Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach

Background: Central venous cannulation in infants remains challenging evenfor experienced paediatric anaesthesiologists. Ultrasound (US)-guidancetechniques are proven to be safer for internal jugular veincatheterization. But the subclavian vein (SCV) is often thepreferred site for long-term central venous catheterizationin children. We describe a novel US-guided approach for SCVcannulation in infants and children. Methods: The principle of this technique is to place the US probe atthe supraclavicular level to obtain a longitudinal view of theSCV, and to gain access to the vein via the usual infraclavicularroute to cannulate it under ultrasonic control. Details andpitfalls of this technique are described. The prospectivelycollected results of our first 25 punctures are reported. Results: Patients' weight and age range were 2.2–27 kg and 1 dayto 9 yr, respectively: 76% of the children weighed less than10 kg. The success rate at the first attempt was 84% and 100%after two attempts. An asymptomatic thrombus in the SCV couldalso be detected with this technique. Conclusions: This US-guided approach of the SCV offers a new possibilityfor central venous catheterization in children. This techniqueseems promising for children less than 10 kg and probably alsofor older children. It provides good quality needle guidanceand allows to check the vessel patency before puncture.     

Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach

Background: Ultrasound (US) guidance techniques are reported to be safe for internal jugular vein catheterization, although anatomic conditions are not favorable for this approach in infants. The subclavian vein (SCV) seems to be a better site for long‐term central venous catheterization in children, with a supraclavicular approach to avoid compression of the central venous catheter between the clavicle and the first rib (‘pinch‐off’ syndrome). We describe a new US‐guided approach for supraclavicular SCV cannulation in infants. Methods: The principle of this technique is to place the US probe at the supraclavicular level to obtain a longitudinal view of the SCV, and to gain access to the vein with a total ultrasonic control (in‐plane puncture) via a supraclavicular approach known since 1965, but rarely used in blind puncture. The results of 37 US‐guided SCV cannulations in infants weighing <10 kg are reported. Results: Forty–two infants were enrolled in this observational study, and five infants with bad visualization of SCV were excluded. The procedure duration was <5 min in all cases except one. The success rate at the first attempt was 81% and 100% after two attempts. No major complications were reported. Conclusions: This US‐guided supraclavicular approach for SCV puncture is a new possibility for central venous catheterization in small infants, offering all the advantages of SCV cannulation without the risk of ‘pinch‐off’ syndrome. This technique seems valuable for children and infants and quite easy to apply for physicians trained to US guidance punctures.     

Real‐time ultrasound‐guided axillary vein cannulation in children: a randomised controlled trial

The axillary vein is a good site for ultrasound‐guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real‐time ultrasound‐guided axillary vein cannulation with conventional infraclavicular landmark‐guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound‐guided axillary vein (axillary group) or landmark‐guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first‐attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25–6.48, p = 0.010). The first‐attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real‐time ultrasound‐guided in‐plane technique is useful and effective in paediatric patients.     

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6–8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.     

Ultrasound‐guided catheterisation of the subclavian vein: freehand vs needle‐guided technique

The objective of this prospective, randomised study was to examine the impact of a multi‐angle needle guide for ultrasound‐guided, in‐plane, central venous catheter placement in the subclavian vein. One hundred and sixty patients were randomly allocated to two groups, freehand or needle‐guided, and then 159 catheterisations were analysed. Cannulation of the first examined access site was successful in 96.9% of cases with no significant difference between groups. There were three arterial punctures and no other severe injuries. Catheter misplacements did not differ between the groups. Higher success rates within the first and second attempts in the needle‐guided group were observed (p = 0.041 and p = 0.019, respectively). Use of the needle guide reduced the access time from a median (IQR [range]) of 30 (18–76 [6–1409]) s to 16 (10–30 [4–295]) s; p = 0.0001, and increased needle visibility from 31.8% (9.7%–52.2% [0–96.67]) to 86.2% (62.5%–100% [0–100]); p < 0.0001. A multi‐angle needle guide significantly improved aligning the needle and ultrasound plane compared with the freehand technique when cannulating the subclavian vein. Use of the guide resulted in faster access times and increased success at the first and second attempts.     

