Comparison of Central Venous Catheterization Sites in Infants

Central venous catheterization site choice based on anatomical landmark technique: a systematic review and meta-analysis

BACKGROUND

Internal jugular vein catheterization (IJVC) and subclavian vein catheterization (SCVC) have been the most preferred central venous catheterizations (CVC) clinically. Individual preference and institutional routine dominate the traditional CVC choice; however, it is lack of high-level evidence. We sought to provide better clinical strategy for CVC site choice based on anatomical landmark technique between IJVC and SCVC.

METHODS

We systematically reviewed eligible studies from PubMed, OVID, Cochrane and ClinicalTrials.Gov till February 2020. The primary outcomes were catheterization time and overall success rate, and the secondary outcomes were the first-attempt success rate and the instant mechanical complications. Ethical problems are not applicable.

RESULTS

A total of 3378 patients from 7 studies were included in the analyses. Neither difference was found on the catheterization time (SMD 95% CI: -0.095-0.124, p = 0.792), nor any difference on the overall success rate (RR = 1.017, 95% CI: 0.927-1.117, p = 0.721, I² = 89.6%) between the 2 procedures. However, subgroup analyses showed overall success rate of IJVC was significantly lower than that of SCVC (RR = 0.906, 95% CI: 0.850-0.965, p = 0.002) in adults. The first-attempt success rate of IJVC group was higher in the adults (RR = 1.472, 95% CI: 1.004-2.156, p = 0.047). No significance was detected in arterial injury (RR = 1.137, 95% CI: 0.541-2.387, p = 0.735) and pneumothorax (RR = 0.600, 95% CI: 0.32-1.126, p = 0.112) between the two procedures. Hematoma was significantly more in IJVC group than that in SCVC group (RR = 2.824, 95% CI: 1.181-6.751, p = 0.02).

CONCLUSIONS

Compared with IJVC, SCVC shows a higher overall success rate while a lower first-attempt success rate in adults, and has involved with less hematoma.

PROSPERO REGISTRATION

CRD42020165444.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children

PURPOSE

To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population.

METHODS

A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals.

RESULTS

A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0 kg (SD 2.9); mean age 10 months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n = 18). The median duration of line placement was 140 days (IQR 146). The most common indications for removal were completion of therapy (n = 7, 39%) and infection (n = 5, 28%). There were no early complications. Long-term complications included infection (n = 5) or catheter malfunction (n = 3).

CONCLUSIONS

Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

[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.

Repetitive urine and blood sampling in neonatal and weaned piglets for pharmacokinetic and pharmacodynamic modelling in drug discovery: a pilot study

Piglets are considered to be suitable animal models for predicting the pharmacokinetics and pharmacodynamics (PK/PD) of test drugs for potential use in the paediatric population. Such PK/PD studies require multiple blood and urine samplings. The goal of the present study was to determine a suitable blood collection strategy applicable in the youngest age categories of six days, four weeks and eight weeks of age, as well as a urine collection technique for male piglets in the same age categories. Blood was collected either by a surgically-placed jugular vein catheter (six days old [ n = 4] and four weeks old [ n = 2] piglets) or by direct venepuncture of the jugular vein (four weeks old [ n = 2] and eight weeks old [ n = 4] piglets). A non-invasive method for total volume urine collection in male piglets was also developed using a urine pouch. No specific complications were encountered during anaesthesia or surgery for jugular catheter placement. After a 24 h recovery period, urine and blood were easily collected without technical complications. One piglet was humanely killed at week 2 because of septicaemia. Histological analysis of both veins in all four piglets revealed negligible damage to the blood vessel wall. In conclusion, the presented techniques for blood (jugular catheter and direct venepuncture) and urine collection (pouches) are suitable for PK/PD studies in piglets.

Percutaneous external jugular vein catheterization in piglets using a triangulation technique

Chronic jugular vein or central venous cannulation is routinely performed in human and animal patients for access to blood circulation. In mature swine, chronic catheter placement techniques have typically involved venous isolation via extensive cut-down, blunt dissection and manipulation of ventral neck tissues prior to catheter placement. More recently, guide-wire-assisted percutaneous techniques have become standard practice in human and veterinary medicine due to the minimization of soft tissue and vessel damages. Laboratory animal piglets are becoming more popular research models because of their immature immunological system, ease of handling and costs. However, external jugular veins are very difficult to catheterize in paediatric animals including freshly weaned piglets. The objective of this study was to develop a simple, safe and efficient method for external jugular vein cannulation in young piglets. In total, 20 piglets were anaesthetized and percutaneously catheterized with a guide-wire technique using palpable anatomical landmarks and triangulation. With this minimally invasive catheterization, it has allowed our veterinarians and veterinary technicians to quickly and easily obtain central venous access in piglets undergoing operative procedures.

Percutaneous translumbar inferior vena cava catheter placement for long-term hemodialysis treatment

Central venous access for long term dialysis has always been a major difficulty, especially in cases where the traditional sites are no longer available. We present a case of a pediatric patient where the usual sites were occluded and he needed a reliable venous access for his dialysis. The inferior vena cava has been used in adult patients, but no reports were found in the pediatric literature. We chose this site as an alternative for this patient. The catheter was placed via a percutaneous translumbar approach, and remained in place for almost 2 years until the patient received a renal transplant.

The optimal depth of central venous catheter for infants less than 5 kg

To avoid fatal complications of central venous catheterization such as cardiac tamponade, the tip of the central venous catheter (CVC) should be placed outside of the cardiac chamber. To suggest a guideline for a proper depth of CVC in infants, we measured the distance from the skin puncture site to the junction between superior vena cava and right atrium (SVC-RA junction) by using transesophageal echocardiography (TEE). Fifty infants less than 5 kg undergoing surgery for congenital heart disease were enrolled in this prospective study. After the induction of general anesthesia, CVC was inserted via the right subclavian vein. After the tip of the CVC was placed at the SVC-RA junction using TEE guidance, the length of the CVC inserted beneath the skin was measured. The measured distance had a high correlation with the patient's height, weight, and age (r = 0.88, 0.76, and 0.64, respectively). In infants smaller than 5 kg, the following guideline can avoid intraatrial placement of the CVC: a depth between 40 and 45 mm for infants 2.0-3.0 kg in weight, 45-50 mm for those 3.0-3.9 kg, and 50-55 mm for those more than 4.0 kg.