Utility of ultrasound-guided central venous cannulation in pediatric surgical patients: a clinical series

BACKGROUND: Central venous cannulation can be particularly difficult in pediatric patients. Central line placement is associated with many well-known complications. While ultrasound-guided techniques are well established, the majority of central venous catheters are placed using landmark guidance. This retrospective study compares the safety and efficacy of ultrasound guidance vs landmark guidance in central venous cannulation of pediatric cardiac surgery patients. METHODS: The medical records of 149 pediatric patients undergoing cardiac surgery over 3-year period were reviewed. Patients were classified into two cohorts based on whether central venous cannulation of the internal jugular vein was performed by ultrasound or landmark guidance. Overall success and traumatic complication rates were compared between the two groups. Additionally, comparisons between the groups were made to determine if patient size or age affected the success rate of either approach in different manner. RESULTS: Patients in the ultrasound-guided (n = 47) and the landmark-guided (n = 102) groups were similar with respect to age, weight, and surgical procedure for which central venous access was indicated. The overall success rate for cannulation of the internal jugular vein was 91.5% in the ultrasound-guided group and 72.5% in the landmark-guided group (P = 0.010). But in the subgroup of children under 1 year of age, success rate was 77.8% in ultrasound group and 60.9% in landmark group (P = 0.44); in children under 10 kg in weight, success rate was 80% in ultrasound group and 56.7% in landmark group (P = 0.19). There were no significant differences in the rate of traumatic complications between the two methods. CONCLUSIONS: The overall success of internal jugular vein cannulation for pediatric cardiac surgery is significantly improved with the use of ultrasound guidance, without a significant difference in traumatic complications. However, mostly children above 1 year of age or 10 kg of weight experience advantages of ultrasound technique.     

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

Purpose: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy.Methods: This was a retrospective review of the charts of all patients at Children’s Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed.Results: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray.Conclusions: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.     

Conversion of temporary hemodialysis catheters to permanent hemodialysis catheters: a retrospective study of catheter exchange versus classic de novo placement

Many clinicians believe that de novo access is required when converting temporary hemodialysis (HD) catheters to long-term or permanent catheters. However, since vascular access sites are at a premium in the dialysis patient, it is important to preserve existing central venous catheters and conserve future access sites. In this retrospective study, data from 94 patients referred to interventional radiology for placement of long-term, tunneled HD catheters between July 2001 and September 2002 were reviewed. The study group consisted of 42 patients in whom the temporary catheter was exchanged for a peel-away sheath and a tunneled catheter inserted using the existing venous access site. The control group included 52 patients who received traditional de novo placement of permanent catheters. Based on available follow-up data, we report a 100% technical success rate, with 72% patency at 30 days in the study group (n = 32; mean age 58 years). By comparison, de novo catheter placement (n = 35; mean age 59 years) yielded a 100% technical success rate, with 83% patency at 30 days. The overall infection rate was 0.30 per 100 catheter-days (total 3036 catheter-days) and 0.36 per 100 catheter-days (total 3295 catheter-days), respectively (chi2 = 0.64, p > or = 0.05). There was no incidence of exit site infection, tunnel infection, or florid sepsis in either group. Likewise, no stenosis or bleeding complication was noted. Thus conversion of a temporary HD catheter to a tunneled catheter using the same venous insertion site is safe, does not increase the risk of infection, and allows conservation of other central venous access sites.     

Ultraschallgestützte zentrale Venenpunktion bei Erwachsenen und Kindern

Central venous line placement is a standard procedure in critical care and peri-operative medicine. This procedure can be associated with severe complications. In contrast to the landmark technique, ultrasound-guided punctures can significantly reduce the rate of complications. Patients with a high risk for difficult vascular access include critical care and emergency patients as well as patients on anticoagulation medication and dialysis. Placement of central venous catheters can be difficult in ventilated patients and if there has been prior surgery in the puncture area. In children and small infants central venous access can also be challenging due to the anatomical relationship in the head and neck region. Puncture techniques are explained briefly by means of ultrasound anatomy. Typical ultrasonographic images visualize pathological findings in order to identify dangers and complications in central venous catheterization.     

