Correspondence
Central venous catheter placement in children SIR— The authors have to be congratulated on their editorial on ‘central venous catheter placement in children: How good is good enough?’ (1). However, their report includes a few points which we want to discuss in this article. Seven of their 16 references are mainly adult-related ones, whereas none of the numerous papers dealing with the ultrasound-guided cannulation of the internal jugular, femoral, subclavian, or brachiocephalic vein in children has been mentioned apart from the one by Grebenik which can be criticized for the way it was carried out, that is, by operators with no ultrasound experience (1). We do agree with their statement that there is no evidence for an association between the selected vein of insertion and the risk of infection. Nevertheless, there does exist a slight hint in neonates that internal jugular venous catheters may have a higher infection rate than subclavian venous catheters (2). The major disadvantage of internal jugular and femoral venous cannulations in small infants is the vessel collapse by the approaching needle which can be nicely visualized via ultrasound. This is not true of the subclavian and brachiocephalic vein as they are fixed to the clavipectoral fascia (3). Therefore, we do disagree with the statement by Kamra K. and Hammer G.B. in their editorial that the subclavian vein is generally more difficult to visualize via ultrasound in children. To the authors knowledge, there exist two studies about the infraclavicular and six about the supraclavicular cannulation of the subclavian or brachiocephalic vein in small infants proposing an in-plane cannulation technique with an excellent sonographic view of these veins via an ultrasound probe placed vertically at the supraclavicular fovea along the clavicle (3–5) (Figure 1). The in-plane technique also enables the view of the advancing needle over the entire distance above all when the supraclavicular cannulation technique is used (Figure 1). This does not apply to the out-of-plane cannulation techniques of the femoral and internal jugular veins in small infants where the sonographic visualization of the needle is difficult. A portion of the barrel of the needle can also easily be mistaken for the tip. Unfortunately, there do not exist any papers comparing the palpation with the ultrasound-guided technique in children in terms of the subclavian vein. Such studies may also never come up as the ultrasound users will not turn back to the palpation method just for the sake of a study to convince the nonadaptors. 344
CL Cannula
AscM
BCV Ant FR Lat
Lung tissue
Figure 1 22-gauge i.v. cannula (Abbocath) within the left BCV of a 3 kg infant. Small picture: Operator maneuvering the i.v. cannula with the right hand while holding the US probe in the left hand. CL, clavicle. Ultrasound image: BCV, brachiocephalic vein; FR, first rib; AscM, anterior scalene muscle.
No doubt ultrasound machines may not be available for this purpose in many countries. That is why the palpation method for central venous catheter placement in children can still not be completely neglected. Summarizing the authors would have appreciated a more comprehensive inclusion of the well described ultrasound-guided cannulation methods other than the internal jugular venous approach in children. Despite the lacking evidence, the authors are convinced that it will soon be a medicolegal issue not to use ultrasound guidance for any central venous catheter placement in children in countries where ultrasound machines are readily available. Acknowledgments No funding was received for this letter. Conflict of interest No conflict of interests declared. Christian Breschan1 & Peter Marhofer2 Department of Anaesthesia, Klinikum Klagenfurt, Klagenfurt Austria 2 Department of Anaesthesia, AKH Vienna, Vienna, Austria Email: [email protected] 1
doi:10.1111/pan.12333
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
Correspondence
References 1 Kamra K, Hammer GB. Central venous catheter placement in children: ‘How good is good enough?’. Pediatr Anesth 2013; 23: 971–973. 2 Breschan C, Platzer M, Jost R et al. Comparison of catheter-related infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates. Anesthesiology 2007; 107: 946–953.
3 Pirotte T, Veyckemans F. Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. Br J Anaesth 2007; 98: 509–514. 4 Rhondali O, Attof R, Combet S et al. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Pediatr Anesth 2011; 21: 1136–1141.
5 Breschan C, Platzer M, Jost R et al. Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children. Br J Anaesth 2011; 106: 732–737.
