Comparison of Ultrasonography-Guided Central Venous Catheterization Between Adult and Pediatric Populations

Short peripheral intravenous cannula and straight-tip guide wire in ultrasound-guided neonatal central venous catheterization

BACKGROUND

Inserting a J-tip guide-wire into a vein's lumen is often difficult when using the Seldinger or modified Seldinger technique for central venous catheterization (CVC) in newborns. This study was designed to compare the efficacy and safety of guide-wire insertion using the combination of a short peripheral intravenous cannula with a straight-tip guide-wire vs. a needle with a J-tip guide-wire for ultrasound-guided (USG) cannulation of the internal jugular vein (IJV) in newborns using an in-plane technique.

METHODS

One hundred and thirty newborn patients (weight, 1.4-5.2 kg) scheduled for selective or emergency surgery, were randomly assigned to either the needle group (combined with a J-tip guide-wire) or cannula group (combined with a straight-tip guide-wire). The primary outcome was the rate of successful guide-wire insertion on the first attempt. The puncture attempts, catheter placement attempts, and mechanical complications were also compared between the groups.

RESULTS

The rate of successful guide-wire insertion on the first attempt was higher in the cannula group (97%) than in the needle group (76%) (p < 0.05, χ2 = 11.233). Moreover, fewer insertion attempts were needed in the cannula group (1.0 ± 0.2) than in the needle group (1.7 ± 1.1) (p < 0.05, 95% CI [0.449, 1.028]). The time to successful guide-wire insertion was shorter in the cannula group (63 ± 32 s) than in the needle group (92±50 s) (p < 0.05, 95% CI [14.024, 43.063]). No differences were found about other catheterization parameters and complications between the groups.

CONCLUSION

The short peripheral cannula combined with a straight-tip guide-wire was superior to the needle combined with a J-tip guide-wire for USG newborn IJV catheterization in terms of successful guide-wire insertion on the first attempt and overall number of insertion attempts.

Combined short-axis out-of-plane and long-axis in-plane approach versus long-axis in-plane approach for ultrasound-guided central venous catheterization in infants and small children: A randomized controlled trial

The ultrasound-guided long-axis in-plane approach for central venous catheterization in infants and small children can prevent posterior wall penetration. The combined short-axis out-of-plane and long-axis in-plane approach reportedly prevents such penetration in adults. To test the hypothesis of non-inferiority of the combined approach to the long-axis in-plane approach, we compared the two approaches in infants and small children. Patients were randomized based on whether they underwent ultrasound-guided internal jugular vein catheterization using the combined or long-axis in-plane approach. Posterior wall penetration rates, first-attempt success rates, overall success rates within 20 min; scanning, puncture, and procedure durations; and number of attempts were compared between the groups. In the combined and long-axis in-plane groups (n = 55 per group), the posterior wall penetration rates were 5.5% (3/55) and 3.6% (2/55) (P = 0.65), the first-attempt success rates were 94.5% (52/55) and 92.7% (51/55) (P = 0.70), and the overall success rates within 20 min were 100% (55/55) and 98.2% (54/55) (P = 0.32), respectively. In the combined and long-axis in-plane groups, the median (interquartile range) scanning durations were 21 (16.5–34.8) s and 47 (29.3–65) s (P<0.0001), the puncture durations were 114 (83–170) s and 74 (52.3–117.3) s (P = 0.0002), and the procedure durations were 141 (99–97.8) s and 118 (88.5–195.5) s (P = 0.14), respectively. The median number of attempts was 1 (interquartile range: 1–1, range: 1–3) in both groups (P = 0.72). Similar to the long-axis in-plane approach, the combined approach for internal jugular vein catheterization prevented posterior wall penetration in infants and small children.

Trial registration: This trial was registered before patient enrollment in the University Hospital Medical Information Network Clinical Trials Registry, registration number UMIN000039387 (https://upload.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000044907).

Long-Axis In-Plane Approach Versus Short-Axis Out-of-Plane Approach for Ultrasound-Guided Central Venous Catheterization in Pediatric Patients: A Randomized Controlled Trial

OBJECTIVES

The aim of this study was to compare the occurrence of posterior wall puncture between the long-axis in-plane and the short-axis out-of-plane approaches in a randomized controlled trial of pediatric patients who underwent cardiovascular surgery under general anesthesia.

DESIGN

Prospective randomized controlled trial.

SETTING

Operating room of Osaka Women's and Children's Hospital.

PATIENTS

Pediatric patients less than 5 years old who underwent cardiovascular surgery.

INTERVENTIONS

Ultrasound-guided central venous catheterization using the long-axis in-plane approach and short-axis out-of-plane approach.

