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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 455-460

Ultrasound-guided supraclavicular brachiocephalic vein cannulation versus internal jugular vein cannulation in young children


Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission21-Oct-2018
Date of Acceptance01-Jul-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
MD Mofeed A Abdelmaboud
Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine, Al-Azhar University, 12992 Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_81_18

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  Abstract 

Background Ultrasound (US) guided supraclavicular approach of brachiocephalic vein (BCV) cannulation was recently described in children.
Aim The primary outcome was to evaluate which is better, US-guided BCV cannulation or internal jugular vein (IJV) cannulation. The secondary outcome was to examine possible complications.
Patients and methods According to the site of central line cannulation, 80 children undergoing open cardiac surgery were classified into group I (US-guided supraclavicular BCV cannulation) and group II (US-guided IJV cannulation). The cannulation time (min), first-attempt success rate, overall success rate, number of cannulation attempt, and possible complications (such as artery puncture, difficulty of threading the wire, catheter malposition, multiple puncture, and pneumothorax) were recorded.
Results The cannulation time (min) was significantly shorter in group I than group II, and first-attempt success rate was significantly higher in group I than group II. The number of cannulation attempt was significantly higher in group II than group I, and the overall success rate was slightly higher in group I than group II, with no significant difference. There were no significant differences between the two groups regarding complications.
Conclusion US-guided supraclavicular BCV cannulation was easier with higher success rate and shorter cannulation time with slightly less complications compared with IJV cannulation.

Keywords: brachiocephalic vein, internal jugular vein cannulation, supraclavicular, ultrasound, young children


How to cite this article:
Abdelmaboud MA. Ultrasound-guided supraclavicular brachiocephalic vein cannulation versus internal jugular vein cannulation in young children. Res Opin Anesth Intensive Care 2019;6:455-60

How to cite this URL:
Abdelmaboud MA. Ultrasound-guided supraclavicular brachiocephalic vein cannulation versus internal jugular vein cannulation in young children. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2020 Jan 29];6:455-60. Available from: http://www.roaic.eg.net/text.asp?2019/6/4/455/275144


  Introduction Top


Landmark-based cannulation of brachiocephalic vein (BCV) in the supraclavicular fossa was initially described in 1965 by Yoffa [1]. This approach did not gain popularity owing to early reports of pneumothorax in 1969 [2].

Recently, ultrasound (US) cannulation has become a standard procedure in adults and children [3].

Preprocedural US examination allows detailed evaluation of the vein size, patency, and vascular anatomy [4]. Furthermore, US guidance helps the ability to advance the needle under direct vision, thereby decreasing complications such as arterial puncture and pneumothorax. Lastly, US allows early detection of complications such as pneumothorax and catheter tip malposition [5].

Central venous cannulation (CVC) in children is more challenging, especially in neonates and small infants as the anatomical landmarks are not easily defined, limited puncture area, and small vein size, with more failure rates (4–38%) [6].

In 2011, Breschan et al. [7] first described US-guided cannulation of BCV in children.

Recently, in-plane supraclavicular cannulation of the BCV has been used as an alternative approach which may offer advantages during difficult CVC that may occur in neonates and small infants [8].

Oulego et al. [9] described the technical success and safety profile of US-guided BCV cannulation in neonates. Oulego et al. [10] compared US-guided BCV and internal jugular vein (IJV) cannulation in critically ill children. Oulego et al. [11] studied the safety and feasibility of US-guided cannulation of the BCV in neonates and infants. Breschan et al. [12] studied US‐guided supraclavicular cannulation of the BCV in infants.


  Aim Top


The primary outcome was to evaluate which is easier, US-guided BCV cannulation or IJV cannulation. The secondary outcome was to examine possible complications (such as arterial puncture, catheter malposition, difficulty of guide-wire threading, multiple puncture, and pneumothorax).


  Patients and methods Top


After approval from Al-Azhar Anesthesia and Intensive Care Department for boys and from local ethical committee, and informed written consent from children’s parents, this study was carried out at Al-Hussein University Hospital in the period from June 2017 to June 2018.

