Teaching successful central venous cannulation in infants and children: audio Doppler versus anatomic landmarks

Central venous catheterization in infants and children--small caliber audio-Doppler probe versus ultrasound scanner

BACKGROUND

Ultrasound guidance for cannulation of the internal jugular vein has been shown to increase the success rate and reduce the incidence of complications in infants and children. We compared the use of a small caliber audio-Doppler probe with an ultrasound scanner for cannulation of a central venous (CV) line via the right internal jugular vein in infants and children.

METHODS

Fifty-two infants and 29 children scheduled for open-heart surgery were enrolled. Cannulation was guided using a small caliber audio-Doppler probe (the AU group, n = 42), or an ultrasound scanner image (the US group, n = 39). Ultimate success rate, success rate at the first attempt, success rate within 5 min, and complications were compared for the two groups.

RESULTS

In children (>12 months), both methods were equally efficient. But in infants (<12 months), success rate at the first attempt using audio-Doppler was worse than the rate using an ultrasound scanner and there were more complications when audio-Doppler was used.

CONCLUSIONS

We conclude that application of both the audio-Doppler and the ultrasound scanner is useful in children over 1 year of age for access to the internal jugular vein. However, in infants and neonates, the ultrasound scanner would be more useful than the audio-Doppler.

Central venous catheter use in the pediatric patient: mechanical and infectious complications

OBJECTIVE

Following the introduction and widespread use of central venous catheters (CVCs) in adults, these devices are being used with increasing frequency in the pediatric population. This review will focus on differences between adults and children regarding CVC use and its potential complications. Both mechanical and infectious complications will be discussed.

DATA SOURCES

Systematic review of the literature.

CONCLUSIONS

CVC-related complications in pediatric patients are closely linked to age, body size, and age-related immune status. In older children, many complications are similar to those encountered in adult patients. Because of ongoing growth and body changes, a cutoff point beyond which children can be regarded as "young adults" is difficult to define; many of our recommendations are therefore age-related. More frequently than in adults, an implanted port may be the first choice in pediatric patients when long indwelling times are expected. The optimal site of insertion also depends on factors such as the patients' age as well as the need for sedation and analgesia during the insertion procedure. In contrast to guidelines in adult patients, we recommend that a radiograph always be made following CVC insertion to check the position of the catheter. Regarding prevention of infectious complications, we recommend full sterile barrier precautions during CVC insertion and strict protocols for catheter care. CVCs should be removed as soon as possible when they are no longer needed, but there is no place for elective CVC replacement on a routine basis. New developments such as the use of impregnated catheters might help reduce infection rates; however, additional research will be required to provide more evidence of benefit in the pediatric population.

Audio-Doppler guidance using a small-caliber Doppler probe for internal jugular venous puncture for central venous catheterization in infants and children

BACKGROUND

We evaluated an audio-Doppler with a small-caliber probe as a guide for central venous cannulation (CVC) via the internal jugular vein (IJV) in infants and children.

METHODS

The right IJV was located with a small-caliber (2.0 mm in diameter) audio-Doppler probe using 10 MHz ultrasound. The probe was placed on the neck about the level of sixth cervical vertebra and was moved until the crisp pulsatile sound of the carotid artery was identified. Then the probe was moved laterally to identify the low-pitched venous hum of the right IJV. After marking the puncture site on the skin, a sterile cannulation procedure was performed. Ultimate success rate, cannulation time < 10 min, successful cannulation within three punctures, and complications were recorded.

RESULTS

Ultimate success rate was 65.6% (42/64) in infants (< 12 m), and 94.7% (72/76) in children (12 m or older). Cannulation time < 10 min was 48.4% in infants, and 85.5% in children. Successful cannulation within three punctures was 45.3% in infants and 82.8% in children. Three carotid arterial punctures occurred.

