title: The effects of the simulated Valsalva maneuver, liver compression, and/or Trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children.
abstract: We calculated the effects of the simulated Valsalva (V), liver (L) compression, and Trendelenburg (T) position on the cross-sectional area (CSA) of the right internal jugular vein by using planimetry (Aloka ultrasound machine) in 84 infants and young children. Eight combinations of positions and interventions were studied for each patient, with the patient supine, in the T position, during the simulated V maneuver, with L compression and a combination of maneuvers. Data were analyzed by using Friedman's chi(2) test and Wilcoxon's signed rank test. An increase of >25% in the CSA of the internal jugular vein was considered significant. In infants, the maximal mean increase achieved with the combination of all 3 maneuvers was only 17.4% +/- 16.1%. As a single maneuver, the simulated V was the most effective (11.6% +/- 11.5%). In children, the combination of all 3 maneuvers performed simultaneously produced a mean 65.9% (SD +/- 44.7%) increase in the CSA, which was larger than the increase by all other maneuvers alone or in a single combination (Friedman's test, P < 0.001 and Wilcoxon's test, P < 0.002). As a single maneuver, V produced the most increase (40.4% +/- 32.2%) compared with L compression (14.3% +/- 18.9%) or T position (24.3% +/- 27.1%).
  
  
  CONCLUSIONS
  The combinations of simulated Valsalva, liver compression, and Trendelenburg maneuvers produce the maximal mean increase in the size of the internal jugular vein in infants and young children, with the Valsalva maneuver being the most effective single maneuver. This increase is significant in young children, but negligible in infants.
authors.affiliation: Department of Anesthesiology, Children's National Medical Center and George Washington University Medical Center, Washington, DC 20010, USA. sverghese@cnmc.org
authors.forename: Susan T
authors.initials: ST
authors.lastname: Verghese
authors.forename: Ajay
authors.initials: A
authors.lastname: Nath
authors.forename: David
authors.initials: D
authors.lastname: Zenger
authors.forename: Ramesh I
authors.initials: RI
authors.lastname: Patel
authors.forename: Richard F
authors.initials: RF
authors.lastname: Kaplan
authors.forename: Kantilal M
authors.initials: KM
authors.lastname: Patel
mesh_terms: D002405:Catheterization, Central Venous; D002648:Child; D002675:Child, Preschool; D018475:Head-Down Tilt / Q000502:physiology*; D006801:Humans; D007223:Infant; D007601:Jugular Veins / Q000000981:diagnostic imaging* / Q000502:physiology; D008099:Liver / Q000502:physiology*; D011312:Pressure; D016683:Supine Position; D014463:Ultrasonography; D014636:Valsalva Maneuver / Q000502:physiology*