MEASUREMENTS AND MAIN RESULTS

The occurrence of posterior wall puncture was compared between the long-axis in-plane and short-axis out-of-plane approaches for ultrasound-guided central venous catheterization. Patients were randomly allocated to a long-axis group or a short-axis group and underwent ultrasound-guided central venous catheterization in the internal jugular vein using either the long-axis in-plane approach (long-axis group) or the short-axis out-of-plane approach (short-axis group). After exclusion, 97 patients were allocated to the long-axis (n = 49) or short-axis (n = 48) groups. Posterior wall puncture rates were 8.2% (4/49) and 39.6% (19/48) in the long-axis and short-axis groups, respectively (relative risk, 0.21; 95% CI, 0.076-0.56; p = 0.0003). First attempt success rates were 67.3% (33/49) and 64.6% (31/48) in the long-axis and short-axis groups, respectively (relative risk, 1.04; 95% CI, 0.78-1.39; p = 0.77). Overall success rates within 20 minutes were 93.9% (46/49) and 93.8% (45/48) in the long-axis and short-axis groups, respectively (relative risk, 0.99; 95% CI, 0.90-1.11; p = 0.98).

CONCLUSIONS

The long-axis in-plane approach for ultrasound-guided central venous catheterization is a useful technique for avoiding posterior wall puncture in pediatric patients, compared with the short-axis out-of-plane approach.

Ultrasound guidance for Port-A-Cath insertion in children; a comparative study

Background

Gaining vascular access in children is challenging. Ultrasound-guided central line insertion in adults became the standard of care; however, its role in children is not clear. Our objective was to evaluate the ultrasound-guided Port-A-Cath or totally implanted long-term venous access device insertion in pediatric patients compared to the traditional approach.

Methods

This single-institution retrospective cohort study included 169 children who had port-A-catheters between May 2016 and Oct 2019. The patients were divided into two groups; group A included patients who had Port-A-Cath insertion using the landmark method (n = 117), and Group B included patients who had ultrasound-guided Port-A-Cath insertion (n = 52). Preoperative, operative, and postoperative data were collected and compared between the two groups. The study outcomes were operative time and catheter insertion-related complications.

Results

There was no significant difference in age or gender between both groups (P = .33 and .71, respectively). Eleven cases in group A and two cases in group B were converted to cut down technique because of difficulty in inserting the guidewire. There was no difference in the indication of the need for the port-A-Cath between both groups. The mean operative time for group A was 47 min and for group B was 41.7 min (P < .042). Two patients had intraoperative bleeding and hemothorax and required blood transfusion and chest tube insertion in group A. No statistically significant difference was found in the reported complications between the groups. However, the insertion-related complications were higher in group A (P = .053). No procedure-related mortality was reported.

Conclusions

Ultrasound-guided insertion of Port-A-Cath is an effective and safe technique with a reduction of failure rate. It should be considered the standard technique for Port-A-Cath insertion in the pediatric population.

Ultrasonographic Assessment of Anatomic Relationship Between the Internal Jugular Vein and the Common Carotid Artery in Infants and Children After ETT or LMA Insertion: A Prospective Observational Study

Background: Central venous catheterization is used for fluid management and infusion of drugs, but it is difficult to perform and carries a high incidence of complications in infants and children. In adults, the anatomic relationship and the overlap index between the internal jugular vein (IJV) and the common carotid artery (CCA) changed significantly after laryngeal mask airway (LMA) placement. However, there are conflicting results regarding the anatomic relationship between the IJV and the CCA after endotracheal tube (ETT) or LMA insertion in pediatric populations. Aim: The aim of this study was to compare the overlap index and anatomic relationship between the IJV and the CCA in infants and children after ETT or LMA insertion by ultrasonography. Method: This single-center, prospective, observational study including 92 infants and children, aged 1 month to 6 years, were grouped according to the airway devices placed: Group ETT (n = 44) and Group LMA (n = 48). The overlap index and anatomic relationship between the IJV and the CCA before and after airway device insertion at neutral and 30° head rotation position were evaluated by ultrasonography. Results: Before airway device insertion, as the head was rotated 30° to the contralateral side, the overlap index increased significantly on the right side of the neck compared to the neutral head position. In Group ETT, there was no significant difference in the overlap index after intubation in the neutral head position or 30° head rotated position on either side. In Group LMA, the overlap indexes were increased significantly after LMA insertion in the neutral head position on both sides. Likewise, the overlap indexes were increased significantly after LMA insertion in the 30° head rotated position on both sides. The most common positional relationship between the IJV and the CCA was anterolateral (AL) in both the right side and left side in the neutral head position. In Group ETT, the AL position was still the most common position relationship between the IJV and the CCA before and after intubation in the 30° head rotated position. In Group LMA, the anterior (A) position increased significantly after LMA insertion in the left side. In the 30° head rotated position, there was a significant increase to the A position after LMA insertion in both the right side and left side. The change from AL to A was increased after LMA insertion, especially in the 30° head rotated position. Conclusions: The overlap indexes of the IJV and the CCA increased significantly in both sides of the neck after LMA placement in the neutral head position, especially in 30° head rotated position. The IJVs after LMA placement had a tendency to become anterior to the CCA when the head of the patient rotated to the opposite direction in infants and children.

