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Table of Contents
LETTERS TO EDITOR
Year : 2020  |  Volume : 36  |  Issue : 4  |  Page : 569-570

Preoperative planning for central venous cannulation in conjoint twins


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India

Date of Submission10-Oct-2020
Date of Acceptance12-Oct-2020
Date of Web Publication18-Jan-2021

Correspondence Address:
Prof. Renu Sinha
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_596_20

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How to cite this article:
Kaur M, Sinha R, Chowdhury AR, Sharma S, Nagarajan B, Baishya M, Subramaniam R. Preoperative planning for central venous cannulation in conjoint twins. J Anaesthesiol Clin Pharmacol 2020;36:569-70

How to cite this URL:
Kaur M, Sinha R, Chowdhury AR, Sharma S, Nagarajan B, Baishya M, Subramaniam R. Preoperative planning for central venous cannulation in conjoint twins. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2021 Mar 4];36:569-70. Available from: https://www.joacp.org/text.asp?2020/36/4/569/307210



Dear Editor,

Anaesthesia management of conjoined twins for separation surgery is a challenging task due to the management of two patients simultaneously with their unique physiological changes like crossed circulation, distribution of blood volume and organ sharing. Separation surgery requires meticulous planning with multidisciplinary involvement for a successful outcome. Anaesthesiologist and surgeon have to compromised for positioning of conjoint twins during procedures. Separation surgery is usually long duration surgery with anticipated massive fluid shifts mandating the need for invasive monitoring like central venous and arterial monitoring. We herein discuss the steps undertaken for site selection for successful cannulation for invasive monitoring.

Female pyopagus conjoined twins aged 2 years with a combined weight of 15 kg were planned for separation surgery. Twins had bony fusion from S1 vertebra, the fused spinal cord from L3 onwards and common anal canal. The left twin also had severe scoliosis. Anticipated duration of surgery was 18-20 hours due to multidisciplinary surgical corrections.

Central venous cannulation was planned for intraoperative hemodynamic monitoring, fluid infusion, medication administration, and blood sampling. We planned ultrasound-guided internal jugular venous (IJV) cannulation of twins. Initially, due to relative ease of positioning, right IJV cannulation for the right twin and left IJV cannulation for the left twin was planned. As the left IJV cannulation in children can be difficult,[1] we did ultrasound scanning a day before surgery in the ward to evaluate the optimal position and size of IJV on both sides in conjoint twins. It was noticed that the left twin's left IJV lumen was relatively small compared to the right IJV and the lumen of the right IJV of right twins was better than the left-side IJV [Figure 1]. It is known that cannulating the vein with larger lumen is easier.[2] We noticed that after positioning, space between twins around head and neck will allow the insertion of right IJV in the left twin [Figure 2]. This plan was executed successfully in a single attempt intraoperatively.
Figure 1: (a) Ultrasound image of the Right Internal Jugular Vein, 1(b) Ultrasound image of the Left Internal Jugular Vein

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Figure 2: Line diagram of both the twins depicting positioning for central venous cannulation

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Hence, preoperative ultrasound scan and positioning rehearsal for central line cannulation should be incorporated into preoperative assessment and planning of the conjoint twins.

Declaration of patient

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lorchirachoonkul T, Ti LK, Manohara S, Lye ST, Tan S-A, Shen L, et al. Anatomical variations of the internal jugular vein: Implications for successful cannulation and risk of carotid artery puncture. Singapore Med J 2012;53:325-8.  Back to cited text no. 1
    
2.
Bos M. Comparison of the Diameter, Cross-Sectional Area and Position of the Left and Right Internal Jugular Vein in Adults using Ultrasound [Internet]. clinicaltrials.gov; 2014. Report No.: NCT01599299. Available from: https://clinicaltrials.gov/ct2/show/NCT01599299. [Last cited on 2020 Jun 18].  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]



 

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