A total of 80 patients of both sexes, aged between 1 day and 4 years old, with American Society of Anesthesiologist physical status II, with platelet count above 100 000/μl, and normal coagulation profile scheduled for elective on-pump cardiac surgery were included in this study.

Exclusion criteria included patients with neck musculoskeletal anomaly, hematoma at puncture site, local skin infection, previous neck radiotherapy, radical neck surgery, and patients who had CVC for any indication before cardiac surgery.

After reaching the operating room, and inserting a peripheral venous cannula, routine monitors (ECG, noninvasive blood pressure, and SpO2) were applied.

After induction of anesthesia, endotracheal intubation, complete sterilization, and drabbing of the head, neck, and upper chest, the 80 patients were randomly divided by sealed envelopes into two equal groups (40 patients each):
  1. Group I: CVC was inserted into the right BCV by supraclavicular approach guided by US.
  2. Group II: CVC was inserted into the right IJV guided by US.


The US probe together with some sterile gel was inserted into a long sterile sheath.

Equipment

Mindray diagnostic ultrasound system, model Z5 (Shenzhen Mindray Bio-Medical Electronics Co. Ltd, Nanshan, Shenzhen, P.R. China), was used. Amecath triple-lumen central venous catheter kit (batch no. 333017-N, ref. CTLC-0720-K; Ameco Medical Industries, Ramadan City, Egypt) was used.

Ultrasound scanning technique

Scanning of the brachiocephalic vein (long-axis view)

Needle puncture was started just lateral to the clavicular head of sternomastoid muscle and above the clavicle directed toward sternomandibular joint in long-axis approach ([Figure 1]).
Figure 1 (a) Long-axis view of internal jugular vein; the supraclavicular vein (SCV) union at the confluence of brachiocephalic vein, (b) Doppler used to verify the flow in the vein. Notice the flow changes with respiration.

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Scanning of the internal jugular vein (long-axis view)

The probe was placed at the apex of the triangle ([Figure 2]) formed by two heads of sternomastoid muscle and clavicle with its long axis parallel to the long axis of the vessel.
Figure 2 External landmarks for internal jugular vein cannulation. SCM, sternocleidomastoid.

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Needle entry was 0.5 cm proximal to probe at angle of 30°–45° to the skin.

On US, vein was nonpulsatile and compressible, with characteristic Doppler venous hum, but the artery was round, noncompressible, and pulsatile, with characteristic Doppler pulsatile waveform.

Insertion technique

After aspiration of continuous venous blood, the guide wire was threaded from its J-tip end through the needle, and then the needle was withdrawn leaving the guide wire inside the vein ([Figure 3] and [Figure 4]).
Figure 3 Long-axis view of brachiocephalic vein with guide wire.

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Figure 4 Long-axis view of internal jugular vein with guide wire.

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Skin incision was made with scalpel over the guide wire, and the skin and subcutaneous tissue were dilated with dilator followed by removal of the dilator and insertion of the catheter over the guide wire (Seldinger’s technique), and then the guide-wire was removed. Blood aspiration was confirmed through all ports and flushed with saline. The catheter was secured with suture and covered with sterile dressing.

When there was pulsatile bright red blood, this indicated arterial puncture, and the needle was removed and pressure was applied for 5–10 min. Another attempt was made at a separate skin puncture.

Chest radiograph was done for all patients within 1 h after the procedure ([Figure 5]).
Figure 5 Complications recorded in the studied groups.

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The cannulation time (min) (starting from skin puncture till securing the CVC with sutures), first-attempt success rate, overall success rate, and number of cannulation attempt were recorded. Complications (such as artery puncture, difficulty of threading the wire, catheter malposition, multiple puncture, and pneumothorax) were recorded.

Statistical analysis

Data were expressed as mean±SD, number or percentage and compared using SPSS version V17, (SPSS Inc. company, Chicago, Illinois, USA), t-test was utilized for parametric data. Chi-square test was used for the percentages and incidence. P value < 0.05 was considered statistically significant.