Dynamic ultrasound‐guided short‐axis needle tip navigation technique vs. landmark technique for difficult saphenous vein access in children: a randomised study

Dynamic ultrasound‐guided short‐axis needle tip navigation is a novel technique for vascular access. After venipuncture, the needle and catheter are further advanced within the vessel lumen under real‐time ultrasound guidance with constant visualisation of the needle tip in the short‐axis view. This can minimise the risk of transfixing the cannulated vessel. We compared two techniques for non‐visible saphenous vein cannulation under general anaesthesia in children weighing ≥ 3 kg and less than four years of age: dynamic ultrasound‐guided short‐axis needle tip navigation technique (ultrasound group) vs. landmark technique. Venous cannulation was performed by three experienced anaesthetists. The primary outcome measure was first‐attempt success rate. Success rate within 10 min was a secondary outcome. A total of 102 patients were randomly allocated to either the ultrasound group or the landmark group. First‐attempt success rate was 90% in the ultrasound group compared with 51% in the landmark group, p<0.001, difference 39%, 95% confidence interval (CI) of the difference 23–55%. Success rate within 10 min was 92% in the ultrasound group compared with 63% in the landmark group, p = 0.001, difference 29%, 95%CI of the difference 14–45%. We conclude that, when performed by experienced anaesthetists, the dynamic ultrasound‐guided short‐axis needle tip navigation technique improved non‐visible saphenous vein cannulation in children compared with the landmark technique.     

Ultrasound guided internal jugular vein access in children and infant: A meta‐analysis of published studies

Introduction: Central venous catheter placement is technically difficult in pediatric population especially in the younger patients. Ultrasound prelocation and/or guidance (UPG) of internal jugular vein (IJV) access has been shown to decrease failure rate and complications related to this invasive procedure. The goal of the present study was to perform a systematic review of the advantages of UPG over anatomical landmarks (AL) during IJV access in children and infants. Material and methods: A comprehensive literature search was conducted to identify clinical trials that focused on the comparison of UPG to AL techniques during IJV access in children and infants. Two reviewers independently assessed each study to meet inclusion criteria and extracted data. Data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), and their 95% confidence intervals [CI 95%]. I² statistics were used to assess statistics heterogeneity and to guide the use of fixed or random effect for computation of overall effects. Subgroup analysis was used to clarify the effects of the techniques used (prelocation or guidance) or the experience of practitioners. Results: Literature found five articles. Most of the patients were cardiac surgery patients. In comparison with AL, UPG had no effect on IJV access failure rate (OR = 0.28 [0.05, 1.47], I² = 75%, P = 0.003), the rate of carotid artery puncture (OR = 0.32 [0.06, 1.62], I² = 68%, P = 0.01), haematoma, haemothorax, or pneumothorax occurrence (OR = 0.40 [0.14, 1.13], I² = 17%, P = 0.30, OR = 0.72, OR = 0.81 [0.18, 3.73], I² = 0%, P = 0.94, respectively) and time to IJV access and haemothorax/pneumothorax occurrence. Subgroup analysis found an efficacy of ultrasound when used by novice operators or during intraoperative use. Discussion: This current meta‐analysis does not found the utility of ultrasound during IJV access in children and infants in increasing the success rate and in decreasing complications.     

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.     

Brachial plexus injury following subclavian vein catheterization: a case report

Subclavian vein cannulation may be complicated by lesions of the peripheral nervous system, such as injury to the recurrent laryngeal nerve, phrenic nerve, and brachial plexus. We describe a case of lesion of the upper trunk of the brachial plexus during multiple attempts at subclavian vein catheterization. This type of complication, ascribed to erroneous application of procedures or anatomical variations, may be minimized by abstaining from multiple attempts at venipuncture.