• Claudia Ehrlich, Christian Hohenstein, Johannes Winning, and Hendrik Rüddel.
• Department of Anesthsiology and Intensive Care Medicine.
• Eur J Emerg Med. 2020 Apr 1; 27 (2): 110-113.

ObjectiveGuidelines recommend Trendelenburg position for central venous cannulation. Critically ill patients in the emergency department often do not tolerate this positioning or have contraindications. Thirty-degree dorsal elevated position with positive end-expiratory pressure by noninvasive ventilation could pose an alternative. This is the first trial to investigate the feasibility of alternative for central venous cannulation in critically ill emergency department patients.MethodsNinety-one critically ill patients in the emergency department of Jena University Hospital were examined between August 2014 and May 2015. The cross-sectional area of the right internal jugular vein was measured in 3 different positions: 30° elevation, supine, and Trendelenburg position. Measurements were repeated with a continuous application of noninvasive ventilation.ResultsCross-sectional area of the right internal jugular vein in Trendelenburg position was largest (0.99 ± 0.66 cm) compared to supine (0.57 ± 0.58 cm) and 30° elevated position (0.25 ± 0.41 cm). In 30° elevated positioning, application of positive end-expiratory pressure significantly enlarged cross-sectional area (0.62 ± 0.70 cm). Noninvasive ventilation was a well-tolerated procedure (98%). In 30° elevated positioning with positive end-expiratory pressure a safe puncture (cross-sectional area ≥ 0.4 cm) could be expected in 68.1% of cases.ConclusionThirty-degree elevated positioning with positive end-expiratory pressure via noninvasive ventilation could be a safe and well-tolerated alternative for central venous cannulation, especially for critically ill patients in emergency department unable to remain in Trendelenburg position. This proof-of-concept trial enables further studies with actual central venous cannulation.

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