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

Translating Guidelines into Practical Practice: Point-of-Care Ultrasound for Pediatric Critical Care Clinicians

Point-of-care ultrasound (POCUS) is now transitioning from an emerging technology to a standard of care for critically ill children. POCUS can provide immediate answers to clinical questions impacting management and outcomes within this fragile population. Recently published international guidelines specific to POCUS use in neonatal and pediatric critical care populations now complement previous Society of Critical Care Medicine guidelines. The authors review consensus statements within guidelines, identify important limitations to statements, and provide considerations for the successful implementation of POCUS in the pediatric critical care setting.

US-guided central venous catheter placement in the neonatal intensive care unit: Brachiocephalic vein or internal jugular vein?

BACKGROUND

Centrally inserted central catheters (CICCs) are commonly used to monitor venous pressure and administer parenteral nutrition and drugs in newborns. In the present study, we evaluated cannulation success rates, cannulation time, and frequency of complications in catheterization of the internal jugular vein (IJV) and brachiocephalic vein (BCV).

METHODS

The present study included patients who underwent IJV and BCV catheterization under ultrasound (US) guidance. The patients were divided into two groups, IJV and BCV, depending on the vein in which the CICC was utilized. We documented the diameters of the IJVs and BCVs, first attempt and overall success rates, mean cannulation time, and complication rates.

RESULTS

A total of 79 patients were evaluated, 37 in the BCV group and 42 in the IJV group. No significant differences were observed between the two groups in terms of sex, mean age, or weight range (p > 0.05).The mean vein diameter was significantly larger in the BCV group than in the IJV group (p < 0.001); the mean number of attempts was significantly higher in the IJV group than in the BCV group (p < 0.001); the mean cannulation time was significantly longer in the IJV group than in the BCV group (p < 0.001); and the first attempt success rate was 50% in the IJV group, versus 94.6% in the BCV group. The overall success rate was 100% in both groups. The rate of complications was 8.6% in the IJV group, while no complications developed in the BCV group.

CONCLUSIONS

Given the larger diameter of the vessel, BCV catheterization was found to result in quicker cannulation and lower complication rates. The results of the present study suggest that BCV catheterization should be the first choice for neonatal intensive care unit (NICU) patients who require parenteral support or close venous pressure monitoring.

Safety and outcome of ultrasound-guided tunneled central venous catheter in children with cancers from low middle-income country: A prospective study

BACKGROUND

Central venous access devices (CVAD) are vital for cancer therapeutics in pediatric oncology. Tunneled vascular access devices (TVAD) are preferred in children for prolonged and frequent vascular access. Data on insertion, care, and complications of CVAD in children from low middle-income countries (LMIC) are scarce, heterogeneous, and retrospective.

PROCEDURE

This prospective observational study on eligible children <12 years with pediatric malignancies requiring chemotherapy for minimum 6 months from diagnosis excluded children with mucosal bleeding, coagulopathy, and infections. TVAD insertion was ultrasound (USG) guided. Number of catheter-days, surgical and nonsurgical complications, and risk factors for catheter-related bloodstream infections (CRBSI) were noted TVAD removal due to complications, therapy completion, tumor progression, or death.

RESULTS

Data from 61 of 86 eligible children with median age 42 months (range 1-144) were analyzed. Hematological malignancy and severe thrombocytopenia were seen in 37/61 (61%) and 18/61 (30%) children, respectively. First-attempt success rate was 74%. Surgical complications were seen in four of 61 (7%). Nonsurgical complications were seen in 33/61 (54%) children; CRBSI was commonest 24/61 (39%), causing removal of TVAD in 14/61 (23%). Incidence per 1000 catheter-days for CRBSI was 3.24. Antibiotic lock therapy could salvage nine of 24 TVAD with CRBSI. Thrombus and accidental removal was seen in six of 61 (10%) and four of 61 (7%). None of the studied risk factors were significantly associated with CRBSI. The mean insertion duration of TVAD was 121 ± 90 days.

CONCLUSION

USG-guided TVAD insertion is safe and reliable way for chemotherapy administration with acceptable complications in children with malignancies in LMIC, including children with severe thrombocytopenia.

The Right Internal Jugular at the Cricoid Cartilage Level May Represent the Optimal Central Vein Puncture Site in Pediatric Patients

OBJECTIVE

Internal jugular vein puncture or cannulation is far more difficult in children compared with adults. Anthropometric measures of the internal jugular vein acquired by two-dimensional ultrasound are useful in the practice of puncture and catheterization. The aim of this study is to measure anthropometric parameters of bilateral internal jugular veins in children and to determine the best puncture site based on these parameters.

MATERIALS

A total of 107 pediatric patients undergoing elective operation were included. Ultrasound-visible evaluation of bilateral internal jugular veins was used to obtain the depth from skin, maximum antero-posterior diameter, and cross-sectional area at the levels of the superior border of thyroid cartilage and cricoid cartilage. Statistical analysis was performed using these anthropometric data and demographic variables of all studied pediatric patients, such as age, height, and weight.

RESULTS

A very weak correlation was noted between the depth, maximal antero-posterior diameter, and cross-sectional area of both internal jugular veins and the age, height, weight, and body surface index of all included children. All Pearson's R correlation coefficients were <0.45. The largest diameter and cross-sectional area were in the right internal jugular vein at the cricoid cartilage level (p < 0.01) followed by the left internal jugular vein at this level (p < 0.01). In addition, the internal jugular vein at the cricoid cartilage level was more superficial than that of the superior border of the thyroid cartilage (p < 0.01).

CONCLUSION

The right internal jugular vein at the cricoid cartilage level is the best site for puncture. The most appropriate alternative site is the left internal jugular vein on the same level. Better correlation was not observed between the anthropometric parameters of the internal jugular vein and children's biological characteristics. This finding should be confirmed in a larger-scale demographical study in the future.