Reply to Breschan et al, re ‘Central venus catheter placement in children’ SIR—We appreciate the comments by Drs. Breschan and Marhofer pursuant to our editorial, ‘Central venous catheter placement in children: How good is good enough?’ The authors take issue with our statement, ‘the subclavian vein is generally more difficult to visualize via ultrasound’ than the internal jugular vein in children. We certainly respect the expertise of the authors and others using ultrasound to identify a variety of central venous cannulation sites. On the other hand, our statement is not controversial in the context of anesthesia practice. In the hands (and eyes) of most anesthesiologists performing central venous catheter insertion in children, the internal jugular vein is easier to visualize than the subclavian vein. To a significant extent, this accounts for the widespread use of the former in anesthesia practice. In our practice of cardiac anesthesia in infants and children, as well as in other sites with which
we are familiar in the United States, the UK, Europe, and Asia, the internal jugular vein is used almost exclusively during anesthesia. That the internal jugular vein is easier to visualize by ultrasound accounts for the relative safety of central venous catheter insertion in this site compared to the subclavian vein. We appreciate the authors’ reference to additional citations describing the use of the full range of central venous structures. For purposes of brevity in our editorial; however, we limited the number of citations commensurate with limiting our overall word count. Komal Kamra & Greg Hammer Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA Email: [email protected] doi:10.1111/pan.12352
Epidural blood patch relieves positional diplopia following lumbar punctures SIR—Significant positional headache after lumbar punctures (spinal headache) refractory to conservative measures such as hydration, bed rest, caffeine, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs) is often treated with epidural blood patch with immediate and good symptom relief. Positional diplopia in the absence of headache is an atypical manifestation of intracranial hypotension due to cerebrospi© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
nal fluid leak following lumbar puncture (1). We report the first case of an adolescent patient who had positional horizontal diplopia following multiple lumbar puncture attempts which was relieved by an epidural blood patch. A 13-year-old, 104 kg, obese girl was initially presented with fever, headache, vomiting, and a finding of papilledema. A diagnostic lumbar puncture ruled out 345
Central venous catheter placement in children SIR— The authors have to be congratulated on their editorial on ‘central venous catheter placement in children: How good is good enough?’ (1). However, their report includes a few points which we want to discuss in this article. Seven of their 16 references are mainly adult-related ones, whereas none of the numerous papers dealing with the ultrasound-guided cannulation of the internal jugular, femoral, subclavian, or brachiocephalic vein in children has been mentioned apart from the one by Grebenik which can be criticized for the way it was carried out, that is, by operators with no ultrasound experience (1). We do agree with their statement that there is no evidence for an association between the selected vein of insertion and the risk of infection. Nevertheless, there does exist a slight hint in neonates that internal jugular venous catheters may have a higher infection rate than subclavian venous catheters (2). The major disadvantage of internal jugular and femoral venous cannulations in small infants is the vessel collapse by the approaching needle which can be nicely visualized via ultrasound. This is not true of the subclavian and brachiocephalic vein as they are fixed to the clavipectoral fascia (3). Therefore, we do disagree with the statement by Kamra K. and Hammer G.B. in their editorial that the subclavian vein is generally more difficult to visualize via ultrasound in children. To the authors knowledge, there exist two studies about the infraclavicular and six about the supraclavicular cannulation of the subclavian or brachiocephalic vein in small infants proposing an in-plane cannulation technique with an excellent sonographic view of these veins via an ultrasound probe placed vertically at the supraclavicular fovea along the clavicle (3–5) (Figure 1). The in-plane technique also enables the view of the advancing needle over the entire distance above all when the supraclavicular cannulation technique is used (Figure 1). This does not apply to the out-of-plane cannulation techniques of the femoral and internal jugular veins in small infants where the sonographic visualization of the needle is difficult. A portion of the barrel of the needle can also easily be mistaken for the tip. Unfortunately, there do not exist any papers comparing the palpation with the ultrasound-guided technique in children in terms of the subclavian vein. Such studies may also never come up as the ultrasound users will not turn back to the palpation method just for the sake of a study to convince the nonadaptors. 344
CL Cannula
AscM
BCV Ant FR Lat
Lung tissue
Figure 1 22-gauge i.v. cannula (Abbocath) within the left BCV of a 3 kg infant. Small picture: Operator maneuvering the i.v. cannula with the right hand while holding the US probe in the left hand. CL, clavicle. Ultrasound image: BCV, brachiocephalic vein; FR, first rib; AscM, anterior scalene muscle.
