Journal of Pediatric Surgery xxx (2015) xxx–xxx

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Ultrasound guided percutaneous internal jugular vein access in neonatal intensive care unit patients Chaeyoun Oh a, Sanghoon Lee b,⁎, Jeong-Meen Seo b, Suk-Koo Lee b a b

Department of Surgery, Seoul National University College of Medicine, Seoul, Korea Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

a r t i c l e

i n f o

Article history: Received 30 June 2015 Received in revised form 16 September 2015 Accepted 20 September 2015 Available online xxxx Key words: Ultrasound-guided Neonate Internal jugular vein Percutaneous Seldinger Central venous access

a b s t r a c t Background/Purpose: Internal jugular vein (IJV) access is commonly performed in neonates and infants with open cut-down method. We report the results of ultrasound guided percutaneous venous access in newborn patients in the neonatal intensive care unit (NICU). Methods: We retrospectively examined the medical records of NICU patients who underwent therapeutic percutaneous IJV access under ultrasound guidance from October 2015 to May 2015. Under general anesthesia, IJV was punctured with a 21 gauge needle after identification by ultrasound. Catheter was inserted with Seldinger’s technique. Results: Twelve ultrasound-guided percutaneous IJV accesses were performed in eight patients and eleven cases were successful (91.6%). Procedure was performed at the median age of 4.5 days (range 2 days–47 days). Median body weight was 3030 g (range 1760 g–4100 g) and median operative time was 19 minutes (range 8 minutes–80 minutes). Indications for central venous access were hyperammonemia caused by urea cycle defect (four patients) and mitochondrial disease (one patient), acute kidney injury (two patients), and congenital renal dysgenesis (one patient). Catheters were inserted in the right IJV in nine cases while two cases were done on the left IJV. All catheters functioned normally. Seven out of seven cases that were examined for venous patency by ultrasonography after catheter removal showed patent IJV. Among these seven cases, four reinsertions were attempted and successfully performed. There was one complication of hemopericardium with cardiac tamponade which is thought to be caused by direct injury from the guidewire. The patient underwent pericardiocentesis. Conclusion: Ultrasound guided IJV access in NICU patients can be performed safely and is associated with preserved venous patency after catheter removal. © 2015 Elsevier Inc. All rights reserved.

Percutaneous central venous catheterization enables nutritional support, blood sampling, hemodialysis and hematological procedures. However, in pediatric patients, because of lower success rates and higher complication rates compared to adult patients, it is considered a difficult procedure [1,2]. Ultrasound-guided percutaneous method for central venous access is considered the first choice in adults [3]. A few studies describe the use of this method in pediatric patients including infants, while supporting data in neonates is still lacking [1,4,5]. This study was designed to assess the safety, practicability, and venous patency after catheter removal of ultrasound-guided percutaneous internal jugular vein access based on the cases performed in neonatal intensive care unit (NICU) patients in our center. 1. Materials and methods We retrospectively reviewed 12 consecutive procedures of ultrasonography guided percutaneous IJV access performed on 8 patients in ⁎ Corresponding author at: Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwonro, Gangnam-gu, Seoul 135-710, Korea. Tel.: +82 2 3410 3469; fax: +82 2 3410 0040. E-mail address: [email protected] (S. Lee).

Samsung Medical Center from October 2014 to May 2015. All patients underwent identical procedures. Patients were sedated with midazolam (0.1–0.2 mg/kg/h) or remifentanil (0.25–0.3 mcg/kg/min) and mechanically ventilated. Patients were put in Trendelenburg position with a pillow under the shoulders. The patency of both IJVs was checked by ultrasonography. When the diameters were similar, the right IJV was chosen for venous access. A percutaneous procedure was attempted only when the diameter of the IJV measured by ultrasonography was greater than 150% of the diameter of the catheter. After choosing the side of the procedure, the patient’s head was tilted 20 to 40 degrees opposite to the side of the procedure. After sterile draping of the field, a linear ultrasonography probe was covered with sterile vinyl cover. Venipuncture was performed with a 21 gauge micropuncture needle. The needle was introduced with a tilting angle of approximately 45 to 60 degrees relative to the patient’s skin. Success in puncture was confirmed with an ultrasonography detecting the needle’s tip in the IJV simultaneously with blood withdrawal into the syringe. The needle was removed after inserting a 0.018 inch guidewire (Nitinol, Torq-Flex wire guide, Cook, USA) through the needle. We used “increase of the P wave on intracavitary ECG” for confirmation of tip location. Portable radiography was used to double check that the guidewire has been

http://dx.doi.org/10.1016/j.jpedsurg.2015.09.019 0022-3468/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Oh C, et al, Ultrasound guided percutaneous internal jugular vein access in neonatal intensive care unit patients, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.09.019

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C. Oh et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx

correctly inserted into the IJV. The use of portable radiography was a more prudent approach to ensure correct tip location. After confirmation, the catheter was inserted by guidance of the guidewire using Seldinger’s maneuver. The position of the catheter tip was adjusted after taking another portable radiography. GamCath double lumen catheter (6.5 French, length: 10 cm, Gambro) and two lumen indwelling catheter (4 French, length: 13 cm, Teleflex) were used in the procedures, as indicated by the patient’s medical condition. Ultrasound equipment was Sonoline Antares with a linear probe, 4–9 MHz (Siemens Medical Solutions. USA). Catheterization was performed by two experienced surgeons who had performed more than 30 cases of ultrasound guided internal jugular vein access in children.