Long-Term Follow-Up Examination of the Internal Jugular Vein After Vessel-Sparing Implantation of a Hickman Catheter or Port Catheter

Introduction: Both a Hickman catheter (HC) and port catheter (Port) can be inserted either percutaneously by the Seldinger technique or by surgical venous cut-down. Catheters are inserted with a vessel-sparing technique when they are placed in the internal jugular vein (IJV) by venous cut-down. Although this technique is common, data are sparse regarding the vessel's state at long-term follow-up. This study was aimed at determining the flow pattern and constitution of the IJV after vessel-sparing implantation of an HC or Port and comparing the outcomes to those of implantation with the Seldinger technique. Methods: One hundred children (58 boys, 42 girls) between 33 days and 18 years of age who underwent a vessel-sparing implantation of an HC or Port in the IJV were prospectively included. All patients underwent surgical venous cut-down at a single institution. Patency and shape of the IJV were determined by ultrasound and categorized according to 2 possible outcomes: relevant alteration (including occlusion of the IJV) and no relevant alteration, with relevant alteration defined as changes that caused an altered flow pattern. Results: Median age was 6 years at the time of operation, and the median indwelling time of catheters was 271 days. Twenty-two of our patients (22%) showed relevant alterations. These changes included high-grade stenosis or lesion in 13 patients (13%) and occlusion in 9 patients (9%). There were no operation-associated complications, such as pneumothorax, hematopericardium, or accidental puncture of the carotid artery. Statistical analysis did not reveal any specific parameter as a risk factor for relevant structural abnormalities. Discussion: In a comparison of our data to the literature, venous cut-down showed an alteration rate of 26% and a patency rate of 85%, whereas the Seldinger technique was found to cause alteration in 15%, with a patency rate of 97% but a successful placement rate of only 90.3-91.6%. Conclusion: The indication for long-term catheter placement may determine which method is preferable. A child who is likely to need more catheters in the future might benefit from the Seldinger technique, since there is a higher chance of long-term patency of the vessel. A patient undergoing chemotherapy might benefit more from the surgical venous cut-down with less placement-associated complications.

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial

OBJECTIVE

We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians.

DESIGN

Randomised controlled trial.

SETTING

A paediatric intensive care unit of a teaching hospital.

PATIENTS

80 children (aged 28 days to <14 years).

INTERVENTIONS

Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique.

MAIN OUTCOME MEASURES

Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications.

RESULTS

We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all).

CONCLUSIONS

Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience.

TRIAL REGISTRATION NUMBER

RBR-4t35tk.

The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children

INTRODUCTION

We compared the effects of various surgical positions, with and without the Valsalva manoeuvre, on the diameter of the right internal jugular vein (RIJV).

METHODS

We recruited 100 American Society of Anesthesiologists physical status class I patients aged 2-12 years. The patients' heart rate, blood pressure, peripheral oxygen saturation and end-tidal CO2 pressure were monitored. Induction of anaesthesia was done using 1% propofol 10 mg/mL and fentanyl 2 µg/kg, while maintenance was achieved with 2% sevoflurane in a mixture of 50/50 oxygen and air (administered via a laryngeal mask airway). The RIJV diameter was measured using ultrasonography when the patient was in the supine position. Thereafter, it was measured when the patient was in the supine position + Valsalva, followed by the Trendelenburg, Trendelenburg + Valsalva, reverse Trendelenburg, and reverse Trendelenburg + Valsalva positions. A 15° depression or elevation was applied for the Trendelenburg position, and an airway pressure of 20 cmH2O was applied in the Valsalva manoeuvre. During ultrasonography, the patient's head was tilted 20° to the left.

RESULTS

When compared to the mean RIJV diameter in the supine position, the mean RIJV diameter was significantly greater in all positions (p < 0.001) except for the reverse Trendelenburg position. The greatest increase in diameter was observed in the Trendelenburg position with the Valsalva manoeuvre (p < 0.001).

CONCLUSION

In paediatric patients, the application of the Trendelenburg position with the Valsalva manoeuvre gave the greatest increase in RIJV diameter. The reverse Trendelenburg position had no significant effect on RIJV diameter.