Ultrasound-guided brachiocephalic vein access in neonates and pediatric patients

Central venous accesses in neonates and pediatric patients represent a common and important procedure for both, intraoperative and postoperative care. Point-of-care ultrasound-guided technique has been proposed to increased success rate and efficiency, as well as to decrease the number of complications. Ultrasound-guided internal jugular vein cannulation is considering the "gold standard" in children. Another central venous cannulation option in neonates and children has been supraclavicular ultrasound-guided cannulation of the brachiocephalic vein using the in-plane approach. This article gives a review of the current evidence, the basic knowledge of the technique and the structured approach to follow for supraclavicular ultrasound-guided brachiocephalic vein access in children and neonates.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Real time wire localization by ultrasound during central line insertion improves accurate positioning in all upper torso sites

PURPOSE

To investigate whether point of care ultrasound can improve central venous catheter tip positioning.

MATERIAL AND METHODS

A single center retrospective case control study. We compared the precision of central venous catheter tip positioning between two intensive care units while in only one of the units, we used point of care ultrasound for guidewire identification.

RESULTS

207 cases in which central venous catheter was inserted using point of care ultrasound guided method, compared to 192 controls. The primary outcome of correct placement of the central venous catheter tip was significantly higher in the point of care ultrasound guided group (97.6% vs 88.0% p = 0.001). Central venous catheter tip was located too low among 12% of patients in the control group while in only 2.4% of patients in the point of care ultrasound group (p = 0.001). Logistics regression analysis revealed that the correct placement of central venous catheter tip in the point of care ultrasound group versus the control group had an odds ratio of 4.9 (CI 1.6-14.5 P = 0.004).

CONCLUSION

Point of care ultrasound for guidewire identification and localization, while inserting central venous catheter from all upper torso sites, improves precision positioning.

Ultrasound-Guided Central Venous Access With Different Anesthesia Methods in Neonatal Intensive Care Unit

Background: Ultrasound (US)-guided internal jugular vein (IJV) catheterization in newborns is usually performed in the operating room with general anesthesia. This study aimed to show that US-guided IJV catheterization can be successfully performed with local anesthesia and sedation in newborns.

Methods: The files of newborn patients who underwent US-guided IJV catheterization between May 2017 and May 2020 were examined. Two groups were created according to the type of anesthesia applied during the procedure. The general characteristics of the newborns, the success of the procedure, the number of punctures, and the complication rates in both groups were compared.

Results: A total of 53 newborns were included in this study. Of the 62 procedures, 30 were performed under general anesthesia (group A) and 32 were performed under sedation (group B). Twenty-six (86.6%) of the newborns in group A and 19 (59.3%) in group B were catheterized at the first puncture. The median puncture numbers in groups A and B were 1 (1-3) and 1 (1-5), respectively. All of the patients in group A were successfully catheterized (n = 30; 100%), and all but one in group B could be catheterized (n = 32; 96.8%).

Conclusion: No significant differences in complications or procedural success rates were observed between newborns undergoing general anesthesia or sedation. US-guided IJV catheterization can be safely performed with sedation alone.

Ultrasound-guided brachiocephalic vein access in neonates and pediatric patients

Central venous accesses in neonates and pediatric patients represent a common and important procedure for both, intraoperative and postoperative care. Point-of-care ultrasound-guided technique has been proposed to increased success rate and efficiency, as well as to decrease the number of complications. Ultrasound-guided internal jugular vein cannulation is considering the "gold standard" in children. Another central venous cannulation option in neonates and children has been supraclavicular ultrasound-guided cannulation of the brachiocephalic vein using the in-plane approach. This article gives a review of the current evidence, the basic knowledge of the technique and the structured approach to follow for supraclavicular ultrasound-guided brachiocephalic vein access in children and neonates.

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.

Selection and Insertion of Vascular Access Devices in Pediatrics: A Systematic Review

OBJECTIVE

To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).

DATA SOURCES

Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.

STUDY SELECTION

Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.

DATA EXTRACTION

Articles were independently reviewed to extract and summarize details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications.

RESULTS

VAD selection and insertion decision-making in general hospitalized and some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope.

LIMITATIONS

Limitations include the lack of formal assessment of the quality of evidence and the lack of RCTs and systematic reviews. Consequently, clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations.

CONCLUSIONS

This is the first synthesis of available evidence for the selection and insertion of VADs in pediatric patients and is important for determining the appropriateness of VADs in pediatric patients.

Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications

Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.

Computer-assisted needle navigation for pediatric internal jugular central venous cannulation: A feasibility study

INTRODUCTION

Vascular access for central venous catheter placement is technically challenging in children. Ultrasound guidance is recommended for pediatric central venous catheter placement, yet many practitioners rely on imprecise anatomic landmark techniques risking procedure failure due to difficulty mastering ultrasound guidance. A novel navigation system provides a visual overlay on real-time ultrasound images to depict needle trajectory and tip location during cannulation. We report the first pediatric study assessing feasibility and preliminary safety of using a computer-assisted needle navigation system to aid in central venous access.

METHODS

A prospective, institutional review board-approved feasibility study was performed. All participants provided written informed consent. Ten patients (mean age: 11.4 years, five males) underwent central venous catheter placement with ultrasound and navigation system guidance. All procedures were performed by interventional radiologists expert in vascular access. Feasibility was measured through binary (yes/no) responses from participating users assessing device usability and feasibility. The number of needle passes and procedure time measures were also recorded.

RESULTS

Internal jugular veins (seven right sided, three left sided) were cannulated in all patients with no complications. Users confirmed navigation system feasibility in all 10 participants. Mean vein diameter and depth was 13.3 × 9.8 ± 3.4 × 2.1 and 7.0 ± 1.7 mm, respectively. Successful cannulation occurred in all patients and required only a single needle pass in 9 of 10 patients. Mean device set-up and vascular access times were 5:31 ± 2:28 and 1:48 ± 2:35 min, respectively.

