Seeing beneath the surface: Harnessing point-of-care ultrasound for internal jugular vein evaluation

Abstract

Point-of-care ultrasound (POCUS) of the internal jugular vein (IJV) offers a non-invasive means of estimating right atrial pressure (RAP), especially in cases where the inferior vena cava is inaccessible or unreliable due to conditions such as liver disease or abdominal surgery. While many clinicians are familiar with visually assessing jugular venous pressure through the internal jugular vein, this method lacks sensitivity. The utilization of POCUS significantly enhances the visualization of the vein, leading to a more accurate identification. It has been demonstrated that combining IJV POCUS with physical examination enhances the specificity of RAP estimation. This review aims to provide a comprehensive summary of the various sonographic techniques available for estimating RAP from the internal jugular vein, drawing upon existing data.

Keywords: Bedside ultrasound; Central venous pressure; Internal jugular vein; Point-of-care ultrasound; Right atrial pressure.

Figure 1

Estimation of right atrial pressure by inferior vena cava ultrasound in spontaneously breathing patients, based on current guidelines[8]. IVC: Inferior vena cava; RA: Right atrium; HV: Hepatic vein; RAP: Rright atrial pressure.

Figure 2

Internal jugular vein collapse point compared to a wine bottle and paint brush. Figures adapted from NephroPOCUS.com with permission.

Figure 3

Anteroposterior diameter of the internal jugular vein. M-mode tracing depicts respiratory variation in the diameter.

Figure 4

Increase in the size of internal jugular vein with Valsalva maneuver by several folds in a spontaneously breathing person with normal right atrial pressure.

Figure 5

Minimal increase in the size of internal jugular vein with Valsalva maneuver in a spontaneously breathing heart failure patient with elevated right atrial pressure.

Figure 6

Measurement of right atrial depth using parasternal long axis view on focused cardiac ultrasound. RVOT: Right ventricular outflow tract; LV: Left ventricle; LVOT: LV outflow tract; LA: Left atrium; NCC: Non-coronary cusp of aortic valve.

Figure 7

Diagnostic algorithm in a case of cirrhosis and suspected hemodynamic acute kidney injury. Incorrect angle of insonation is a frequent source of error when assessing LVOT VTI (surrogate for stroke volume) and other Doppler measurements listed. Adapted from Ref. 33 with kind permission of the publisher (corresponding author’s prior open access publication). Blue boxes: Right heart; Red boxes: Left heart-related sonographic parameters; Green outlines: Volume tolerance phenotype; Orange outlines: Volume intolerance. POCUS: Point-of-care ultrasonography; VTI: Velocity time integral; E/e′: Ratio of the early diastolic waves of the mitral inflow Doppler and mitral annular tissue Doppler; LA: Left atrium; RV: Right ventricle; RVSP: Right ventricular systolic pressure; TAPSE: Tricuspid annular plane systolic excursion; S′: Tricuspid annular systolic velocity; SVC: Superior vena cava; ARDS: Acute respiratory distress syndrome; HV: Hepatic vein; PV: Portal vein.