A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. (Kamat)

Malbezin S, Gauss T, Smith I, Bruneau B, Mangalsuren N, Diallo T, Skhiri A, Nivoche Y, Dahmani S, Brasher C. A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. Paediatr Anaesth. 2013 Nov;23(11):974-979.

OBJECTIVE: To review the results of an anesthesiologist led pediatric percutaneous central venous access service.

METHODS: Prospective data on percutaneous pediatric central venous catheter (CVC) insertions were collected over 22 years. Data included age, gender, weight, previous central CVCs, venous thromboses, investigations for great vein patency, type of CVC, external diameter, previous CVC insertions, intended use, operator identity, and the vein into which the CVC was inserted. The default technique was internal jugular vein cannulation using landmark technique (LT). Complication was defined as the following: failure to cannulate any vein, hemothorax, pneumothorax, right atrial perforation, extravenous wire positioning or CVC position and whether the patient was taken back to theater for CVC repositioning.

RESULTS: Five thousand four hundred and thirty-four percutaneous CVC insertion procedures were performed on 3954 patients. One-third involved children <1 year of age (n = 1823: 34%). Five thousand one hundred and twenty-five CVCs (95.3%) were inserted into internal jugular veins. The majority were tunneled CVCs (n = 5190: 96.2%). The perioperative complication rate was 1.3%. Successful cannulation occurred in 99.5% of patients. Failure was more likely in children ❤ kg, during large bore hemodialysis CVC insertions and during the first 4 years of the service – the latter suggesting a learning curve. Ninety-nine percent of CVCs were inserted using LTs.

CONCLUSION: This study demonstrates a high success rate and low complication rate during pediatric percutaneous internal jugular vein CVC insertions by trained anesthesiologists using LTs. Smaller children, hemodialysis CVCs, and the team’s learning curve were identified as risk factors for insertion failure.

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Trendelenburg position does not increase cross-Sectional area of the internal jugular vein predictably. (Kamat)

Chest. 2013 Feb 7. doi: 10.1378/chest.11-2462. [Epub ahead of print] PMID: 23392444

BACKGROUND: The Trendelenburg position is used to distend the central veins, improving both success and safety of vascular cannulation. The purpose of this study was to measure the cross-sectional area (CSA) of the internal jugular vein (IJV) in three different positions using surface ultrasound.

METHODS: Fifty one subjects were enrolled. A Sonosite Titan 180 or M-Turbo portable ultrasound machine with a 10.5 mHz broadband linear surface probe was used. We measured the CSA of the IJV (at end-expiration at the level of the cricoid cartilage) in three positions: 15 degrees reverse Trendelenburg, supine, and 15 degrees Trendelenburg.

RESULTS: The mean CSA at 15 degrees reverse Trendelenburg was 0.83 cm2 (Std Dev 0.86), in the supine position it was 1.25 cm2 (Std Dev 0.98) and at minus 15 degrees Trendelenburg it was 1.47 cm2 (Std Dev 1.03). Moving from reverse Trendelenburg to supine, CSA increased 50 percent. In contrast, lowering the head to a Trendelenburg position increased mean CSA only 17 percent. Surprisingly, Trendelenburg positioning reduced CSA in 9 of 51 subjects.

CONCLUSIONS: Trendelenburg positioning augments CSA only modestly, on average, compared with the supine position, and in some patients reduces the CSA. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01099254.

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