Central venous cannulation: ultrasound techniques

Central venous cannulation is commonly undertaken by a range of specialties in diverse clinical settings. Central veins may be cannulated by the landmark, ultrasound-guided or open surgical cut-down techniques. Complications of central venous catheter (CVC) insertion are common and may lead to significant morbidity and very occasional mortality. Two-dimensional ultrasound-guided central venous catheter placement has been shown by randomized controlled trials to be superior to the landmark technique. It reduces both the number of needle passes required for successful placement and the incidence of complications. Constant needle-tip visualization is a challenge for the novice operator.The UK National Institute for Clinical Excellence (NICE) has recommended since 2002 that following appropriate training, clinicians should use ultrasound wherever practical in both elective and emergency internal jugular vein catheterization. Most clinicians would now recommend its use for all routes of access.     

Radiation burden of pediatric ultrasound-guided percutaneous central venous access devices: A prospective cohort study

Permanent central venous access is essential for the management of many pediatric patients. Knowing the amount of ionizing radiation used during the insertion of these devices is important. Our aim was to identify the radiation used in percutaneous insertion of central venous access devices, and to correlate radiation exposure to patient weight.

Thoracoscopic-Assisted Placement of Azygos Vein Central Venous Catheter in a Child

Loss of central venous access in intestinal failure patients is a potentially fatal complication, and an indication for intestinal transplantation. Thrombosis of the superior vena cava (SVC) has historically been considered a contraindication to small bowel transplantation; however, unconventional central venous access can facilitate survival and eventual transplant procedure in patients with end-stage central venous access. We describe a technique for azygos vein central catheter insertion utilizing thoracoscopic guidance in a 14-year-old girl with thrombosis of the SVC and chronic idiopathic pseudo-obstruction syndrome awaiting multivisceral transplantation. The technique is simplified by utilizing carbon dioxide (CO₂) insufflation of the thoracic cavity to collapse the lung instead of double-lumen endotracheal tube placement, and no postoperative chest tube drainage of the pleural space is required. Thoracoscopic-assisted central access can also be used in children requiring chronic hemodialysis with limited venous sites due to thrombosis or small size of vessels.     

From the simulation center to the bedside: Validating the efficacy of a dynamic haptic robotic trainer in internal jugular central venous catheter placement

BackgroundThe objective of this study was to validate the transfer of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) placement skills from training on a Dynamic Haptic Robotic Trainer (DHRT), to placing US-IJCVCs in clinical environments. DHRT training greatly reduces preceptor time by providing automated feedback, standardizes learning experiences, and quantifies skill improvements.MethodsExpert observers evaluated DHRT-trained (N = 21) and manikin-trained (N = 36) surgical residents on US-IJCVC placement in the operating suite using a US-IJCVC evaluation form. Performance and errors by DHRT-trained residents were compared to traditional manikin-trained residents.ResultsThere were no significant training group differences between unsuccessful insertions (p = 0.404), assistance on procedure (p = 0.102), arterial puncture (p = 0.998), and average number of insertion attempts (p = 0.878). Regardless of training group, previous central line experience significantly predicted whether residents needed assistance on the procedure (p = 0.033).ConclusionThe results failed to show a statistical difference between DHRT- and manikin-trained residents. This study validates the transfer of skills from training on the DHRT system to performing US-IJCVC in clinical environments.     

