to avoid strain or tension on the catheter.
• Apply dressing as per hospital protocol.

image After Procedure

Postprocedure Care

• Lateral cervical spine x-ray should be used to confirm adequate catheter tip placement, which should be above the C1-C2 level in order to minimize contamination with blood coming from the facial vein.
• The Opticath intravascular catheter is removed by a physician. It is generally removed when ICP has been normal for 24 hours without specific treatment.
• Patient must be in Trendelenburg position.
• Remove sutures securing the catheter to the skin.
• Carefully pull out the Opticath intravascular catheter.
• Apply pressure to site for a few minutes to prevent bleeding.
• Apply sterile dressing.
• Assess for bleeding or signs of infection.
• Dispose of Opticath intravascular catheter per hospital protocol.
• Clean the optical module and cable for storage.

Complications

• Carotid artery puncture
• Skin hematoma
• Pneumothorax
• Hemothorax
• Jugular vein thrombosis
• Nerve injury
• Catheter misplacement
• Infection

image Outcomes and Evidence

• Normal jugular bulb oxygen saturation values are between 55% and 75%.

• <55% indicates relative cerebral hypoperfusion.
• >75% suggests luxury perfusion.
• Please refer to the standard critical care guidelines for management.

image Brain Tissue Oxygen Probe and Microdialysis Catheter Placement: Before Procedure

Indications

• Severe traumatic brain injury
• Aneurysmal subarachnoid hemorrhage
• Malignant stroke
• Vasogenic edema
• To assess brain tissue oxygenation, detect brain hypoxia, and for continuous monitoring of brain tissue chemistry (metabolites, drugs, etc.)

Contraindications

• Absolute:

• Infection and/or lack of skin at the site of planned insertion
• Coagulopathy

• Relative:

• Incompatibility with available magnetic resonance imaging (MRI) system if MRI of the brain is needed

Equipment

• Sterile gown pack
• Sterile gloves
• Sterile linen pack
• Sterile 4 × 4 gauze bandages
• Mask
• Shave prep kit
• Betadine bottle
• 16-gauge (orange) angiocatheter to tunnel the probe
• Cranial access tray
• One refrigerated combined LICOX probe box
• “Smart card” (enclosed in the sterile LICOX probe container)

• NOTE: Do not discard the probe packaging before the probe smart card has been removed from the packaging. Use only the smart card supplied with the probe (the serial number on probe should match the number on the smart card). Use of the wrong smart card can cause measurement errors. If serial numbers do not match, use another LICOX probe box, and return the first one to the vendor.

• #11 blade
• Nylon 3-0 suture
• CMA 70 Brain Microdialysis catheter
• Central nervous system (CNS) perfusion fluid
• CMA 106 syringe
• Surgeon’s head light
• Standard surgical suction
• LICOX monitor with complete set of cables
• Module box and link box and cable (to attach LICOX monitor to bedside monitor)
• Power cord to red AC wall outlet
• CMA 106 Microdialysis Pump with battery

image Anatomy

Ideally, the probe should be placed in the area at risk for brain hypoxia. However, if a computed tomography (CT) scan shows no areas at risk for hypoxia, the probe may be placed 2 to 4 cm off the midline just anterior to the coronal suture and at least 1 cm from the other probe when possible. Preparation must include shaving the patient’s head to a diameter of approximately 2 to 4 cm off the midline just anterior to the coronal suture.

image Procedure

• Because these patients are critically ill, vital signs such as invasive blood pressure, central venous pressure, ECG, pulse oximetry, and core temperature must be continuously monitored.
• Patient must be under sedation throughout the procedure and have intravenous access and mechanical ventilatory support.
• Wash hands. All staff involved in the procedure should wear a surgical mask and gloves throughout the entire procedure.
• After reviewing patient’s CT head scan, the physician will determine the anatomic area for catheter placement.

• As noted earlier, the probe is generally placed in the area at risk for brain hypoxia, but if the CT scan does not show areas at risk for hypoxia (i.e., diffuse axonal injury), place the probe at least 1 cm from the intracranial pressure probe.