CONCLUSION

This pilot study suggests that it is feasible to use a novel computer-assisted needle navigation system to safely obtain central venous access under ultrasound guidance in pediatric patients.

Evaluation of upper limb superficial venous percussion as a sign of anatomical location and venous permeability. A comparative study of superficial venous percussion to ultrasound findings on non-renal patients and on chronic kidney disease patients

METHODS

An analytical cross-sectional study with 70 individuals divided into two groups. Group A consisted of 35 volunteers who were being preoperatively prepared for the construction of arteriovenous fistula. Group B consisted of 35 non-renal patients selected by convenience. Each participant underwent physical examination, including venous percussion, of the dominant upper limb and then ultrasound. Interobserver agreement was assessed between a trained vascular surgeon performing percussion and fourth-year medical student. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value of percussion were determined in relation to ultrasound. The agreement between the methods, venous percussion and venous duplex ultrasound was also evaluated by the Kappa index.

RESULTS

The overall interobserver agreement for the percussion was 0.74 (95% CI 0.632 to 0.851). It was observed that the results were more favorable in the cephalic vein than in the basilic vein, emphasizing that the cephalic is more used in venous punctures, because of its anatomical location and visibility, and in fistula construction. The 35 percussions of the cephalic forearm vein in Group A resulted in a sensitivity of 1.0 (95% CI 0.63 to 1.00), specificity of 0.96 (95% CI 0.81 to 1.00), a positive predictive value of 0.89(95% CI 0.52 to 1.00) and a negative predictive value of 1.00 (95% CI 0.87 to 1.00), with an accuracy of 0.97 (95% CI 0.85 to 1.00) and Kappa index of 0.92 (95% CI 0.77 to 1.00) in relation to ultrasound. Overall, when all venous segments were analyzed in group A, the Kappa index of agreement between the percussion and the ultrasonography reached 0.56 (95% CI 0.401 to 0.72). All venous segments in Group A had a sensitivity of 0.54 (95% CI 0.37 to 0.70) and a specificity of 0.96 (95% CI 0.90 to 0.99). When all venous segments were analyzed in group B, the Kappa index of agreement between the percussion and the ultrasonography reached 0.48 (95% CI 0.34 to 0.62). All venous segments in Group B had a sensitivity of 0.70 (95% CI 0.59 to 0.79) and a specificity of 0.82 (95% CI 0.69 to 0.91).

CONCLUSION

Venous percussion of the upper limbs has a high positive predictive value and high specificity, when compared to ultrasound as a way to evaluate the patency and adequacy of the cephalic vein. Although there is not enough evidence to preclude ultrasound, percussion should definitely be included in the traditional physical exam evaluation of upper limbs superficial veins.

Ultrasound-guided supraclavicular brachiocephalic vein catheterization in children: Syringe-free in-plane technique with micro-convex probe

Central venous catheterization of children is often a challenging procedure due to small anatomical structures. Ultrasound guidance has been shown to reduce complications and improve cannulation success as compared with the landmark-based technique. In-plane techniques allow for longitudinal visualization of the vessels and real-time visualization of needle track during its advancement. When in-plane and syringe-free techniques are combined, advancement of the guidewire can also be visualized. We aim to introduce our supraclavicular approach for brachiocephalic vein cannulation in pediatric patients. A syringe-free and in-plane technique is used to cannulate the patients. The subclavian, jugular, and the brachiocephalic veins were visualized by endocavity micro-convex ultrasound probe as a Y shape during the cannulation procedure. We present a case series of successful cannulation by using this technique.

Ultrasound guidance improves safety and efficiency of central line placements

BACKGROUND

Use of ultrasound-guidance for central venous access in adults is the standard of care. There is, however, less clarity in the role of routine ultrasound use in obtaining venous access in children. We sought to evaluate safety and efficiency of the placement of central lines utilizing an ultrasound-guided approach compared to the traditional, landmark approach in pediatric patients.

STUDY DESIGN

A single-institution retrospective chart review, using CPT codes, was performed for all tunneled central venous catheters in children between 2005 and 2017 by the same pediatric surgery group. During the study period, a practice change occurred from exclusively landmark-based line placement to ultrasound-guided line placement. Groups were divided into three phases: a traditional/landmark era (Phase 1), transitional period (Phase 2), and the ultrasound era (Phase 3). The primary outcomes analyzed were postoperative chest tube insertions and operative time.

RESULTS

A total of 2010 tunneled central lines were included for analysis: Phase 1 (N = 930), Phase 2 (N = 313) and Phase 3 (N = 767). Venous access for chemotherapy was the most common indication (29%). Phase 1 had a chest tube placement rate of 9.7/1000 procedures, while Phase 2 had a rate of 6.4/1000 procedures, and Phase 3 had no chest tube insertions (p = 0.009). Phase 1 had longer OR times compared to Phase 2 (57 vs. 49, p = 0.0026) and Phase 3 (57 vs. 46 min, p < 0.001).

CONCLUSIONS

This study represents the largest analysis of ultrasound-guided access for children. A complete practice transition to the ultrasound-guided approach was feasible within a two-year period. The ultrasound-guided approach had a shorter operative time and less chest tube insertions than the traditional, landmark technique in children. Level III evidence.

Central venous catheters: Indications, techniques, and complications

Central venous catheters (CVC) are commonplace in the management of critically ill patients and serve a variety of purposes. Venous access is important for the administration of fluid and medications as well as blood procurement needed for lab analyses. However, not every critically ill patient requires a CVC. This article highlights the key considerations, pitfalls and evidence-based practices regarding the use pediatric central venous catheters.

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.

