Unilateral giant Internal Jugular Vein impeding brachial plexus nerve block

Sir Ultrasound-guided regional nerve blocks form an important procedure in the practice of anaesthesiology. The use of ultrasound facilitates the visualization of the various anatomical variations with regard to the size and the relation of the structures nearby and has improved the success rates. In this report, we present an interesting case of unilateral giant internal jugular vein (IJV) obstructing the approach to right supraclavicular brachial plexus nerve block in a 31-year-old patient with thermal burns scheduled to undergo below elbow debridement. He had sustained a road traffic accident complicated by a thin subdural haematoma with fully preserved neurological functions. His past medical history suggested no medical comorbidities related to cardiovascular or respiratory system. Our plan of anaesthesia was to give right supraclavicular brachial plexus nerve block and continuous sedation with dexmedetomedine infusion. However, when the ultrasound probe was placed to visualise the right-side brachial plexus supraclavicularly, there was a very large IJV covering the brachial plexus, as shown in Figure 1a–c. This giant IJV spanned the entire area of the neck obviating higher, lower, medial or lateral approaches to the plexus without puncturing the huge vein. Left IJV was normal in size [Figure 1d]. We then proceeded for an ultrasound-guided right infraclavicular block with 20-mL 0.5% bupivacaine, 30-μg clonidine, and lignocaine with adrenaline and the surgery proceeded uneventfully.Figure 1: (a) Ultrasound image showing right supraclavicular brachial plexus (encircled) located below a giant hypoechoic ovoid structure, internal jugular vein (IJV). (b) Colour Doppler showing flow in the right IJV and adjoining veins. (c) M-mode ultrasonography through the hypoechoic right IJV. (d) The left IJV and common carotid artery (CCA) on the ultrasonographyIJV anomalies have been described more commonly with reference to the branching or duplication or in relation to multiple sclerosis patients. An ultrasonographic survey in uraemic patients revealed unilateral anomalies in 17.3% and bilateral IJV anomalies in 8.7% patients.[1] The aim of this case report was to report such an anomaly that may complicate supraclavicular blocks in the form of intravascular injection, haematoma formation, or a possible thrombosis and infection in case of catheter insertion. This emphasises the need to make ultrasound guidance for regional anaesthesia a standard of care in day-to-day practice. Declaration of patient consent 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.