• This area will be prepped with Betadine. Strict sterile field and technique must be maintained throughout the procedure.
• Drape the patient with the sterile blanket.
• Place the patient in a semi-Fowler position, raising the head of the bed to the level of the physician’s preference.
• If a ventriculostomy was previously placed, the same incision may be used for probe placement. If no incision exists, make a 3-cm linear incision, carrying it down to the bone.
• Infiltrate the incision with local anesthetic and epinephrine to help control the bleeding from the scalp incision.
• A self-retaining retractor is then inserted to provide good bone exposure.
• The blunt end of the forceps can be used to remove the periosteum.
• Drill the hole in the skull at the desired catheter insertion site, using a hand drill.
• Remove the drill, and rinse the hole with sterile isotonic solution.
• Incise the dura carefully with a style or a #11 blade, securing hemostasis as necessary.
• Insert the sharp end of the 16-gauge angiocatheter needle from the inside out through the scalp, 5 cm distant from the burr hole.
• Remove only the needle, leaving the angiocatheter.
• Remove the LICOX catheter from its sterile package.
• Remove the probe from the humidity protection chamber.
• Insert the LICOX probe distal tip into the angiocatheter, and tunnel it below the scalp toward the burr hole.
• Pull the angiocatheter completely out of the scalp.
• Using forceps, insert the distal end of the probe into the brain parenchyma. Ensure that the catheter body is not damaged during insertion.
• If necessary, adjust the position of the probe to allow the distal catheter tip to be positioned correctly with respect to the insertion site.
• Use a single suture to secure the probe to the scalp near the insertion; this must be done carefully to avoid damaging or dislodging the catheter.
• To place the microdialysis catheter, insert the sharp end of the 16-gauge angiocatheter needle from the inside out through the scalp 5 cm distant from the burr hole and approximately 1 cm from the brain tissue PO2 probe insertion site in the scalp.
• After removing the protection tube from the shaft, gently flush with CNS perfusion fluid, both inlet and outlet tubes, and insert a sterile microvial into the microvial holder.
• Tunnel the microdialysis catheter as previously described for the brain tissue PO2 probe.
• Grip the catheter shaft with the forceps, proximal to the distal end where the delicate membrane is. An intact membrane is vital for microdialysate return.
• Insert the membrane into the brain tissue through the burr hole used to insert the brain tissue PO2 probe.
• Fix the tubing to the scalp, using one suture around the catheter.
• Carefully remove the retractor.
• Make sure both probes remain in place.
• At the burr hole site, close the scalp incision using standard closure techniques; this must be done with extreme caution to avoid damaging any of the probes.
• Apply an extra transparent and soft-cloth adhesive dressing or any appropriate dry sterile occlusive dressing.
• Date and initial the dressing.
• Change the LICOX dressing every 48 hours or whenever saturated, using sterile technique including mask and sterile gloves, and cleanse the insertion site with Betadine swabs from the central line dressing kit.

image After Procedure

Postprocedure Care

• Securing of LICOX cables:

• The cables should be taped to an arm board and then pinned to the patient’s gown, allowing enough slack to accommodate movement of the patient for turning, transferring, and the like.
• Plug in the connecting cable to the proximal end of the probe.
• Connect both ends of the Y cable to the LICOX monitor. Insert the smart card in the card slot.
• Power-on the LICOX monitor.
• Wait a few seconds for a stable reading; it may take up to 2 hours for reliable readings.
• Connect the LICOX monitor to the bedside monitor, using the link box and cable.
• Attach the Luer-Lok connector to the CMA 106 syringe filled with CNS perfusion fluid.
• Place the CMA syringe in the CMA 106 pump, and close the lid.
• Inspect the microvial after 6 minutes to see that the microdialysate flows through the catheter.
• Replace the microvial every hour or as needed.
• Discard the first 2 microvials, since this microdialysate is purely CNS perfusion fluid.
• If the microdialysate contains blood, it may harm the CMA 600 microdialysis analyzer; if this occurs, the catheter must not be used.
• A CT scan of the head should be obtained after the procedure is complete to confirm the location of the probes.

• Discontinuation of the LICOX CMP system:

• It is recommended that LICOX probes not be left in tissue for more than 5 days.
• The probes should be removed by a physician. Probes are generally removed after ICP has been normal for 24 hours without intervention.
• Remove sutures securing the probe to the scalp.
• Carefully pull out the probes.
• Suture the insertion site in the scalp with a single stitch.
• Assess for bleeding, cerebrospinal fluid (CSF leak), and signs of infection.
• Clean the skin and apply sterile dressing.

• Dispose of probes per hospital protocol.
• Clean the cables and attach to the monitor for storage. Blood and debris may be removed from the cables with a towel and aqueous soap solution that also may contain formaldehyde. Disinfectants containing a high percentage of alcohol or phenol will damage the cables.

Complications

• Common:

• Generally there are no common complications.

• Infrequent:

• Infection and contusion <2%

• Serious, rare complications:

• Thrombosis and hemorrhage

image Outcomes and Evidence

• Normal brain tissue PO2 values are between 25 and 50 mm Hg.

• <20 mm Hg indicates impending cerebral hypoxia
• <10 mm Hg indicates critical hypoxia

• Please refer to the standard critical care guidelines for management of cerebral hypoxia.
• Normal values for microdialysate are less well defined; please refer to the textbook for further review.

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