Central Line in Long-term Parenteral Nutrition in Children: A European Survey

BACKGROUND AND AIMS

The guidelines for the insertion and maintenance of the central venous catheter (CVC) in children on long-term parenteral nutrition (PN) were published 12 years ago and studies evaluating the outcomes are limited. Therefore, the aim of the present study was to perform a survey about criteria for CVC insertion and maintenance in intestinal failure/rehabilitation centers treating children on home PN.

METHODS

An online cross-sectional survey based on previous European Society of Paediatric Gastroenterology, Hepatology and Nutrition PN guidelines was distributed electronically to the members of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition networking group, Network for Intestinal Failure and Transplantation in Europe and tertiary pediatric gastroenterology centers in Europe.

RESULTS

Overall, 55 responses from 49 centers in 18 European countries and Israel were collected. The majority of respondents were from the United Kingdom (10, 19%), followed by Germany (7, 13%) and France (6, 11%). Eleven centers (21%) cared for >30 patients, 8 (15%) centers between 20 and 30 patients, 18 (34%) centers between 10 and 20 patients, and 16 (30%) <10 patients on home PN. There was a high variability in the majority of answers to the cross-sectional survey.

CONCLUSIONS

CVC insertion and maintenance in children on home PN varies largely amongst centers in Europe. These differences could be at least partially explained by the lack of updated guidelines and limited evidence. There is an urgent need for collaborative research to make recommendations about the best possible practice.

International Scope of Emergency Ultrasound: Barriers in Applying Ultrasound to Guide Central Line Placement by Providers in Nairobi, Kenya

Background

While ultrasound (US) use for internal jugular central venous catheter (CVC) placement is standard of care in North America, most developing countries have not adopted this practice. Previous surveys of North American physicians have identified lack of training and equipment availability as the most important barriers to the use of US.

Objective

We sought to identify perceived barriers to the use of US to guide CVC insertion in a resource-constrained environment.

Methods

Prior to an US-guided CVC placement training course conducted at the Aga Khan University Hospital in Nairobi, Kenya, physicians were asked to complete a survey to determine previous experience and perceived barriers. Survey responses were analyzed using summary statistics and the Rank-Sum test based on different specialty, gender, and previous US experience.

Results

There were 23 physicians who completed the course and the survey. 52% (95% CI: 0.30–0.73) had put in >20 CVCs. 21.7% (95% CI: 0.08–0.44) of participants had previous US training, but none in the use of US for CVC insertion. The respondents expressed agreement with statements describing the ease of the use and improved success rate with US guidance. There was less agreement to statements describing the relative convenience and cost effectiveness of US CVC placement compared to the landmark technique. The main perceived barriers to utilization of US guidance included lack of training and limited availability of US equipment and sterile sheaths.

Conclusion

Perceived barriers to US-guided CVC placement in our population closely mirrored those found among North American physicians, including lack of training and limited availability of US machines and equipment. These barriers have the potential to be addressed by targeted educational and administrative interventions.

The intracavitary electrocardiography method for tip location of jugular internal vein access device in infants of less than 5 kg: A pilot study

Purpose:

This is a prospective observational study conducted by neonatologists in neonatal intensive care unit from Sant’Anna and San Sebastiano Hospital, Caserta, Italy. The objective of the study is to verify the feasibility of intracavitary electrocardiography method for tip location of central venous access device in infants of less than 5 kg and evaluate the accuracy of the method in comparison with post-procedural echocardiographical verification of the tip position.

Patients and methods:

We enrolled 27 patients weighted between 0.660 and 5 kg, requiring central vascular access. Ultrasound-guided jugular internal vein access was used and after cannulation, we applied the intracavitary electrocardiography for tip location as well as post-procedural echocardiography.

Results:

No significant complication related to intracavitary electrocardiography occurred in the studied infants. The increase in P wave on intracavitary electrocardiography was detected in all cases (27/27). In only one case (false positive), the catheter had the tip out of cavoatrial junction–target zone (to post-procedural echocardiography).

Conclusion:

The intracavitary electrocardiography method for tip location of central venous access device is safe and accurate in infants, as demonstrated by post-procedural comparative echocardiographic controls. As an alternative to echocardiography, not always achievable, the diffusion of intracavitary electrocardiography method could reduce X-ray exposition and complications of a malpositioned tip.

How useful is ultrasound guidance for internal jugular venous access in children?

PURPOSE

The aim of this study was to determine whether US reduces number of puncture attempts, procedure time, and complication rate during IJV access in children.

METHODS

A prospective study was performed in children (age ≤18years) admitted to our institution, from September 2013 to July 2014, with indications for central venous access. Patients meeting the inclusion criteria were randomized to the US-guided or control groups. The same physician performed all IJV cannulations in both groups. The end-points for comparison were: length of time to venous access, number of attempts, and rate of complications.

RESULTS

Fifty-one patients were included: 23 in the US-guided group and 28 in the control group. There were no between-group differences in weight, age, or sex. In the US-guided group, the number of punctures needed to achieve IJV access (median [interquartile range], 3 [2-5] vs. 1 [1, 2]; P<0.001), time to achievement of venous access, and complication rate (39% vs. 4.3%, P<0.009) were significantly lower.

CONCLUSION

US guidance is a useful adjunct to central venous access in children, facilitating the procedure, decreasing time to cannulation, and increasing safety.

TYPE OF STUDY

Prospective randomized study.

LEVEL OF EVIDENCE

1.