Embolization of a fractured central venous catheter placed using the internal jugular approach

INTRODUCTIONFracture and embolization of central venous catheters placed via the subclavian approach is well recognized, but fractured catheters placed via the internal jugular vein are extremely rare.PRESENTATION OF CASEA 65-year-old man presented with a catheter embolus after placement of a central venous port using the internal jugular approach undertaken to administer adjuvant chemotherapy for colon cancer with lung metastases. Goose neck and conformational loop snares were successfully used to percutaneously retrieve the severed catheter, which had migrated to the right ventricle.DISCUSSIONCatheter fracture may occur even after placement via the internal jugular approach and may be underestimated because it is often asymptomatic. Interventional radiology techniques using goose-neck and conformational loop snares may be useful to retract an intravascular foreign body.CONCLUSIONImaging studies such as a chest X-ray are mandatory to check that the catheter tip is in the appropriate position during the entire follow-up period even if it was placed through the internal jugular vein.     

Chest radiograph after central line placement under fluoroscopy: utility or futility?

Background

Postoperative portable chest films are routinely performed after fluoroscopic placement of central venous catheters to evaluate positioning and to rule out significant complications (eg, pneumothorax). Emerging evidence in the literature has called this practice into question suggesting that routine postoperative chest x-ray is unnecessary. Therefore, we investigated our recent experience to examine the utility of these films, to examine the development of symptoms relative to therapeutic intervention, and to report a cost-benefit analysis.

Methods

After obtaining institutional review board approval, all charts of patients undergoing central venous catheter placement from January 2004 to December 2005 at our institution were reviewed. Outcome measures included whether or not there was a complication and whether or not that complication required an intervention. Peripherally inserted central catheters were not included.

Results

In the study population, 237 catheters were placed in the operating room. There were two complications, both pneumothoraces (0.085%). One patient required tube thoracostomy, whereas the other was asymptomatic and the pneumothorax resolved spontaneously. Fourteen patients had no postoperative chest film without adverse consequences. Total cost for portable chest films was $56,196.

Conclusions

For catheters placed under fluoroscopic guidance, postoperative chest films in asymptomatic patients add unnecessary cost. For this reason, we feel discontinuation of postoperative chest films in asymptomatic patients undergoing catheter placement with fluoroscopy is justifiable.     

Ultrasound-guided insertion of subclavian venous access ports

INTRODUCTION: Central venous cannulation is an integral part of venous access port (portacath) placement for intravenous chemotherapy. NICE guidelines have suggested that CVC should be performed under ultrasound guidance. The technique of ultrasound-guided subclavian cannulation is reviewed and our experience presented.PATIENTS AND METHODS: Retrospective analysis of data on patients undergoing ultrasound-guided portacath placement for the failure rate and the incidence of complications.RESULTS: We were successful in cannulating the subclavian vein in 44 of 55 patients. There was one arterial puncture and no haemothorax or pneumothorax with the technique (complication rate 1.8%).CONCLUSION: An ultrasound-guided approach should be the standard technique for central venous cannulation in portacath placement.     

Conversion of temporary hemodialysis catheters to tunneled hemodialysis catheters

PURPOSE: To determine the feasibility and clinical outcomes of conversion of temporary to tunneled hemodialysis catheters using the same venous insertion site. METHODS: Data from 42 patients with existing temporary hemodialysis catheters referred for placement of tunneled hemodialysis catheters were retrospectively reviewed. In these patients, the temporary catheter was exchanged for a peel-away sheath, and a tunneled catheter was inserted using the existing venous access site. Technical success, procedural complications, and clinical outcomes were evaluated. Hemodialysis records were reviewed to assess catheter patency during a 30-day follow-up period. RESULTS: The study group consisted of 20 males and 22 females (mean age: 58 years). All 42 temporary catheters were successfully converted to tunneled hemodialysis catheters without immediate procedure-related complications. Follow-up data were available for 32 patients (total: 3038; median 71 catheter days). Nine catheters were removed for infection, yielding a catheter infection rate of 0.30/100 catheter days; three catheters were removed for blood flow <200 ml/min. 13 patients had catheters removed when catheters were no longer needed. Three patients died with working catheters. The patency rate was 72% at 30 days, with four catheters functioning at the end of the study period. CONCLUSION: Conversion of a temporary hemodialysis catheter to a tunneled hemodialysis catheter using the same venous insertion site is a safe procedure that avoids complications associated with venotomy and allows conservation of other central venous access sites. Patency and infection rates in these catheters are comparable to several studies of catheter exchange and de novo placement of tunneled hemodialysis catheters.     