Comparison of ultrasound guided brachiocephalic and internal jugular vein cannulation in critically ill children

PURPOSE

To determine whether ultrasound (US)-guided longitudinal in-plane supraclavicular cannulation of the brachiocephalic vein (BCV) improves cannulation success rates compared to transverse out-of-plane internal jugular vein (IJV) cannulation in urgent insertion of temporary central venous catheters (CVC) in critically ill children.

MATERIALS AND METHODS

Prospective open pilot (non-randomized) comparative study carried out in a pediatric intensive care unit (PICU) of a university-affiliated hospital. Newborns and children aged 0 to 14 years admitted to the PICU in whom an urgent CVC was clinically indicated and was inserted in the IJV or BCV by US guidance were eligible. First-attempt success rate, overall success rate, number of puncture attempts, and cannulation time were compared between IJV and BCV techniques.

RESULTS

Forty-six procedures (24 IJV and 22 BCV) in 38 patients were included. Full-sample median (range) age and weight were 13 (0.6-160) months and 9.5 (0.94-50) kg. No significant differences between IJV and BCV groups were observed for sex, age, weight, admission diagnosis, intra-procedural mechanical ventilation and sedation protocol. First attempt success rate was higher in the BCV than the IJV group (73 vs 37.5%, P= .017). Overall success rate was slightly higher in the BCV group (95 vs 83%, P = nonsignificant). Median (range) number of cannulation attempts [1 (1-3) vs 2 (1-4)] and cannulation time [66 (25-300) vs 170 (40-500) seconds] were significantly lower in the BCV group (P< .05). Patient's weight was inversely related to the number of cannulation attempts (Pearson coefficient -0.537, P= .007) and cannulation time (Pearson coefficient -0.495, P= .014) in the IJV but not in the BCV group. No major complications were observed.

CONCLUSIONS

Ultrasound-guided supraclavicular in-plane BCV cannulation improved first attempt CVC cannulation success rates and reduced puncture attempts and cannulation time compared to US-guided out-of-plane IJV in critically ill children. A large randomized clinical trial is warranted to confirm our results.

Ultrasound guided percutaneous internal jugular vein access in neonatal intensive care unit patients

BACKGROUND/PURPOSE

Internal jugular vein (IJV) access is commonly performed in neonates and infants with open cut-down method. We report the results of ultrasound guided percutaneous venous access in newborn patients in the neonatal intensive care unit (NICU).

METHODS

We retrospectively examined the medical records of NICU patients who underwent therapeutic percutaneous IJV access under ultrasound guidance from October 2015 to May 2015. Under general anesthesia, IJV was punctured with a 21 gauge needle after identification by ultrasound. Catheter was inserted with Seldinger's technique.

RESULTS

Twelve ultrasound-guided percutaneous IJV accesses were performed in eight patients and eleven cases were successful (91.6%). Procedure was performed at the median age of 4.5days (range 2days-47days). Median body weight was 3030g (range 1760g-4100g) and median operative time was 19minutes (range 8minutes-80minutes). Indications for central venous access were hyperammonemia caused by urea cycle defect (four patients) and mitochondrial disease (one patient), acute kidney injury (two patients), and congenital renal dysgenesis (one patient). Catheters were inserted in the right IJV in nine cases while two cases were done on the left IJV. All catheters functioned normally. Seven out of seven cases that were examined for venous patency by ultrasonography after catheter removal showed patent IJV. Among these seven cases, four reinsertions were attempted and successfully performed. There was one complication of hemopericardium with cardiac tamponade which is thought to be caused by direct injury from the guidewire. The patient underwent pericardiocentesis.

CONCLUSION

Ultrasound guided IJV access in NICU patients can be performed safely and is associated with preserved venous patency after catheter removal.

Comparison of central venous catheterization techniques in pediatric patients: needle vs angiocath

BACKGROUND

A needle or an angiocath has been generally used as a route for inserting a guide wire during central venous catheterization. We compared the needle with the angiocath for ultrasound-guided central venous catheterization in pediatric patients concerning accuracy and easiness.

METHODS

One hundred and thirty-two patients aged between 1 day and 5 years were randomized into the needle and the angiocath groups. The study was separately carried out in two age groups: newborns vs infants and children. The primary outcome was time to successful insertion of the guide wire. Secondary outcomes including other time variables (time to 1st successful puncture of the vein, time between 1st successful puncture of the vein and successful insertion of the guide wire, total time to successful central venous catheterization), frequency variables (number of the puncture attempts, number of the guide wire insertion attempts), success rates (1st successful puncture rate, 1st successful guide wire insertion rate), and complications.