Supraclavicular catheterization of the brachiocephalic vein: a way to prevent or reduce catheter maintenance-related complications in children

Placement of a central venous catheter (CVC) in the brachiocephalic vein (BCV) via the ultrasound (US)-guided supraclavicular approach was recently described in children. We aimed to determine the CVC maintenance-related complications at this site compared to the others (i.e., the femoral, the subclavian, and the jugular). We performed a retrospective data collection of prospectively registered data on CVC in young children hospitalized in a pediatric intensive care unit (PICU) during a 4-year period (May 2011 to May 2015). The primary outcome was a composite of central line-associated bloodstream infection (CLABSI) and deep-vein thrombosis (CLAT) according to the CVC site. Two hundred and twenty-five children, with respective age and weight of 7.1 (1.3-40.1) months and 7.7 (3.6-16) kg, required 257 CVCs, including 147 (57.2%) inserted in the BCV. The risk of the primary outcome was lower in the BCV than in the other sites (5.4 vs 16.4%; OR: 0.29; 95% CI: 0.12-0.70; p = 0.006). CLABSI incidence density rate (2.8 vs 8.96 per 1000 catheter days, p < 0.001) and CLAT incidence rate (2.7 vs 10%, p = 0.016) were also lower at this site.

CONCLUSION

BCV catheterization via the US-guided supraclavicular approach may decrease CVC maintenance-related complications in children hospitalized in a PICU. What is Known: • Placement of a central venous catheter (CVC) in children is associated with mechanical risks during insertion, and with infectious and thrombotic complications during its maintenance. • Ultrasound (US)-guided supraclavicular catheterization of the brachiocephalic vein (BCV) is feasible in infants and children. What is New: • This observational study suggested that BCV catheterization via the US-guided supraclavicular approach was associated with a lower risk of CVC insertion and maintenance-related complications, compared with the other catheterization sites.

Point-of-care ultrasound in pediatric anesthesiology and critical care medicine

Ultrasound has increasingly become a clinical asset in the hands of the anesthesiologist and intensivist who cares for children. Though many applications for ultrasound parallel adult modalities, children as always are not simply small adults and benefit from the application of ultrasound to their management in various ways. Body composition and size are important factors that affect ultrasound performance in the child, as are the pathologies that may uniquely afflict children and aspects of procedures unique to this patient population. Ultrasound simplifies vascular access and other procedures by visualizing structures smaller than those in adults. Maturation of the thoracic cage presents challenges for the clinician performing pulmonary ultrasound though a greater proportion of the thorax can be seen. Moreover, ultrasound may provide unique solutions to sizing the airway and assessing it for cricothyroidotomy. Though cardiac ultrasound and neurosonology have historically been performed by well-developed diagnostic imaging services, emerging literature stresses the utility of clinician ultrasound in screening for pathology and providing serial observations for monitoring clinical status. Use of ultrasound is growing in clinical areas where time and diagnostic accuracy are crucial. Implementation of ultrasound at the bedside will require institutional support of education and credentialing. It is only natural that the pediatric anesthesiologist and intensivist will lead the incorporation of ultrasound in the future practice of these specialties.

Ultrasound guided internal jugular vein cannulation in infants: Comparative evaluation of novel modified short axis out of plane approach with conventional short axis out of plane approach

Background and Aims:

Central venous cannulation (CVC) through right internal jugular vein (IJV) route is routinely performed in paediatric patients undergoing major surgery and in those admitted to intensive care units. A novel technique (modified short-axis out-of-plane [MSA-OOP]) to improve first pass success rate of ultrasound-guided IJV CVC in neonates and infants is being compared with conventional SA-OOP method.

Methods:

A total of 120 patients were enroled in the study over a period of 6 months. All paediatric patients with age <1 year and weight <10 kg who underwent a major surgery requiring CVC were included. Patients were randomised to either of the two approaches of ultrasound-guided IJV cannulation; SA-OOP and modified SA-OOP (MSA-OOP). In modified approach, the midline of probe footprint was marked with a radio-opaque barium wire that casted a central acoustic shadow on ultrasound screen.

Results:

In MSA-OOP group, 83.1% of patients were cannulated in the first attempt as compared to 49.2% patients in group SA-OOP. Patients in MSA-OOP group required significantly fewer attempts for successful CVC as compared to patients in the SA-OOP group ( MSA-OOP: median = 1, interquartile range [1-1]; SAOOP: median = 2, interquartile range [1-2], P < 0.001, Mann–Whitney U-test).

Conclusion:

The use of MSA-OOP ultrasound technique for IJV CVC cannulation results in a higher first-attempt success rate and reduces the number of cannulation attempts.

Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children

PURPOSE

To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children.

METHODS

A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6 months. Children 0-18 years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (> 3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders.

RESULTS

Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p < 0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient - 0.51 (95% confidence interval - 1.01 to - 0.03), p = 0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p = 0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications.

CONCLUSIONS

Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.

Anatomic variations of neck vessels and the course of pediatric internal jugular veins

BACKGROUND

Landmark-guided internal jugular vein cannulation is difficult for pediatric patients but useful, especially when ultrasound equipment is unavailable. Therefore, it is important to define the adjacent anatomic characteristics of the pediatric internal jugular vein.

METHODS

In 210 children the course of the internal jugular vein, and common carotid and vertebral arteries was measured from the level of the cricoid cartilage to the supraclavicular area using ultrasound.

RESULTS

From the level of the cricoid cartilage to the supraclavicular area, vessel diameter increased with internal jugular vein increasing by 12%, and common carotid and vertebral arteries increasing by 5% each. From the level of the cricoid cartilage to the supraclavicular area, the number of patients with a medial common carotid artery position relative to the internal jugular vein increased, whereas those with a lateral position decreased; the number of patients with nonoverlapped common carotid artery-internal jugular vein increased, and those with totally overlapped decreased. In contrast, the overlapping status of vertebral artery-internal jugular vein changes oppositely. More than 97.14% of the vertebral artery lies lateral to the internal jugular vein at these levels. The minimal vertebral artery-internal jugular vein depth decreased from 0.46±0.20 to 0.37±0.19 cm. The angle from the internal jugular vein line to the horizontal line of the body was 83.35±9.04 degrees.

CONCLUSION

The common carotid artery and internal jugular vein are farther apart as one moves down the neck, whereas the vertebral artery and internal jugular vein are getting together. Additionally, the diameter of the internal jugular vein increased.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med. 2017;45:1061-1093. [PMID: 28509730 DOI: 10.1097/ccm.0000000000002425]

OBJECTIVES

The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock."

