Incidental detection of idiopathic IJV thrombus in pediatric
Published in the Journal of Anaesthesiology Clinical Pharmacology, the authors report a case of a child of acyanotic congenital heart disease in which internal jugular vein thrombosis (IJVT) was incidentally detected during central venous cannulation.

A 4-year-old child, a known case of peri-membranous ventricular septal defect (VSD) was admitted for surgical correction of the same. Preoperative history from mother, general physical examination, and vitals were unremarkable except for the shortness of breath for the past 1 year, the New York Heart Association (NYHA) class II. Auscultation revealed pan systolic murmur all over the precordium and bilateral normal breath sounds.

The abdomen was soft with no organomegaly. All hematological investigations were within normal limits. Chest X-ray showed cardiomegaly with prominent pulmonary vascular markings. Preoperative echocardiography findings were perimembranous VSD (Pm VSD) 4 mm with normal left ventricular (LV) function. The child was accepted under the American Society of Anesthesiologists Physical Status III (ASA-PS III).

On the day of surgery, child was shifted to operation theater after standard premedication with midazolam (100 mcg/kg) IV in the preoperative room under monitoring. Child was preoxygenated, anesthesia induced and trachea intubated using fentanyl (2 mcg/kg) and titrated dose of thiopentone to maintain hemodynamic stability. The left radial artery was cannulated using 22G catheter for continuous invasive blood pressure monitoring.

After preparing for the right IJV cannulation, the pre-procedural scan was done at puncture site. IJV cannulation was attempted on the right side with real-time ultrasound. The venous puncture was successful in the first attempt but there was resistance while passing the guide-wire. The guide-wire was removed and entire course of IJV was scanned to look for the cause. It revealed a normal IJV at the insertion site but a large thrombus was detected in the right IJV, as the probe was moved down.

This was confirmed by both short and long axis view using color Doppler mode and non-compressibility. The left IJV was scanned and was found normal. The left IJV cannulation was successful. Surgical procedure was uneventful, and he was shifted to postoperative ICU for elective ventilation.

Postoperatively, a radiologist confirmed thrombus in IJV and ruled out thrombus in other major vessels. He was started on heparin and the repeat ultrasound on the third day revealed no evidence of thrombus. Postoperative course was unremarkable and discharged.

Major takeaway:-
This report highlights the importance of pre-procedural scan, which should not be confined only to or close to the puncture site, but should involve the entire length of internal jugular vein (IJV).

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