RESULTS

There were no statistically significant differences in time and frequency variables, success rates, and complications between both the age groups. Time to 1st successful puncture of the vein (36.8 ± 31.7 vs 19.8 ± 27.1 s; 95% CI of mean difference 2.2-31.8; P = 0.03) and number of puncture attempts (1.6 ± 0.7 vs 1.3 ± 0.8; P = 0.02) were significantly greater in newborns with the needle, whereas with the angiocath, the number of puncture attempts was larger in newborns than in infants and children (1.7 ± 1.2 vs 1.2 ± 0.7; P = 0.02).

CONCLUSION

The angiocath showed no superiority over the needle for ultrasound-guided central venous catheterization in pediatric patients. Regardless of the needle or the angiocath, puncture of the vein was more difficult in newborns than in infants and children.

Effects of incrementally increasing tidal volume on the right internal jugular vein in pediatric patients

PURPOSE

The aim of the present study was to evaluate the effects of incremental increases of tidal volume (TV) on the cross-sectional area (CSA) and size of the right internal jugular vein (RIJV), and the relationship between RIJV and the carotid artery (CA).

METHODS

This prospective study included 23 pediatric patients aged between 7 and 12 years who were anesthetized. Using a standard anesthesia protocol, the TV was increased from 6 to 10 mL/kg in 1 mL/kg increments. For each TV, images of the RIJV and CA at the level of the cricoid cartilage were recorded at the end of the inspiration. From these results, the CSA and size of the RIJV and the percentage of CA overlap were calculated.

RESULTS

The median (interquartile range) RIJV CSA was 0.82 (0.52-1.07) cm2 at a TV of 6 mL/kg and significantly increased to 0.86 (0.58-1.05), 0.88 (0.55-1.08), 0.95 (0.62-1.17) and 1.02 (0.70-1.20) cm2 at TVs of 7, 8, 9 and 10 mL/kg, respectively. There were no significant differences in the percentage overlap of the CA between all TVs. The median (interquartile range) transverse diameter was 1.16 (0.99-1.36) cm at a TV of 6 mL/kg and significantly increased to 1.20 (1.10-1.41), 1.26 (1.05-1.45), 1.28 (1.10-1.49) and 1.35 (1.12-1.52) cm at TVs of 7, 8, 9 and 10 mL/kg, respectively. The median (interquartile range) anteroposterior diameter was 0.77 (0.72-0.90) cm at a TV of 6 mL/kg and significantly increased to 0.81 (0.72-0.94), 0.85 (0.74-0.99), 0.88 (0.75-1.02) and 0.89 (0.79-1.06) cm at TVs of 7, 8, 9 and 10 mL/kg, respectively.

CONCLUSIONS

This study reveals that a TV of 10 mL/kg in anesthetized children achieved the greatest size in the RIJV, and caused no difference in the CA overlap. These results suggest that a TV of 10 mL/kg is the optimal choice when facilitating catheterization and in the avoidance of complications in anesthetized children connected to mechanical ventilator that are required to undergo RIJV catheterization.

Comparison between radiation exposure levels using an image intensifier and a flat-panel detector-based system in image-guided central venous catheter placement in children weighing less than 10 kg

BACKGROUND

Ultrasound-guided central venous puncture and fluoroscopic guidance during central venous catheter (CVC) positioning optimizes technical success and lowers the complication rates in children, and is therefore considered standard practice.

OBJECTIVE

The purpose of this study was to compare the radiation exposure levels recorded during CVC placement in children weighing less than 10 kg in procedures performed using an image intensifier-based angiographic system (IIDS) to those performed in a flat-panel detector-based interventional suite (FPDS).

MATERIALS AND METHODS

A retrospective review of 96 image-guided CVC placements, between January 2008 and October 2013, in 49 children weighing less than 10 kg was performed. Mean age was 8.2 ± 4.4 months (range: 1-22 months). Mean weight was 7.1 ± 2.7 kg (range: 2.5-9.8 kg). The procedures were classified into two categories: non-tunneled and tunneled CVC placement.

RESULTS

Thirty-five procedures were performed with the IIDS (21 non-tunneled CVC, 14 tunneled CVC); 61 procedures were performed with the FPDS (47 non-tunneled CVC, 14 tunneled CVC). For non-tunneled CVC, mean DAP was 113.5 ± 126.7 cGy cm(2) with the IIDS and 15.9 ± 44.6 cGy · cm(2) with the FPDS (P < 0.001). For tunneled CVC, mean DAP was 84.6 ± 81.2 cGy · cm(2) with the IIDS and 37.1 ± 33.5 cGy cm(2) with the FPDS (P = 0.02).

