The carina is not a landmark for central venous catheter placement in neonates

The Role of POCUS and Monitoring Systems during Emergency Pericardial Effusion in the NICU

Central venous catheterization is, now, one of the most routinely used procedures in the NICUs, helping during the care of very sick infants. Pericardial effusion is a very rare but severe complication, with a high mortality. The cases described are part of an ongoing retrospective study where the use of central catheters inserted in our surgical NICU, and its complications is being analyzed. 16 cases over 13 years are presented in this article, varying in severity from mild, self-resolving cases that were discovered during routine cardiac POCUS to cases with important hemodynamic impact associated with cardiac tamponade and cardiac arrest. Due to immediate intervention, only one of the cases led to catheter-related mortality and that was under particular conditions. Our aim is to highlight the severity of this complication, the importance of early intervention, and the impact of a highly technologized unit and widely available cardiac POCUS.

A narrative review on tip navigation and tip location of central venous access devices in the neonate: Intracavitary ECG or real time ultrasound?

The proper location of the tip of a central venous access device plays a crucial role in minimizing the risks potentially associated with its use. Recent guidelines strongly recommend preferring real-time, intra-procedural methods of tip location since they are more accurate, more reliable and more cost-effective than post-procedural methods. Intracavitary electrocardiography and real time ultrasound can both be applied in the neonatal setting, but they offer different advantages or disadvantages depending on the type of central venous access device. Reviewing the evidence currently available about the use of these two methods in neonates, in terms of applicability, feasibility and accuracy, it can be concluded that (a) real time ultrasound is the only acceptable methodology for tip navigation for any central venous access device in neonates, (b) intracavitary electrocardiography is the preferred method of tip location for central catheters inserted by ultrasound-guided cannulation of the internal jugular vein or the brachiocephalic vein, and (c) real time ultrasound is the preferred method of tip location for umbilical venous catheters, epicutaneo-cava catheters, and central catheters inserted by ultrasound-guided cannulation of the common femoral vein.

Real-Time Ultrasound Tip Location Reduces Malposition and Radiation Exposure during Epicutaneo-Caval Catheter Placement in Neonates

OBJECTIVE

Epicutaneo-caval catheters (ECCs) are essential for the care of sick infants who require long-term medical and nutritional management. The aim of this study was to investigate the use of real-time ultrasound as an alternative to X-rays to reduce the incidence of primary malpositions during catheter insertion.

STUDY DESIGN

Data on ECCs were retrospectively collected in a tertiary neonatal intensive care unit. Catheter were analyzed considering the tip location technique (standard chest-abdominal radiograph vs real-time ultrasound) RESULTS:  A total of 248 ECCs were analyzed. Of these, 118 catheters had primary malposition (47.6%). The tip of 165 catheters was assessed using standard chest-abdominal X-rays and 107 (64.8%) were found to be in an inappropriate location. In the group of 83 catheters that were placed using real-time ultrasound for tip location, only 11 catheters (13.2%) had primary malposition. The rate of malposition among the two groups showed a statistically significant difference (p < 0.001). Hypothetically, 300 chest X-rays could have been saved if real-time ultrasound had been used to locate the tip, reducing radiation exposure to infants.

CONCLUSION

The use of a real-time ultrasound may be beneficial in reducing primary catheter malpositions compared with conventional radiography. In addition, secondary malpositions and catheter-related complications can be monitored over time.

KEY POINTS

· Conventional radiology cannot be considered the "gold standard" for ECC tip location.. · Ultrasound is more accurate and reduces insertion time reducing the rate of primary malposition.. · Ultrasound can be performed in real time and it is the best technique for ECC tip location in infants..

Ultrasound Guided Catheter Tip Location in Neonates: A Prospective Cohort Study

OBJECTIVE

To assess point-of-care-ultrasound (POCUS) guided catheter tip location in a neonatal cohort after insertion of percutaneously inserted central catheters (PICCs) from the upper part of the body.

STUDY DESIGN

This was a prospective, observational study on PICC tip location. Tip site was assessed by radiological landmarks or direct ultrasound (US) visualization of the cardiovascular structures.

RESULTS

One hundred eighteen PICCs (28Gauge/1French) were studied in 102 neonates (mean postmenstrual age 31 weeks, range 25-43 weeks; mean weight at positioning 1365 g, range 420-4180 g). Feasibility of POCUS guided tip location was 92.3% in our population. Failures were significantly associated with mechanical ventilation (aOR 5.33; 95% CI 1.13-29.5; P = .038). Agreement between US and radiographic methods was found in 88 of 109 cases (80.7%). Fifteen of 21 discordant cases led to a change in clinical management.