  Results Top


The two groups were comparable regarding demographic data ([Table 1]).
Table 1 Demographic data

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Regarding insertion characteristics ([Table 2]), the cannulation time (min) was significantly shorter in group I than group II, and first-attempt success rate was significantly higher in group I than group II, but the number of cannulation attempt was significantly higher in group II than group I, and the overall success rate was slightly higher in group I than group II, with no significant difference.
Table 2 Insertion characteristics

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There were no significant differences between the two groups regarding complications ([Figure 6]).
Figure 6 Chest radiograph done 1 h after central venous cannulation.

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Group I underwent US-guided right BCV cannulation, group II underwent US-guided right IJV cannulation. Data are represented as mean±SD and number. (P>0.05 was statistically not significant, P<0.05 was statistically significant, and P<0.001, highly significant).


  Discussion Top


Thompson [13] studied the technical feasibility of US-guided cannulation of the BCV in infants and children. Tapia et al. [14] studied efficacy and safety of US-guided IJV catheterization in low-birth-weight newborn. Chaudhari et al. [15] compared US-guided short and long axis cannulation of IJV.

This study showed that, the cannulation time (min) was significantly shorter (P<0.005) in BCV group (10±6) than IJV group (15±9 min). In agreement with our study, Oulego et al. [10] demonstrated that cannulation time was significantly shorter (P<0.05) in the BCV group [66 (25-300) s] than the IJV group [170 (40–500) s]. Moreover, Tapia et al. [14] observed that cannulation time was 16.8 (10–40) min in right internal jugular vein (RIJV) cannulation.

This study showed that the first-attempt success rate was significantly higher (P<0.001) in BCV group (80%) than IJV group (52.5%). Matching with this study, Oulego et al. [9] observed that the first-attempt success rate was 72.5% in US-guided BCV cannulation in neonates. Oulego et al. [10] demonstrated that first-attempt success rate was significantly higher (P=0.017) in the BCV (73%) than the IJV group (37.5%) in critically ill children. Moreover, Oulego et al. [11] showed that the first-attempt success rate was 66.6% in the US-guided BCV cannulation in neonates and infants. However, in contrary to this study, Chaudhari et al. [15] showed that first-attempt success rate was 92% in long-axis US-guided IJV cannulation.

This study showed that the number of cannulation attempt was significantly higher (P<0.001) in IJV group (2±0.3) than BCV group (1±0.4). In agreement with this study, Oulego et al. [10] demonstrated that median (range) number of cannulation attempts was 1 (1–3) and 2 (1–4) in BCV group and IJV group respectively in critically ill children, Oulego et al. [11] showed that the number of cannulation attempts was 1–2 in US-guided BCV cannulation in neonates and infants, and also Tapia et al. [14] observed that one attempt was necessary in 50% and up to five attempts in 95.7%, with mean of two (1–8) attempts in US-guided IJV catheterization in low-birth-weight newborns.

This study showed that the overall success rate was slightly higher in BCV group (95%) than IJV group (85%), with no significant difference (P=0.264). This was matched with Oulego et al. [10] who demonstrated that the overall success rate was slightly higher in the BCV group (95%) than the IJV group (83%) P=NS; Oulego et al. [9] who observed that the overall success rates was 95% in US-guided BCV cannulation in neonates; Oulego et al. [11] who showed that the overall success rate was 100% after the second attempt in US-guided BCV cannulation in neonates and infants; and also agreed with Thompson [13] who found that the overall success rate was 100% in US-guided cannulation of the BCV in infants and children. However, in contrast to this study, Chaudhari et al. [15] showed that the overall success rate was 100% in long axis US-guided IJV cannulation.

This study demonstrated that there were no significant differences between the two groups regarding complications.