Novel technique for placement of hemodialysis catheters using a combined open procedure with the Seldinger micropuncture technique

Percutaneous placement of large-diameter dialysis catheters via the Seldinger technique can be technically challenging in patients with coagulopathy, difficult anatomy, or several previous central line insertions. We describe a method for achieving safer access by combining an open approach to delineate the venous anatomy of the chest wall, with a micropuncture device and smaller diameter guidewire to gain intravascular access to the cephalic vein or its major tributaries. Serial dilation of otherwise unusable vessels can then permit successful and safer hemodialysis catheter insertion in these difficult cases.     

Ultrasound-guided infraclavicular axillary vein cannulation

Background and objectivePercutaneous central venous cannulation is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. We wanted to evaluate an ultrasound-guided technique for the axillary vein cannulation, looking specifically at the ease of use, success rate and decreased complications.MethodsSixty consecutive surgical patients scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding an in plane puncture of axillary vein was used. After locating the vessels, an echo-guided sterile procedure was performed to cannulate the vein.ResultsCannulation was successful in all patients, and there were no complications during insertion of the catheters. Both axillary veins were cannulated, and the vein was punctured successfully at first attempt in 95% of the patients. The median time from the start of the first puncture (of the skin) until the aspiration of blood was 15 (7– 135) seconds.ConclusionThis ultrasound-guided technique for inserting central venous catheters in axillary vein was easy to apply. This procedure could increase precision and safety in patients undergoing axillary vein cannulation.     

Comparison of antimicrobial impregnation with tunneling of long-term central venous catheters: a randomized controlled trial

OBJECTIVE: We sought to compare the impact of antimicrobial impregnation to that of tunneling of long-term central venous catheters on the rates of catheter colonization and catheter-related bloodstream infection. SUMMARY BACKGROUND DATA: Tunneling of catheters constitutes a standard of care for preventing infections associated with long-term vascular access. Although antimicrobial coating of short-term central venous catheters has been demonstrated to protect against catheter-related bloodstream infection, the applicability of this preventive approach to long-term vascular access has not been established. METHODS: A prospective, randomized clinical trial in 7 university-affiliated hospitals of adult patients who required a vascular access for > or = 2 weeks. Patients were randomized to receive a silicone central venous catheter that was either impregnated with minocycline and rifampin or tunneled. The occurrence of catheter colonization and catheter-related bloodstream infection was determined. RESULTS: Of a total of 351 inserted catheters, 346 (186 antimicrobial-impregnated and 160 tunneled) were analyzed for catheter-related bloodstream infection. Clinical characteristics were comparable in the 2 study groups, but the antimicrobial-impregnated catheters remained in place for a shorter period of time (mean, 30.2 versus 43.8 days). Antimicrobial-impregnated catheters were as likely to be colonized as tunneled catheters (7.9 versus 6.3 per 1000 catheter-days). Bloodstream infection was 4 times less likely to originate from antimicrobial-impregnated than from tunneled catheters (0.36 versus 1.43 per 1000 catheter-days). CONCLUSIONS: Antimicrobial impregnation of long-term central venous catheters may help obviate the need for tunneling of catheters.     

Thoracoscopic-assisted central line placement for a thrombosed superior vena cava

Background

In children who require prolonged and multiple venous catheterizations, the superior vena cava and iliofemoral veins may become occluded, making central venous access a difficult challenge. We report an innovative technique of catheter insertion percutaneously from the neck into the right atrium traversing a thrombosed superior vena cava using video-assisted thoracoscopic surgery.