No doubt ultrasound machines may not be available for this purpose in many countries. That is why the palpation method for central venous catheter placement in children can still not be completely neglected. Summarizing the authors would have appreciated a more comprehensive inclusion of the well described ultrasound-guided cannulation methods other than the internal jugular venous approach in children. Despite the lacking evidence, the authors are convinced that it will soon be a medicolegal issue not to use ultrasound guidance for any central venous catheter placement in children in countries where ultrasound machines are readily available. Acknowledgments No funding was received for this letter. Conflict of interest No conflict of interests declared. Christian Breschan1 & Peter Marhofer2 Department of Anaesthesia, Klinikum Klagenfurt, Klagenfurt Austria 2 Department of Anaesthesia, AKH Vienna, Vienna, Austria Email: [email protected] 1
doi:10.1111/pan.12333
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
Correspondence
References 1 Kamra K, Hammer GB. Central venous catheter placement in children: ‘How good is good enough?’. Pediatr Anesth 2013; 23: 971–973. 2 Breschan C, Platzer M, Jost R et al. Comparison of catheter-related infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates. Anesthesiology 2007; 107: 946–953.
3 Pirotte T, Veyckemans F. Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. Br J Anaesth 2007; 98: 509–514. 4 Rhondali O, Attof R, Combet S et al. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Pediatr Anesth 2011; 21: 1136–1141.
5 Breschan C, Platzer M, Jost R et al. Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children. Br J Anaesth 2011; 106: 732–737.
Reply to Breschan et al, re ‘Central venus catheter placement in children’ SIR—We appreciate the comments by Drs. Breschan and Marhofer pursuant to our editorial, ‘Central venous catheter placement in children: How good is good enough?’ The authors take issue with our statement, ‘the subclavian vein is generally more difficult to visualize via ultrasound’ than the internal jugular vein in children. We certainly respect the expertise of the authors and others using ultrasound to identify a variety of central venous cannulation sites. On the other hand, our statement is not controversial in the context of anesthesia practice. In the hands (and eyes) of most anesthesiologists performing central venous catheter insertion in children, the internal jugular vein is easier to visualize than the subclavian vein. To a significant extent, this accounts for the widespread use of the former in anesthesia practice. In our practice of cardiac anesthesia in infants and children, as well as in other sites with which
we are familiar in the United States, the UK, Europe, and Asia, the internal jugular vein is used almost exclusively during anesthesia. That the internal jugular vein is easier to visualize by ultrasound accounts for the relative safety of central venous catheter insertion in this site compared to the subclavian vein. We appreciate the authors’ reference to additional citations describing the use of the full range of central venous structures. For purposes of brevity in our editorial; however, we limited the number of citations commensurate with limiting our overall word count. Komal Kamra & Greg Hammer Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA Email: [email protected] doi:10.1111/pan.12352
Epidural blood patch relieves positional diplopia following lumbar punctures SIR—Significant positional headache after lumbar punctures (spinal headache) refractory to conservative measures such as hydration, bed rest, caffeine, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs) is often treated with epidural blood patch with immediate and good symptom relief. Positional diplopia in the absence of headache is an atypical manifestation of intracranial hypotension due to cerebrospi© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
nal fluid leak following lumbar puncture (1). We report the first case of an adolescent patient who had positional horizontal diplopia following multiple lumbar puncture attempts which was relieved by an epidural blood patch. A 13-year-old, 104 kg, obese girl was initially presented with fever, headache, vomiting, and a finding of papilledema. A diagnostic lumbar puncture ruled out 345
