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

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.

Modified anchoring maneuver using pilot puncture needle to facilitate internal jugular vein puncture for small children

OBJECTIVES

Internal jugular vein (IJV) cannulation in infants has been reported with varied success using surface landmark. The aim is to share authors experience of modified anchoring technique used in infants.

METHODS

Anchoring maneuver using pilot needle (PN) has been recently described in adults. We have found that if the PN is left in IJV and then i.v. cannula (22G or 24G) is passed just posterior to the puncture point of PN to track down the PN path at 10-20 degree angles from skin, a natural tumbling movement of the PN helped to anchor anterior wall of IJV and facilitated its puncture. The results of 128 punctures performed in infants (<1 years) were analyzed in two groups of <6 months (n = 52) and >6 months to 1 year (n = 76).

RESULTS

In infants weighing 3.5-14 kg, all cannulations were performed successfully. IJV puncture was detected at the entry of i.v. cannula more often in both the groups (81% in <6 months baby and 84% in >6 months baby) than withdrawing it. In 12 (10%) patients, the puncture site was changed to left IJV as carotid artery was punctured in three and failure to localize right IJV in nine patients by surface landmark.

CONCLUSIONS

In authors experience, the described technique detected IJV cannulation at its entry in majority of infants and so the method is less prone to complications related to overshooting of the needle in lack of IJV puncture detection.

Internal mammary artery injury after central venous catheterization

OBJECTIVE

We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization.

DESIGN

Report of cases.

SETTING

Pediatric intensive care unit.

PATIENTS

The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later.

INTERVENTIONS

None.

CONCLUSIONS

Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.

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.

A randomized-controlled study of ultrasound prelocation vs anatomical landmark-guided cannulation of the internal jugular vein in infants and children

BACKGROUND

A specifically designed ultrasound scanner may be helpful in percutaneous cannulation of the internal jugular vein in pediatric patients. We report a new two-dimensional (2D) ultrasound prelocation (UL) technique using a transesophageal echocardiography (TEE) intraoperative probe instead of the portable scanner, and have compared the new technique with conventional anatomical landmark method (AL) for central venous catheterization in infants and children.

METHODS

Sixty-two infants (body weight <12 kg) undergoing elective surgery for congenital heart disease were randomized into two groups. In the AL group, the landmark for cannulation was the palpation of the common carotid pulsation or the sternocleidomastoid triangle. In the UL group, the central vein was located by 2D ultrasonic imaging using a TEE intraoperative probe for HP SONOS 4500. The number of cannulation attempts, success rate, and complication rate were recorded.

RESULTS

For the UL and AL groups, the cannulation success rate was 100% and 80% (P < 0.05), the incidence of arterial puncture was 3.1% and 26.7% (P < 0.025), and the number of attempts was 1.57 +/- 1.04 and 2.55 +/- 1.76 (P < 0.001), respectively.

CONCLUSIONS

Two-dimensional ultrasound prelocated central venous catheterization in infants and children is convenient and can markedly increase cannulation success rate and reduce the incidence of complications.