CONCLUSION

The use of flat-panel angiographic equipment reduces radiation exposure in small children undergoing image-guided CVC placement.

The simultaneous application of positive-end expiratory pressure with the Trendelenburg position minimizes respiratory fluctuations in internal jugular vein size

Background

The respiratory cycle alters the size of the right internal jugular vein (RIJV). We assessed the changes in RIJV size during the respiratory cycle in patients under positive pressure ventilation. Moreover, we examined the effects of positive-end expiratory pressure (PEEP) and the Trendelenburg position on respiratory fluctuations.

Methods

A prospective study of 24 patients undergoing general endotracheal anesthesia was performed. Images of the RIJV were obtained in the supine position with no PEEP (baseline, S0) and after applying three different maneuvers in random order: (1) a PEEP of 10 cmH₂O (S10), (2) a 10° Trendelenburg tilt position (T0), and (3) a 10° Trendelenburg tilt position combined with a PEEP of 10 cmH₂O (T10). Using the images when the area was smallest and largest, cross-sectional area (CSA), anteroposterior diameter, and transverse diameter were measured.

Results

All maneuvers minimized the fluctuation in RIJV size (all P = 0.0004). During the respiratory cycle, the smallest CSA compared to the largest CSA at S0, S10, T0, and T10 decreased by 28.3 8.5, 8.0, and 4.4%, respectively. Furthermore, compared to S0, a 10° Trendelenburg tilt position with a PEEP of 10 cmH₂O significantly increased the CSA in the largest areas by 83.8% and in the smallest areas by 169.4%.

Conclusions

A 10° Trendelenburg tilt position combined with a PEEP of 10 cmH₂O not only increases the size of the RIJV but also reduces fluctuation by the respiratory cycle.

Ultrasound guided vascular access in pediatric cardiac critical care

INTRODUCTION

Safely obtaining vascular access in the pediatric population is challenging. This report highlights our real-world experience in developing a safer approach to obtaining vascular access using ultrasound guidance in children and infants with congenital heart disease.

METHODS

As part of a quality initiative, we prospectively monitored outcomes of all vascular access attempts guided by ultrasound from January 2010 to September 2010. Variables monitored included age, weight, the time from first needle puncture to wire insertion, site of insertion, number of attempts, type of line, and complications.

RESULTS

There were 77 attempts (15 arterial and 62 venous) to obtain vascular access in 43 patients. The mean age was 15 months (6 days-11 years; median 2.5 months). The mean weight was 7.2 kg (2-46 kg, median 3.8). Success rates were 93% and 95% for arterial and venous cannulation, respectively. Mean time from first needle puncture to wire insertion was 3.9 min (0.5-15 min, median 2 min). Fifty-five (75%) central line cannulations were successful from the first puncture; 17(23%) were successful from the second puncture; and one case (2%) required three punctures. Thirty patients (45%) weighed less than 3.5 kg. This lower body weight did not affect success rate, which was unexpectedly high (96.6%). There were no associated complications.

CONCLUSION

Ultrasound guided vascular cannulation in critically ill pediatric patients is safe, effective and efficient. This approach had a high success rate, and was associated with zero complications in our setting.

Simple manoeuvre to reduce the overlap between the internal jugular vein and carotid artery in infants

BACKGROUND

Catheterisation of the internal jugular vein (IJV) can be difficult in infants. We aimed to evaluate whether a simple manoeuvre, a slight caudo-lateral traction of the ipsilateral arm (CLTIA), could decrease the head rotation-induced overlap of the IJV to the carotid artery (CA) in infants.

METHODS

Twenty-five infants were included. The patients were placed in the 10° Trendelenburg position with a shoulder roll. On both sides of the neck, ultrasound images were obtained in a transverse orientation before and after the CLTIA at 0°, 40°, and 80° of head rotation, respectively. On each image, CA overlap was calculated as follows: CA overlap (%) = (overlap distance/CA diameter) × 100.

RESULTS

The CLTIA decreased CA overlap (%) in 0°, 40°, and 80° of head rotation on the right side of the neck [14 (interquartile range, IQR 0-32) to 0 (IQR 0-14), 24 (IQR 0-46) to 0 (IQR 0-33), and 31 (IQR 12-58) to 23 (IQR 0-34); all P < 0.01] and on the left [29 (IQR 7-61) to 19 (IQR 0-44), 40 (IQR 21-65) to 31 (IQR 0-46), and 44 (IQR 29-97) to 33 (IQR 14-69); all P < 0.01], respectively.

CONCLUSION

The CLTIA successfully reduced the overlap between the IJV and the CA in infants. However, further study should be needed to evaluate the clinical usefulness of the CLTIA during the IJV catheterisation.