Matching with our study, Oulego et al. [9] demonstrated that, no major immediate complications were observed with US-guided BCV cannulation in neonates, and also Thompson [13] found that no immediate complications with US-guided BCV cannulation in infants and children, except for three cases, where one (2%) cas showed artery puncture, and two (4%) cases showed difficulty of wire threading. However, in contrary to this study, Chaudhari et al. [15] showed that arterial puncture was 0% in long-axis US-guided IJV cannulation.


  Conclusion Top


US-guided supraclavicular BCV cannulation was easier with higher success rate and shorter cannulation time with less complications compared with US-guided IJV cannulation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Yoffa D. Supraclavicular subclavian venipuncture and catheterisation. Lancet 1965; 2:614–617.  Back to cited text no. 1
    
2.
Walker MM, Sanders RC. Pneumothorax following supraclavicular subclavian venipuncture. Anesthesia 1969; 24:453–460.  Back to cited text no. 2
    
3.
Johr M, Berger TM. Venous access in children: state of the art. Curr Opin Anesthesiol 2015; 28:314–320.  Back to cited text no. 3
    
4.
Pittiruti M. US guided central vascular access in neonates, infants and children. Curr Drug Targets 2012; 13:961–969.  Back to cited text no. 4
    
5.
Alonso-Quintela P, Oulego-Erroz I, Rodriguez-Blanco S, Muniz-Fontan M, Lapena- Lopez-de Armentia S, Rodriguez-Nunez A. Location of the central venous catheter tip with bedside US in young children: can we eliminate the need for chest radiography? Pediatr Crit Care Med 2015;16:e340–e345.  Back to cited text no. 5
    
6.
Shime N, Hosokawa K, MacLaren G. US imaging reduces failure rates of percutaneous CVC in children. Pediatr Crit Care Med 2015; 16:718–725.  Back to cited text no. 6
    
7.
Breschan C, Platzer M, Jost R, Stettner H, Beyer AS, Feigl G et al. Consecutive, prospective case series of a new method for US-guided supraclavicular approach to the BCV in children. Br J Anaesth 2011; 106:732–737.  Back to cited text no. 7
    
8.
Di Nardo M, Stoppa F, Marano M, Ricci Z, Barbieri MA, Cecchetti C. US guided left BCV cannulation in children with underlying bleeding disorders: a retrospective analysis. Pediatr Crit Care Med 2014; 15:e 44–e 48.  Back to cited text no. 8
    
9.
Oulego EI, Alonso QP, Terroba SS, Jiménez GA, Rodríguez BS, Vázquez MJL. US-guided cannulation of the BCV in neonates and preterm infants: a prospective observational study. Am J Perinatol 2018; 35:503–508.  Back to cited text no. 9
    
10.
Oulego EI, Munoz LA, Alonso QP, Rodriguez NA. Comparison of US-guided BCV and IJV cannulation in critically ill children. J Crit Care 2016; 35:133–137.  Back to cited text no. 10
    
11.
Oulego EI, Alonso QP, Domínguez P, Rodríguez BS, Muñíz FM, Muñoz LA et al. US-guided cannulation of the BCV in neonates and infants. An Pediatr (Barc) 2016; 84:331–336.  Back to cited text no. 11
    
12.
Breschan C, Platzer M, Jost R, Stettner H, Feigl G, Likar R. US‐guided supraclavicular cannulation of the BCV in infants: a retrospective analysis of a case series. Paediatr Anaesth 2012; 22:1062–1067.  Back to cited text no. 12
    
13.
Thompson ME. US-guided cannulation of the BCV in infants and children is useful and stable. Turk J Anaesthesiol Reanim 2017; 45:153–157.  Back to cited text no. 13
    
14.
Tapia FM, Rodríguez TA, Cura-EI , Barreto AI, Hernández GA, Rodríguez BI, Quero J, de la O-Cavazos M. Efficacy and safety of US-guided IJV catheterization in low birth weight newborn. J Pediatr Surg 2016; 51:1700–1703.  Back to cited text no. 14
    
15.
Chaudhari MS, Shah SB, Kamat HV. US-guided IJV cannulation with short and long axis approach − technical ease and complications. Indian J Clin Anaesth 2016; 3:5460.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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