Methods

Two children with irreversible intestinal failure had 4 central venous accesses insertions using the above-mentioned technique. Both had occluded major central veins after multiple catheterizations. An interventional radiologist and cardiologist failed to establish a central venous access in both patients.

Results

A 9-year-old boy has a long-term catheter functioning for 8 months, and in an 18-month-old girl, the line was removed accidentally 6 weeks from its insertion and 2 months later for a line leak. It was then reinserted each time using the same technique.

Conclusion

This technique of catheter placement into the right atrium using video-assisted thoracoscopic surgery when other conduits are unavailable can be lifesaving in children depending on total parenteral nutrition.     

Percutaneous inferior vena cava placement of tunneled silastic catheters for prolonged vascular access in infants

In infants and children requiring prolonged and multiple central venous catheterizations, conventional cannulation sites may become thrombosed or stenotic, making inability to gain vascular access a life-threatening problem. The technique we use for the percutaneous placement of inferior vena caval tunneled silastic catheters via the translumbar and transhepatic approaches is described. Three translumbar placements and one transhepatic placement in three children without immediate complications have been performed. We conclude that percutaneous inferior vena caval cannulation via the translumbar or transhepatic routes offers a viable alternative in these patients with difficult vascular access.     

Abord de la veine sous-clavière par voie sus-claviculaire sous échographie : une nouvelle approche en pédiatrie

The subclavian vein (SCV) is often the preferred site for long-term central venous catheterization in children. It has many advantages over the internal jugular vein. But with the classical landmark technique for SCV catheterization the ultrasound-guidance technique is usually not suitable, because of the clavicle (a bright hyperechoic structure with an acoustic shadow beneath it). Because the SCV can easily be visualized via a supraclavicular approach, we developed a useful ultrasound-guided approach for SCV catheterization in infants and children.     

Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model

BackgroundThe Hemodialysis Reliable Outflow (HeRO) dialysis access device is a permanent tunneled dialysis graft connected to a central venous catheter and is used in patients with end-stage dialysis access (ESDA) issues secondary to central venous stenosis. The safety and effectiveness of the HeRO device has previously been proven, but no study thus far has compared the cost of its use with tunneled dialysis catheters (TDCs) and thigh grafts in patients with ESDA.Materials and methodsA decision analytic model was developed to simulate outcomes for patients with ESDA undergoing placement of a HeRO dialysis access device, TDC, or thigh graft. Outcomes of interest were infection, thrombosis, and ischemic events. Baseline values, ranges, and costs were determined from a systematic review of the literature. Total costs were based on 1 year of post-procedure outcomes. Sensitivity analyses were conducted to test model strength.ResultsThe HeRO dialysis access device is the least costly dialysis access with an average 1-year cost of $6521. The 1-year cost for a TDC was $8477. A thigh graft accounted for $9567 in a 1-year time period.ConclusionsThe HeRO dialysis access device is the least costly method of ESDA. The primary determinants of cost in this model are infection in TDCs and leg ischemia necessitating amputation in thigh grafts. Further study is necessary to incorporate patient preference and quality of life into the model.     

Ultrasound-guided central venous cannulation in infants and children

BACKGROUND: Percutaneous central venous cannulation in infants and children is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. An ultrasound-guided technique is now available and we wanted to evaluate this method in children and infants, looking specifically at the ease of use, success rate and complications. METHODS: Forty-two consecutive infants and children (median 16.5 [0-177] months and 10 [3-45] kg) scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding puncture of vessels was used. After locating the puncture site, a sterile procedure was performed using an accompanying kit to aid puncture of the vessel. RESULTS: Cannulation was successful in all patients and we had no complications during insertion of the catheters. The right internal jugular vein was preferred in most patients, and in 95% of the patients the vein was punctured at the first attempt. The median time from start of puncture to aspiration of blood was 12 (3-180) seconds. CONCLUSION: The ultrasound-guided technique for placement of central venous catheters was easy to apply in infants and children. It is our impression that it increased the precision and safety of the procedure in this group of patients.