Normal sizes of internal jugular veins in children/adolescents aged birth to 18 years at rest and during the Valsalva maneuver

OBJECTIVES

We aimed to establish normal ultrasonographic (US) values of internal jugular vein (IJV) sizes in children/adolescents aged birth to 18 years and to determine the correlation of US measurements with age, height, weight and body surface area (BSA) of children in different age groups.

METHODS

Two hundred and thirty-six healthy children (0-18 years) were divided into four groups according to their age (0-2, 3-6, 7-12, and 13-18 years). US measurements (transverse, anteroposterior diameter, and cross-sectional area at rest and during the Valsalva maneuver) of bilateral IJVs were taken at the level of cricoid cartilage.

RESULTS

Our study gives information about the reference values in children between birth to 18 years of age. There were significant differences between measurements taken at rest and during the Valsalva maneuver in all age groups. Moderate to strong correlations (clinically significant) between age, height and BSA of the subjects and IJV measurements were detected only in the 0-2 years age group. The strength of the correlations decreased with increasing age. Pearson's correlation revealed that height had the strongest and weight had the weakest correlation with US measurements. 'Height' was an independent variable on the right, and 'age' on the left side, except for rest CSA, when a regression analysis was performed for clinically significant correlations.

CONCLUSIONS

Determination of normal reference values for US measurements of the IJV and knowledge of correlation with age, height, weight and BSA might be valuable during interventional procedures and for the diagnosis of phlebectasia in children/adolescents.

Minimizing complications associated with percutaneous central venous catheter placement in children: recent advances

OBJECTIVES

To summarize existing knowledge regarding the prevalence of complications associated with temporary percutaneous central venous catheters placed in critically ill children, and to review evolving strategies to minimize the prevalence of these complications.

DATA SOURCES

Literature review was performed: PubMed and EBSCOhost were searched using the terms central venous catheter, children, ultrasound, infection, thrombosis, and thromboembolism in various combinations. Citations of interest from identified articles were also reviewed.

STUDY SELECTION

The review focused primarily on pediatric literature relevant to the topic of interest.

DATA EXTRACTION AND SYNTHESIS

Randomized clinical trials and other prospective studies were discussed in greater detail than retrospective, single-center investigations.

CONCLUSIONS

Complications during percutaneous central venous catheter placement in children are not rare and may be in part attributable to abnormalities in vascular anatomy. Thromboses in children with central venous catheters are increasingly recognized as an important problem for which evidence-based preventive measures are lacking. Catheter-associated bloodstream infection rates in critically ill children have markedly decreased over the last decade, associated with an increased emphasis on staff education and the use of insertion and maintenance bundles. Available evidence tends to support the use of two-dimensional ultrasound to augment the landmark technique for catheter placement, but more studies are needed.

The effect of passive leg elevation and/or trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children undergoing surgery for congenital heart disease

BACKGROUND

In this study we evaluated the effect of passive leg elevation (LE) and Trendelenburg (T) position on the cross-sectional area (CSA) of the internal jugular vein (IJV) in infants and young children undergoing surgery for congenital heart disease. A secondary aim was to compare the CSA of the IJV between subjects with right-to-left (RL) shunt and left-to-right (LR) shunt.

METHODS

Ninety infants and small children from 10 days to 31 months old weighing from 1.5 to 9.7 kg were assigned to group RL (n = 48) or LR (n = 42). In both groups, the CSA, transverse, and vertical diameters of the IJV on both sides of the neck were measured using a 2-dimensional ultrasound transducer in the following positions: supine position, 15° of T position, supine position with 50° of LE, and 15° of Trendelenburg position with 50° of LE (TLE). A more than 25% increase in mean CSA of the IJV was considered clinically significant.

RESULTS

In group LR, T, LE, and TLE significantly increased CSA of both right (at least 12.3%, 10.3%, and 18.3%, respectively, "at least" refers to the lower 95% confidence limits) and left (at least 15.8%, 15.0%, and 18.9%, respectively) IJVs, whereas only TLE increased the CSA of both IJVs significantly in group RL (at least 8.2% and 7.7% in the right and left, respectively). The increase in the CSA of the right IJV related to T and TLE was larger in group LR than in group RL (at least 12.3% vs 1.2% for T and at least 18.3% vs 8.2% for TLE, respectively). A clinically significant increase in CSA was achieved in both right and left IJVs with TLE in group LR (mean 28.6% and 26.3%, respectively). The CSA of the right IJV was larger than that of the left IJV in most (at least 69.2%) patients.

CONCLUSIONS

Passive LE was as effective as T position to increase the CSA of the IJV, but there was no clinically significant increase in the CSA with any single maneuver. Only T position with passive LE achieved a clinically significant increase in the CSA of both IJVs in infants and young children with LR shunt, but not in the same age group with RL shunt.