CONCLUSIONS

We were not able to demonstrate absolute superiority of the results utilizing this device over the reported results of traditional landmark techniques for CVC via the right IJV. However, this device may contribute to reducing complications and be of value in teaching residents where to insert a needle for an internal jugular puncture.

A procedure for placing pediatric femoral venous catheter tips near the right atrium

OBJECTIVE

To find a body measurement that would serve as an index for determining the length of femoral venous catheter to be inserted to achieve a position near the right atrium.

METHODS

A candidate index measurement was chosen, and radiographic measurements of routine femoral venous catheter placements were compared with the placement that may have resulted from use of the index in a group of patients. In a subsequent group, the candidate index was used to choose catheter insertion length, the accuracy of which was again evaluated from routine placement radiographs.

RESULTS

The first series of radiographic measurements predicted that use of the sternal-umbilical-puncture (SUP) index would result in acceptable and accurate catheter tip placement. This was confirmed in the second group of patients in which 11 of 12 catheter tips were within 1 cm of the target position.

CONCLUSIONS

The use of the SUP index ensures acceptable accuracy in estimating the required insertion length of femoral catheter when tip placement near the right atrium is the clinical goal.

Demand for a new main speciality in image-guided therapy

As image-guided and minimally invasive therapy advances in complexity and volume, it becomes more obvious that none of the existing main specialities in medicine offer the ideal clinical or technological training for the responsible physicians at this time. The radiologists lack a clinical basis, and do not have adequate opportunities for proper pre- and post-procedural follow-up of their patients. The clinical doctors, i.e. cardiologists or vascular surgeons, do not have the proper technological background, or the training in 2D/3D imaging diagnostics or radiation hygiene. Radiology 'possesses' the technology, while the clinical specialities 'possess' the patients. Integrated use of various imaging modalities (fluoroscopy, computed tomography, ultrasound, magnetic resonance imaging, endoscopy or video-assisted techniques) may also be exploited more effectively for guidance and control of surgical or minimally invasive intervention. To pursue the progress and secure the quality and efficiency of future medical developments in the field, a fusion of clinical medicine and radiology into a new speciality is proposed. A basic training of 2 years in surgery or internal medicine, and 2 years of radiology can be followed by organ-wise (gastrointestinal, vascular, cardiology, etc.) subspecialisation. In this way, devastating turf battles and conflicts of interests in the hospital system may be neutralised and the traditional specialities join forces to the best of patients. Proposed terms for this new kind of specialist could be 'Clinical Surgical Radiologist', 'Clinical Cardiological Radiologist', etc., or simply 'Image-guided Therapist'.

A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients

Transesophageal echocardiography (TEE) and central venous catheter (CVC) placement are often used during congenital cardiac surgery. Complications of CVC placement include cardiac perforation, inadvertent arterial placement, and erroneous hemodynamic data from unrecognized malposition. In this study, we used a prospective, randomized, controlled design to evaluate the use of TEE to guide depth of insertion and confirm superior vena cava cannulation, and to improve the percentage of correctly placed CVCs and reduce complications of CVC placement. One hundred forty-five patients were studied. Eighty patients were randomized to have subclavian vein insertion, 64 to have internal jugular insertion, and 1 to have external jugular insertion of CVC. TEE-guided CVC placement resulted in 100% correct placement when assessed by preoperative TEE, versus 86% in the control group (72 of 72 vs. 63 of 73; P = 0.01). There was no difference in correct placement between the two groups when assessed by postoperative chest radiograph (81.9% TEE versus 75.3% control; P = not significant). One significant complication, a superior vena cava perforation, occurred in the control group. Time to placement was 9.6 min in the TEE group versus 8.0 min in the control group (P = 0.015).

IMPLICATIONS

Transesophageal echocardiography can be used to guide central venous catheter placement in congenital heart surgery. Central venous catheters that seem to be located high in the right atrium by chest radiograph in these patients are often actually in the superior vena cava and pose little risk of cardiac perforation.