DESIGN

Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups.

MEASUREMENTS AND MAIN RESULTS

The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations.

CONCLUSIONS

The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Utility of Ultrasound Guidance for Central Venous Access in Children

BACKGROUND

Placement of a central venous catheter (CVC) in a pediatric patient is an important skill for pediatric emergency medicine physicians but can be challenging and time consuming. Ultrasound (US) guidance has been shown to improve success of central line placement in adult patients.

OBJECTIVES

This article aims to review the literature and evaluate the benefit of US guidance in the placement of CVCs, specifically in pediatric emergency department patients, and to review the procedure.

RESULTS

Four meta-analyses of US-guided CVC placement in adult patients concluded that US guidance reduces placement failure, decreases complications, and decreases the need for multiple attempts. Two studies in the emergency department setting support these conclusions. Pediatric-specific data related to US-guided CVC placement include data suggesting a benefit with US guidance, as well as data indicating no difference in outcome measures when US guidance is used compared with the landmark technique.

CONCLUSIONS

The evidence surrounding US-guided CVC insertion supports its use in adult patients. Pediatric-specific literature is sparse and includes mixed results. As more pediatric emergency physicians adopt the use of point-of-care US, we expect an increase in data supporting its use for CVC placement in pediatric emergency department patients.

[Avoidance of complications when dealing with central venous catheters in the treatment of children]

Central venous catheters (CVCs) are an important tool in the treatment of children. The insertion of a catheter may result in different complications depending of the type of catheter, the technique used for the insertion and the location. There are various techniques to reduce the risk of complications. In order to reduce the rate of complications of CVCs it is indispensable to perform a risk-benefit analysis for the individual patient before every insertion. The type of catheter used (for example tunneled catheters versus not-tunneled catheters) influences the rate of catheter-associated infections and the comfort of the patient significantly. The choice of the location is influenced by the expected indwelling time, the weight of the patient and the purpose of the CVC. Insertion via the vena jugularis interna is often chosen because of the reduced rate of complications during insertion. When the planned indwelling time of the catheter is longer or the child is fairly small the vena subclavia appears to be more appropriate. It is of utmost importance that the patient is positioned properly before insertion. Whenever possible the insertion should be performed with the help of ultrasound. The positioning of the catheter should be verified radiographically, possibly sonographically or with an ECG in order to avoid misplacement with potentially severe sequelae. The locally established hygienic guidelines should be strictly adhered to and everyone handling CVCs (doctors, nurses and patients) should have regular training.

Vascular Access in the Pediatric Population

Vascular access procedures are an important and frequent component of the day-to-day practice of the pediatric surgeon. Most access procedures can be performed percutaneously via Seldinger or modified Seldinger technique and are aided by technology, such as ultrasound and fluoroscopy. Complications, such as infection, do occur, and the pediatric surgeon should be able to diagnose and treat these when they arise. The indications, techniques, and complications of vascular access are covered in this article.

Supraclavicular Approach to Ultrasound-Guided Brachiocephalic Vein Cannulation in Children and Neonates

The correct choice of intra vascular access in critically ill neonates should be individualized depending on the type and duration of therapy, gestational and chronological age, weight and/or size, diagnosis, clinical status, and venous system patency. Accordingly, there is an ongoing demand for optimization of catheterization. Recently, the use of ultrasound (US)-guided cannulation of the subclavian vein (SCV) has been described in children and neonates. This article gives an overview of the current use of US for achieving central venous catheter placement in the SCV or the brachiocephalic vein (BCV) in neonates. More than 1,250 catheters have been reported inserted in children and neonates for a cumulated success rate of 98.4% and the complication rate is reported to be low. The technical aspects of various approaches are discussed, and we offer our recommendation of an US-guided technique for SCV and BCV cannulation based on our experience in a large NICU setting. Although the cannulation the SCV or BCV does not substitute the use of peripherally inserted central catheters or umbilical venous central catheters in neonates, it is a feasible route in very small children who are in need of a large caliber central venous access.

The Impact of Central Venous Catheters on Pediatric Venous Thromboembolism

The use of central venous catheters (CVCs) in children is escalating, which is likely linked to the increased incidence of pediatric venous thromboembolism (VTE). In order to better understand the specific risk factors associated with CVC-VTE in children, as well as available prevention methods, a literature review was performed. The overall incidence of CVC-VTE was found to range from 0 to 74%, depending on the patient population, CVC type, imaging modality, and study design. Throughout the available literature, there was not a consistent determination regarding whether a particular type of central line (tunneled vs. non-tunneled vs. peripherally inserted vs. implanted), catheter material, insertion technique, or insertion location lead to an increased VTE risk. The patient populations who were found to be most at risk for CVC-VTE were those with cancer, congenital heart disease, gastrointestinal failure, systemic infection, intensive care unit admission, or involved in a trauma. Both mechanical and pharmacological prophylactic techniques have been shown to be successful in preventing VTE in adult patients, but studies in children have yet to be performed or are underpowered. In order to better determine true CVC-VTE risk factors and best preventative techniques, an increase in large, prospective pediatric trials needs to be performed.

Efficacy and safety of ultrasound-guided internal jugular vein catheterization in low birth weight newborn

BACKGROUND

Central venous catheterization is not the first choice of vascular access in neonates. Success depends on the size of the vessel and the skill of the health professional performing the procedure. The internal jugular vein provides a predictable path for central venous cannulation, although it is more difficult to cannulate infants than adults and even more difficult in smaller newborns.

METHODS

We conducted a prospective study in 100 newborns, in which a 4 Fr ultrasound-guided central venous catheter was placed in the right internal jugular vein (RIJV). The study population was low birth weight (LBW) newborns <2500g, very low birth weight (VLBW) newborns <1500g and extremely low birth weight (ELBW) newborns <1000g.

