The Optimal Length of Insertion for Central Venous Catheters Via the Right Internal Jugular Vein in Pediatric Cardiac Surgical Patients

Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications

AIMS

Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery.

METHODS

Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery.

PRIMARY ENDPOINT

Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used.

RESULTS

Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively.

CONCLUSIONS

Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.

ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.

Point-of-Care Ultrasound-Guided Protocol to Confirm Central Venous Catheter Placement in Pediatric Patients Undergoing Cardiothoracic Surgery: A Prospective Feasibility Study

Background: Central venous catheters (CVC) are commonly required for pediatric congenital cardiac surgeries. The current standard for verification of CVC positioning following perioperative insertion is postsurgical radiography. However, incorrect positioning may induce serious complications, including pleural and pericardial effusion, arrhythmias, valvular damage, or incorrect drug release, and point of care diagnostic may prevent these serious consequences. Furthermore, pediatric patients with congenital heart disease receive various radiological procedures. Although relatively low, radiation exposure accumulates over the lifetime, potentially reaching high carcinogenic values in pediatric patients with chronic disease, and therefore needs to be limited. We hypothesized that correct CVC positioning in pediatric patients can be performed quickly and safely by point-of-care ultrasound diagnostic. Methods: We evaluated a point-of-care ultrasound protocol, consistent with the combination of parasternal craniocaudal, parasternal transversal, suprasternal notch, and subcostal probe positions, to verify tip positioning in any of the evaluated views at initial CVC placement in pediatric patients undergoing cardiothoracic surgery for congenital heart disease. Results: Using the combination of the four views, the CVC tip could be identified and positioned in 25 of 27 examinations (92.6%). Correct positioning was confirmed via chest X-ray after the surgery in all cases. Conclusions: In pediatric cardiac patients, point-of-care ultrasound diagnostic may be effective to confirm CVC positioning following initial placement and to reduce radiation exposure.

Trimmed central venous catheters in pediatric cardiac surgery: Does height or weight correlate with the amount trimmed?

BACKGROUND

Due to excess catheter length, pediatric patients undergoing cardiac surgery frequently have the tip of the central venous catheter trimmed while on bypass to obtain optimal catheter positioning.

AIMS

We sought to determine if there is a correlation between the patient's height or weight and the length of catheter removed. Our secondary aim compared the instances of central line-associated bloodstream infections and venous thromboembolisms between the trimmed and untrimmed catheters.

METHODS

This retrospective study included patients having undergone cardiac surgery over a 3-year period who had an 8 cm central venous catheter placed in the right internal jugular vein. Hospital lists of central line-associated bloodstream infections and venous thromboembolisms that occurred were cross referenced with our study patients.

RESULTS

There were 147 cases where the 8 cm central venous catheter was trimmed, which represents 35% of the cases. Of the catheters that were cut, on average 2.17 cm was removed. There is negligible correlation between the length of catheter removed and patient height (r = -.19, p = .021). There is negligible correlation between the length of catheter removed and patient weight (r = -.17, p = .039). There were no instances of central line-associated bloodstream infections or venous thromboembolisms attributed to the trimmed catheters. Of the 273 untrimmed catheters, there were no instances of an infection and one instance of a venous thromboembolism.

CONCLUSION

Right internal jugular 8 cm central venous catheters are trimmed during pediatric cardiac surgery, and there is minimal correlation between the length removed and the patient height or weight. Due to the difficulty in estimating the proper length of a central venous catheter in smaller pediatric patients, placing an 8 cm long catheter in these patients and then trimming the distal tip while on bypass may be the most accurate way to properly position a catheter.

Optimal insertion depth of subclavian vein catheterization via the right supraclavicular approach in children

BACKGROUND

Methods to determine the optimal insertion depth of ultrasound-guided supraclavicular approach to the subclavian vein (SCV) catheterization, alternatively used for central venous access, are debatable in children.

AIM

We investigated the applicability and reliability of the modified formula for determining the depth of SCV catheterization using an ultrasound-guided supraclavicular approach in children.

METHODS

This prospective observational study included 36 children (age <6 years; weight ≥5 kg) scheduled to undergo congenital heart disease surgery. After intubation, ultrasound-guided supraclavicular approach to the SCV catheterization was performed. Actual insertion depth was determined by real-time transesophageal echocardiography. Insertion depth was calculated by subtracting 1 cm from the sum of the distance from the insertion point to the sternal head of the right clavicle and that from the latter point to the midpoint of a perpendicular line drawn from the sternal head of the right clavicle to the line connecting the nipples.

RESULTS

Insertion depth calculated with the modified formula and actual insertion depth of the SCV catheter correlated strongly (r = .806, 95% confidence interval [CI]: 0.658-0.908; p < .001). Bland-Altman analysis showed a mean bias and precision of 0.36 and 0.65 cm, respectively (95% CI: 0.14-0.58, 95% limits of agreement: -0.92, 1.64). All plots were above the -1.0 line, indicating no catheter tip insertion into the right atrium.

CONCLUSIONS

Optimal insertion depth for an ultrasound-guided supraclavicular approach to the SCV catheterization can be calculated using modification of a surface landmark formula in children younger than 6 years and weight heavier than 5 kg.

[Central Venous Access in Children: Technique and Complications]

Children with complex diseases often need central venous catheter, not only for intraoperative use, but also for parenteral nutrition, multiple blood draw due to lab examination and to administer drugs that cannot be given via peripheral lines. Whereas the landmark driven vascular access was teached for years, nowadays the routine use of ultrasound based techniques can be called the gold standard. This article highlights standard locations for central venous access like cannulation of the internal jugular vein as well as novel alternatives such as the cannulation of the brachiocephalic vein. The correct insertion depth of central lines is essential to avoid serious complications. Several different formulas are available and can be used. Independent of the used formula, you have to make sure that complications due to incorrect depth of central venous line are a topic of the past. Finally, important tips and tricks to avoid failure and serious complications are discussed.