CONCLUSIONS

POCUS guided localization of small bore PICC is a non-invasive and effective alternative to the conventional radiogram. The latter should be recommended when US examination fails to locate the catheter tip.

Multivariate analysis on complications of central venous access devices in children with cancer and severe disease influenced by catheter tip position and vessel insertion site (A STROBE-compliant study)

CONTEXT

Reliable long-term central venous access device (CVAD) is essential for the management of pediatric patients with cancer or chronic diseases. However, there is no general consensus for optimal catheter tip location and vessel insertion site in children.

OBJECTIVE

This single center study analyzes the risk of complications associated with long-term upper body CVAD and evaluates them with respect to catheter tip location as well as vessel insertion site.

DESIGN

Pediatric patients who received long-term upper body CVAD from January 2008 through April 2017 and underwent radiographic documentation of the tip location were retrospectively included in the study. Data on demographics, catheter tip location on chest x-ray, intraoperative vessel insertion sites and postoperative complications were analyzed. Catheter tip location was categorized as "high" (above the right mainstem bronchus), "medium" (at the level of the bronchus), and "low" (below the right mainstem bronchus). Distance to the carina was measured as well.

RESULTS

A total of 396 patients, 74.7% suffering from cancer were included in our study (mean age 6.3 ± 0.3 years). Complications occurred in about one fourth of all patients. Catheter-related blood stream infections (BSI) (n = 40, 36.4%) were most prevalent, but catheter tip position or vessel insertion site had no impact on the risk of infections. Dislodgement (n = 27, 24.6%) and occlusion (n = 11, 10.0%) were more frequent in "high" positioned catheter tips. While there was one patient who developed arrhythmia, no case of cardiac perforation, and in particular, no catheter-related death was recorded in our series. The vessel insertion site seemed to have no influence on the complication frequency of CAVDs.

CONCLUSION

The catheter tip position seems to have an impact on the catheter-related complication profile in children. To avoid complications, we recommend avoiding a "high" localization of the catheter tip above the right main bronchus. "Low" catheter tip placement was associated with the lowest dislocation rate. Given the overall low complication rate, insertion and use of CVADs in children can generally be considered as safe.

The intracavitary electrocardiography method for positioning the tip of epicutaneous cava catheter in neonates: Pilot study

Purpose:

The neonatologists of Sant’Anna and San Sebastiano Hospital of Caserta have carried out a pilot study investigating the safety, feasibility, and accuracy of intracavitary electrocardiography for neonatal epicutaneous cava catheter tip positioning.

Patients and methods:

We enrolled 39 neonates (1–28 days of postnatal age or correct age lower than 41 weeks) requiring epicutaneous cava catheter in the district of superior vena cava (head–neck or upper limbs). Intracavitary electrocardiography was applicable in 38 neonates.

Results:

No significant complications related to intracavitary electrocardiography occurred in the studied neonates. The increase in P wave on intracavitary electrocardiography was detected in 30 cases. Of the remaining eight cases, six malpositioned catheters tipped out of cavoatrial junction–target zone (chest x-ray and echocardiographical control) and two were false negative (tip located in target zone). The match between intracavitary electrocardiography and x-ray was observed in 29/38 cases, and the same ratio between intracavitary electrocardiography and echocardiography was detected.

Conclusion:

We conclude that the intracavitary electrocardiography method is safe and accurate in neonates as demonstrated in pediatric and adult patients. The applicability of the method is 97% and its feasibility is 79%. The overall accuracy is 76% but it rises to 97% if “peak” P wave is detected.

[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.

Defining the surface anatomy of the central venous system in children

Pediatric emergency physicians, pediatric critical care specialists, and pediatric surgeons perform central venous catheterization in many clinical settings. Complications of the procedure are not uncommon and can be fatal. Despite the frequency of application, the evidence-base describing the surface landmarks involved is missing. The aim of the current study was to critically investigate the surface markings of the central venous system in children. The superior vena cava/right atrial (SVC/RA) junction, superior vena cava (SVC) formation, and brachiocephalic vein (BCV) formation were examined independently by two investigators. Three hundred computed tomography (CT) scans collected across multiple centers were categorized by age group into: 0-3 years, 4-7 years, and 8-11 years. Scans with pathology that distorted or obscured the regional anatomy were excluded. The BCV formation was commonly found behind the ipsilateral medial clavicular head throughout childhood. This contrasts with the variable levels of SVC formation, SVC length, and SVC/RA junction. In the youngest group, SVC formation was most commonly at the second costal cartilage (CC), but moved to the first CC/first intercostal space (ICS) as the child grew. The SVC/RA junction was at the fourth CC in the youngest group and moved to the third CC/third ICS as the child grew. This study demonstrates the variable anatomy of SVC formation and the SVC/RA junction with respect to rib level. This variability underscores the unreliability of surface anatomical landmarks of the SVC/RA junction as a guide to catheter tip position.