RESULTS

There were 53% female patients, mean gestational age was 31weeks, mean weight 1352g and the CVC was placed at a mean of 12days of extrauterine life. Birth weight distribution was 39% LBW; 33% VLBW and 28% ELBW. A mean of two (1-8) attempts were necessary with a procedure duration of 16.8 (10-40) minutes. Success of RIJV catheterization was 94%. One attempt was necessary in 50% and up to 5 attempts in 95.7%. Success by weight was VLBW, 97.2%; ELBW, 92.9%; LBW, 91.7%. A venous hematoma occurred in 5% of cases.

CONCLUSIONS

Ultrasound-guided RIJV cannulation with real-time visualization to gain access to the central venous circulation in low birth weight newborns is effective and safe.

A Randomized Controlled Comparison of the Internal Jugular Vein and the Subclavian Vein as Access Sites for Central Venous Catheterization in Pediatric Cardiac Surgery

OBJECTIVES

To compare internal jugular vein and subclavian vein access for central venous catheterization in terms of success rate and complications.

DESIGN

A 1:1 randomized controlled trial.

SETTING

Baskent University Medical Center.

PATIENTS

Pediatric patients scheduled for cardiac surgery.

INTERVENTIONS

Two hundred and eighty children undergoing central venous catheterization were randomly allocated to the internal jugular vein or subclavian vein group during a period of 18 months.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the first-attempt success rate of central venous catheterization through either approach. The secondary outcomes were the rates of infectious and mechanical complications. The central venous catheterization success rate at the first attempt was not significantly different between the subclavian vein (69%) and internal jugular vein (64%) groups (p = 0.448). However, the overall success rate was significantly higher through the subclavian vein (91%) than the internal jugular vein (82%) (p = 0.037). The overall frequency of mechanical complications was not significantly different between the internal jugular vein (25%) and subclavian vein (31%) (p = 0.456). However, the rate of arterial puncture was significantly higher with internal jugular vein (8% vs 2%; p = 0.03) and that of catheter malposition was significantly higher with subclavian vein (17% vs 1%; p < 0.001). The rates per 1,000 catheter days for both positive catheter-tip cultures (26.1% vs 3.6%; p < 0.001) and central-line bloodstream infection (6.9 vs 0; p < 0.001) were significantly higher with internal jugular vein. There were no significant differences between the groups in the length of ICU and hospital stays or in-hospital mortality rates (p > 0.05 for all).

CONCLUSIONS

Central venous catheterization through the internal jugular vein and subclavian vein was not significantly different in terms of success at the first attempt. Although the types of mechanical complications were different, the overall rate was similar between internal jugular vein and subclavian vein access. The risk of infectious complications was significantly higher with internal jugular vein access.

Ultrasound-guided Central Line Insertion and Standard Peripherally Inserted Catheter Placement in Preterm Infants: Comparing Results from Prospective Study in a Single-center

Background:

Among preterm infants, the peripherally inserted central catheter (PICC) is the standard line for central venous access; however, its placement exposes them to hypothermia and pain. Ultrasound (US)-guided central line insertion may be less morbid than standard PICC line.

Aims:

To determine the ease, success rate, and morbidity associated with US-guided central line insertion in the internal jugular vein (IJV) by comparing it to the standard PICC line placement.

Materials and Methods:

This is a single-center nonrandomized prospective study evaluating preterm infants between October 2013 and June 2014. Patients were allocated into two groups: The standard group (control group) who underwent blind PICC line insertion and the intervention group who underwent a percutaneous US-guided central line insertion in the IJV. The epicutaneo-cava-catheter was used in both groups.

Results:

Fifty neonates were enrolled on study. A statistically difference in favor of US-IJV insertion was noted concerning the rate of successful first attempt (P < 0.001), insertion (P = 0.001), and procedure duration (P < 0.001) and number of trials (P < 0.001) compared to PICC. No difference in complications (P = 1.000) was noted.

Conclusion:

US guided catheterization of the IJV technique is faster than PICC line insertion with higher rates of successful first attempt and insertion, less procedure duration and fewer number of trials compared to PICC line insertion. There were no differences in complications.

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.

Effectiveness and complications of ultrasound-guided subclavian vein cannulation in children and neonates

BACKGROUND

The ultrasound (US)-guided supraclavicular approach to subclavian vein (Sup-SCV) catheterisation in children has recently been described and evaluated in a small cohort. The aim of this study was to assess this technique in a large paediatric cohort including neonates.

METHODS

We conducted a prospective observational study between November 2010 and December 2013 which included 615 children divided into two groups according to their weight: Group 1≤5kg (n=124), Group 2>5kg (n=491). All procedures were performed under general anaesthesia by an anaesthesiologist or a supervised resident. The success rates of catheter insertion, the number of punctures required, the procedure time, and the complication rates were analysed.

RESULTS

Sup-SCV catheterisation was successful in 98% of the cases and was higher in Group 2 than in Group 1 (99.4% versus 92.7%, P<0.001). The success rate after the first attempt was higher and the incidence of multiple attempts (≥3 punctures) was lower in Group 2 than in Group 1 (84.2% versus 64.5%, P<0.001 and 4.5% versus 19.4%, P<0.001). The success rate was similar between right and left cannulations (P=0.404), and according to physician experience (P=1.000). Procedure time was fast in both groups with a median time for all procedures of 40 seconds [30-90]. Among the procedures recorded, only five arterial punctures and no cases of pneumothorax were observed.

CONCLUSION

US-guided Sup-SCV catheterisation appears to be fast and safe in children and neonates, even if it remains a little more difficult to achieve in lower-weight patients.

Ultrasound Imaging Reduces Failure Rates of Percutaneous Central Venous Catheterization in Children

OBJECTIVE

Ultrasound imaging has been shown to be beneficial for percutaneous central venous cannulation in systematic reviews of randomized controlled trials in adult patients, but not in pediatrics. The aim of this updated review was to determine whether percutaneous central venous catheterization with the aid of ultrasound reduces cannulation failure in children.

