Prominent Internal Jugular Vein Collapse During Neck Dissection

Presented by Vladimir Nekhendzy, M.D., Director, Stanford Head and Neck Anesthesia and Advanced Airway Management Program, Chair, SHANA Education Board

Dear SHANA members,

I would like to share with you the video of a prominent internal jugular vein (IJ) collapse during neck dissection, which carried a danger of inadvertent venous air embolus (VAE). The collapse resolved after a quick intravenous administration of 500 ml of Hespan (I wish I took another video!).

The incidence of significant VAE during radical neck surgery is unknown, but is likely very small. Maintaining adequate intravascular volume and positive pressure ventilation further decreases the incidence of this complication. A prudent team approach would be to notify the anesthesiologist immediately if a large collection of air bubbles in IJ is observed by the surgeon. These bubbles can be safely aspirated with a fine needle in the field.

In this case, there were no IJ bubbles noted, but the anesthesiologist was not notified of the significant degree of IJ collapse either. This highlights the need for us to watch the other side of the “blood brain barrier” very carefully, and be vigilant at all times despite frequently impeded visualization of the surgical field.

The IJ can serve as a good additional marker of the patient’s volume status, as demonstrated in this video. Does anyone use noninvasive cardiac output-guided fluid optimization for major H&N cancer surgery, including flap reconstruction? We do not in our institution. The outcome studies for other types of surgery are inconclusive. Nevertheless, assessing the postoperative complications, flap viability, and functional outcomes for major H&N cancer surgery using the pragmatic approach vs the perioperative goal-directed hemodynamic optimization could be an interesting subject for a multicenter trial.

Lastly, I would be very interested to learn if anyone uses spontaneous or pressure support ventilation during a neck dissection. Such approaches were advocated in the past, sometimes in conjunction with the cervical epidural analgesia (!).

I am looking forward to hearing your thoughts on SHANA Forum.