Dimension and overlap of femoral and neck blood vessels in neonates

INTRODUCTION

Neonates frequently require access to their central blood vessels. However, limited data exist relating to the size and the anatomical relation of the femoral and neck vessels for neonates of different postmenstrual ages.

HYPOTHESIS

1) The size of central blood vessels increases with postmenstrual age of the neonate. 2). External rotation with abduction at the hip will decrease the degree of overlap between the femoral artery and vein. 3) The degree of overlap decreases with increasing postmenstrual age.

DESIGN

Prospective descriptive cohort study.

MEASUREMENTS AND MAIN RESULTS

Femoral and neck vessel sizes were assessed using ultrasound for three postmenstrual age groups: group A (26 ± 1 wks), group B (32 ± 1 wks), and group C (38 ± 1 wks). The degrees of overlap (major, >50% overlap; minor, ≤50% overlap; no overlap) between the femoral vessels were assessed at the level of the inguinal ligament and 1 cm below the inguinal ligament in a straight hip and in external rotation with abduction of the hip positions. A total of 52 nonconsecutive subjects (group A, seven; group B, 21; group C, 24) were studied. The mean blood vessel dimensions increased with increasing postmenstrual age. Correlation of blood vessel size to growth measurements was better in group A + group B compared to group C. Overlap between the femoral vein and the femoral artery across the neonatal age groups at the level of the inguinal ligament ranged from 57% to 79% and from 43% to 98% at 1 cm below the inguinal ligament. The degree of overlap did not decrease with positioning of the lower extremity in external rotation with abduction of the hip. In the neck blood vessels, the majority of observations showed either minor or major overlap of neck blood vessels in all three groups (group A, 79%; group B, 86%; group C, 90%).

CONCLUSIONS

Central blood vessel size increases with increasing postmenstrual age. Correlation of blood vessel size to anthropometric measurements was better in the premature neonates compared to term neonates. A high degree of overlap exists within the femoral and cervical blood vessels. In the femoral vessels, the degree of overlap did not decrease with external rotation with abduction of the hip at any postmenstrual age.

Ultrasound guided internal jugular vein access in children and infant: a meta-analysis of published studies

INTRODUCTION

Central venous catheter placement is technically difficult in pediatric population especially in the younger patients. Ultrasound prelocation and/or guidance (UPG) of internal jugular vein (IJV) access has been shown to decrease failure rate and complications related to this invasive procedure. The goal of the present study was to perform a systematic review of the advantages of UPG over anatomical landmarks (AL) during IJV access in children and infants.

MATERIAL AND METHODS

A comprehensive literature search was conducted to identify clinical trials that focused on the comparison of UPG to AL techniques during IJV access in children and infants. Two reviewers independently assessed each study to meet inclusion criteria and extracted data. Data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), and their 95% confidence intervals [CI 95%]. I(2) statistics were used to assess statistics heterogeneity and to guide the use of fixed or random effect for computation of overall effects. Subgroup analysis was used to clarify the effects of the techniques used (prelocation or guidance) or the experience of practitioners.

RESULTS

Literature found five articles. Most of the patients were cardiac surgery patients. In comparison with AL, UPG had no effect on IJV access failure rate (OR = 0.28 [0.05, 1.47], I(2) = 75%, P = 0.003), the rate of carotid artery puncture (OR = 0.32 [0.06, 1.62], I(2) = 68%, P = 0.01), haematoma, haemothorax, or pneumothorax occurrence (OR = 0.40 [0.14, 1.13], I(2) = 17%, P = 0.30, OR = 0.72, OR = 0.81 [0.18, 3.73], I(2) = 0%, P = 0.94, respectively) and time to IJV access and haemothorax/pneumothorax occurrence. Subgroup analysis found an efficacy of ultrasound when used by novice operators or during intraoperative use.

DISCUSSION

This current meta-analysis does not found the utility of ultrasound during IJV access in children and infants in increasing the success rate and in decreasing complications.

Ultrasound guided vascular access: efficacy and safety

Central venous catheterisation and arterial catheterisation are common procedures performed by anaesthetists. Traditionally, the technique of locating surface landmarks and palpation was used to assist in vascular access. The introduction of perioperative ultrasonography in the past decade has dramatically changed this procedure. In the United States and United Kingdom, guidelines have recommended the use of ultrasound guidance to reduce complications and improve success in central venous catheterisation. This article summarises the literature on complication rates, efficacy and safety of ultrasound-guided vascular access procedures and describes a practical method of ultrasound-guided central venous access and arterial catheterisation.