DATA SOURCES

PubMed was searched using the terms: ultrasound, catheterization, central vein (including internal jugular and femoral veins), and pediatrics.

STUDY SELECTION

Both nonrandomized comparative studies and randomized controlled trials were eligible for inclusion if they assessed the rate of cannulation failure using real-time, dynamic ultrasound guidance, ultrasound-assisted vein prelocation, and/or anatomic landmark technique.

DATA EXTRACTION

Five nonrandomized studies and nine randomized controlled trials were included. The rates of cannulation failure and arterial puncture were retrieved.

DATA SYNTHESIS

Random-effects meta-analysis was applied.

CONCLUSIONS

The meta-analysis of five nonrandomized studies showed that the rate of cannulation failure was significantly lower with real-time ultrasound guidance than anatomic landmark technique (odds ratio, 0.44 [95% CI, 0.27-0.72]; p = 0.001). The combination of nine randomized controlled trials also showed lower failure rates with either the real-time ultrasound guidance or the prelocation technique over the landmark technique (odds ratio, 0.22 [95% CI, 0.07-0.69]; p = 0.0003) and fewer arterial punctures in the ultrasound group (odds ratio, 0.31 [95% CI, 0.09-1.08]; p = 0.07). However, seven out of nine studies were assessed as having high risk of bias. Since the lower cannulation failure and less frequent chance of arterial puncture with ultrasound were predominantly shown in studies at high risk of bias, further definitive and adequately powered studies with clear outcomes are needed.

Ultrasound-Guided Percutaneous Central Venous Access in Low Birth Weight Infants: Feasibility in the Smallest of Patients

PURPOSE

The insertion of tunneled central venous access catheters (CVCs) in infants can be challenging. The use of the ultrasound-guided (UG) approach to CVC placement has been reported in adults and children, but the technique is not well studied in infants.

SUBJECTS AND METHODS

A retrospective review was performed of infants under 3.5 kg who underwent attempted UG CVC placement between August 2012 and November 2013. All infants underwent UG CVC placement using a standard 4.2-French or 3.0-French CVC system (Bard Access Systems, Inc., Salt Lake City, UT). The UG approach was performed on all infants with the M-Turbo(®) ultrasound system (SonoSite, Inc., Bothell, WA). The prepackaged 0.025-inch-diameter J wire within the set was used in all infants weighing greater than 2.5 kg. A 0.018-inch-diameter angled glidewire (Radiofocus(®) GLIDEWIRE(®); Boston Scientific Inc., Natick, MA) was used in infants less than 2.5 kg. Data collected included infant weight, vascular access site, diameter of cannulated vein (in mm), and complications.

RESULTS

Twenty infants underwent 21 UG CVC placements (mean weight, 2.4 kg; range, 1.4-3.4 kg). Vascular CVC placement occurred at the following access sites: 16 infants underwent 17 placements via the right internal jugular vein, versus 3 infants via the left internal jugular vein. The average size of the target vessel was 4.0 mm (range, 3.5-5.0 mm). One infant had inadvertent removal of the UG CVC in the right internal jugular vein on postoperative Day 7. This infant returned to the operating room and underwent a successful UG CVC in the same right internal jugular vein. There were no other complications in the group.

CONCLUSIONS

The UG CVC approach is a safe and efficient approach to central venous access in infants as small as 1.4 kg. Our experience supports the use of a UG percutaneous technique as the initial approach in underweight infants who require central venous access.

Ultrasound-guided brachiocephalic vein catheterization in infants weighing less than five kilograms

Purpose

To describe our experience with the use of ultrasound-guided supraclavicular brachiocephalic vein approach for central vein catheterization in infants weighing less than 5 kg.

Methods

A retrospective review was performed for infants who underwent ultrasound-guided central vein catheterization from January 2012 to November 2014. Infants weighing less than 5 kg with supraclavicular brachiocephalic vein access were included in the study. Indications for central venous access, venous access side, catheter type and complications were evaluated.

Results

Thirty-four catheterizations in 34 infants weighing from 1.5 to 4.9 kg (median 3.48 kg) were included in the study (aged 11 days to 7 months and 10 days, weight range 1.5 to 4.9 kg). Technical success rate was 97% (33 of 34 infants). No technical or clinical major complications were observed.

Conclusions

Ultrasound-guided supraclavicular brachiocephalic vein access is a favorable alternative for central venous catheterization in low-weight infants with regard to high technical success rate and absence of major complications.

Differences in anatomical relationship between vertebral artery and internal jugular vein in children and adults measured by ultrasonography

Cannulation of the internal jugular vein (IJV) under ultrasound guidance can reduce complications, such as common carotid artery (CCA) puncture, accidental vertebral artery (VA) puncture. However, these complications still occur, especially in pediatric patients probably due to anatomical predisposition of VA. This study compared differences in anatomical location of VA and IJV between pediatric and adult patients. Children with body weight <20 kg (n = 16) and adults who required central venous or pulmonary arterial pressure monitoring (n = 21) were enrolled. After induction of general anesthesia and tracheal intubation, patients were positioned for IJV cannulation. Images of the right CCA, IJV and VA were recorded by ultrasonography. The size of each vessel, anatomical relationship of other vessels, distance between vessels and between each vessel and skin were measured. The size of VA relative to IJV was significantly larger in children than in adults (14 vs 7 %, P < 0.001). The absolute and relative distance between IJV and VA were significantly shorter in children than those in adults (P < 0.01). The anatomical relationships between IJV and CCA and that between IJV and VA were not different between children and adults. In children, VA was relatively larger and located closer to IJV than adults. The results call for careful attention to the position of VA during ultrasound-guided IJV cannulation especially in children.