Simple Formula to Place Central Venous Catheter Tip at T6 After Surgical Cutdown in Neonates

The objective of this paper was to develop a generally applicable formula to estimate correct catheter length after surgical cutdown in right internal jugular vein (RIJV) in neonates. The carina has been utilized as an anatomic landmark indicating superior vena cava-right atrium junction (SVC-RA) for the optimal placement of the central venous catheter (CVC) tip position. However, this landmark may not be accurate in neonates. Recent researches noted that the sixth vertebral body (T6) could better serve as a new landmark of SVC-RA in neonates and smaller children. We prospectively performed RIJV cutdown. For a controlled and reproducible surgical procedure, the venous entry site was consistently taken as the point where the omohyoid muscle crosses the RIJV. On intraoperative infantogram, the vertical distance between the venous entry site and T6 was measured and the catheter was inserted to this length. A linear regression model was investigated using the following variables to elicit the best prediction model for catheter length: gestational age, postconceptional age, birth weight, and weight at operation. Weight at operation best correlated with the measured CVC length (R2 = 0.916, P = 0.00), and the following linear equation was derived: estimated CVC length (mm) = 9 × [weight at operation (Kg)] + 30. There was no statistically significant difference between measured and estimated CVC length. With this formula, the optimal catheter length could easily be estimated when considering RIJV cutdown.

Defining Central venous Line Position in Children: Tips for the Tip

Purpose

The purpose of this study is to analyse literature related to the position of centrally inserted central venous catheters and to review topics related to assessment of tip position of those catheters in children. Applications of specific techniques to PICCs (Periferally Inserted Central Catheters) and umbilical venous catheter will also be reviewed.

Methods

Analysis of 68 original manuscripts, 42 specifically related to the paediatric population, 26 related to the adult population. The papers analysed were published between 1949 and 2014; all articles were in English except one in Italian and one in German.

Results

From the analysed literature, most of the guidelines recommend tip positioning at a level between the superior vena cava and the right atrium. Several methods have been described to evaluate tip position in the paediatric population, but none of those is considered completely reliable. The standard methods used to identify catheter tip position are radiography and fluoroscopy, but no specific landmark can be recommended in the paediatric population. The ultrasonographic approach has been investigated mainly for PICCs positioning in the neonatal population. The electrocardiographic method has been evaluated in the general paediatric population.

Conclusions

No specific recommendation can be given due to the low level of evidence. Ultrasound and ECG (electrocardiogram) techniques are a potential alternative to chest X-ray and further studies should be implemented to establish them. A wider application of these techniques may reduce neonatal and paediatric exposure to radiations and additionally reduce costs.

Vascular access in the neonate

Up to recently, inserting venous or arterial 'lines' in the neonate was essentially based on clinical skill and experience. The recent advent of portable ultrasound (US) machines with paediatric probes has resulted in the development of new approaches that, if correctly learned and used, should allow quicker and safer vascular access in this population. Both classic and new techniques are reviewed on the basis of literature and authors' experience.

Practical anatomic landmarks for determining the insertion depth of central venous catheter in paediatric patients

BACKGROUND

Various methods have been recommended to decide a proper insertion depth of central venous catheter (CVC). The carina is recommended as a useful target level for the CVC tip position. We evaluated the sternal head of a right clavicle and the nipples as anatomic landmarks for determining the optimal depth of CVC in paediatric patients.

METHODS

Ninety children, <5 yr, undergoing catheterization through the right internal jugular vein were enrolled. The insertion depth was determined as follows. The insertion point was designated as 'Point I'. The sternal head of the right clavicle was called 'Point A' and the midpoint of the perpendicular line drawn from Point A to the line connecting both nipples was called 'Point B'. The insertion depth of CVC was determined by adding the two distances (from I to A and from A to B) and subtracting 0.5 cm from this. A chest radiography was taken and the distance of the CVC tip from the carina level was measured by the Picture Archiving and Communicating System.

RESULTS

The mean distance of the CVC tip from the carina level was 0.1 (1.0) (P=0.293) cm above the carina (95% CI 0.1 cm below the carina-0.3 cm above the carina). There was no specific relationship between the distance of the CVC tip from the carina level and the patients' age, height, and weight.

CONCLUSIONS

The CVC tip could be placed near the carina by using the external landmarks without any formulae, images, and devices in children in our study.