3. Discussion It is well known that percutaneous central venous approach is more difficult in pediatric patients compared to adult patients [6–8]. The advantage of IJV access compared to subclavian vein access comes from its superficial location and low incidence of pneumothorax [9]. In 1999, Verghese et al. initially reported a real-time ultrasound guided central vein catheterization in pediatric patient [1]. Di Nardo et al. showed a possibility of percutaneous approach under ultrasound guidance in pediatric patients less than 5 kg [10]. Goldstein et al. recently published the results of their experience with this approach in neonates [11]. However, our study is the first to describe ultrasound-guided percutaneous IJV access performed under a preset protocol in neonates using mainly large-bore catheters (6.5 Fr GamCath). The purpose of this study was to assess the success rate, complication, and patency after removal of percutaneously inserted IJV catheters in pediatric patients in the NICU. The internal jugular vein is generally known to be less frequently associated with mechanical complications during percutaneous puncture and catheter insertion compared to the brachiocephalic or subclavian vein. However, the main reason for the IJV approach was because of the relative rigidity of the 6.5 Fr GamCath compared to smaller central lines (Arrow catheters). Most of the neonates described in this study required venous access for emergency hemodialysis and a brachiocephalic or subclavian approach would not be feasible with the 6.5 Fr GamCath. The procedure was performed by pediatric surgeons who were skilled in ultrasonography and percutaneous central venous approach. Success rate of IJV cannulation was 91.6% with one failed case out of twelve cases. It was the third case performed by percutaneous approach and the second case performed on patient B. The body weight of the patient was 1760 g on the day of the first case (case 2), and 2070 g on the second case (case 3) which failed. Although the cause of failure is thought to be low body weight, immature procedural skills on very low body weight patients may be another cause. Carotid arterial puncture is a less frequent complication of percutaneous IJV access with the use of ultrasound guidance [1,4]. However, a large caliber catheter such as those used in this study accidentally inserted into the carotid artery of a neonate may lead to disastrous outcomes. Among several signs that confirm venipuncture, identifying the venous anatomy using portable radiography is the most reliable method during operation [12–14]. Therefore, we introduced a 0.018 inch guidewire after a 21 gauge needle puncture to visualize the venous anatomy under radiograph. This procedure ensured avoidance of carotid arterial catheterization. Cardiac tamponade is a rare but devastating complication that can occur after central venous catheterization [15,16]. One patient had hemopericardium with tamponade which was managed with pericardiocentesis. It is suspected that deep insertion of the 0.018 inch guidewire directly injured the heart. Protocol of the procedure was changed to insert the guidewire no more than 7 cm from the skin puncture site, and no complication occurred thereafter.

2. Results A total of twelve ultrasound guided IJV accesses were performed in eight neonates. Median gestational age was 39 + 1 weeks (range 31 + 6 weeks–40 + 1 weeks). Median birth weight was 2980 g (range 1780 g–3680 g). Procedure was performed at the median age of 4.5 days (range 2 days–47 days). Median body weight was 3030 g (range 1760 g–4100 g) and median operative time was 19 minutes (range 8 minutes–80 minutes, Table 1). Eleven out of the twelve (90.9%) catheters inserted were 6.5 Fr catheters for hemodialysis. Insertion of 6.5 Fr catheter for hemodialysis was done for the following indications; five hyperammonemia patients including four patients with urea cycle defect and one patient with mitochondrial disease, two patients with acute kidney injury, and one patient with congenital renal dysgenesis. A 4 Fr two-lumen catheter was inserted for fluid resuscitation in one patient. Among twelve trials of venous accesses, eleven cases were successful (91.6%). The failed case was the second procedure performed on patient B (case 3), who previously had a central catheter (case 2) which had been removed after discontinuing hemodialysis. Case 3 was performed because of the reappearance of hyperammonemia. Because of the failure of ultrasound guided IJV access, open cut-down procedure was performed. Patient’s age was 34 days and body weight was 2070 g at the time of the procedure. Nine cases (81.8%) out of eleven were performed on the right IJV. Two cases performed on the left side were a patient who needed an additional venous access for resuscitation with a previously inserted 6.5 Fr catheter in the right IJV and another patient who showed a collapsed right IJV compared to a patent 4 mm left IJV. One patient had hemopericardium with cardiac tamponade and underwent pericardiocentesis. There were no other complications such as wound problem, carotid arterial puncture or hematoma. Mean duration of catheter use after insertion was 15.5 ± 7.4 days. Seven cases out of eleven were examined for IJV patency after removal, and all IJVs were patent (Fig. 1). In four cases, reinsertions were attempted and successfully performed on the same site. Table 1 Characteristics of each case. Patient

Case

Weight (g)

Age (days)

Indication

R/L

Catheter

Operative time (min)

Duration (days)

Patency

A B

1 2 3 4 5 6 7 8 9 10 11 12

3900 1760 2070 2790 3740 4100 2700 2700 3870 3530 2000 3270

15 3 34 2 8 4 4 5 25 47 3 4

UCD UCD

R R R R R L R L R R R R

6.5 Fr 6.5 Fr 6.5 Fr 6.5 Fr 6.5 Fr 6.5 Fr 6.5 Fr 4 Fr 6.5 Fr 6.5 Fr 6.5 Fr 6.5 Fr

17 10

16 30 6 6 11 7 16 14 19 22 8 22

Yes Yes Died before removal Not checked Not checked Died before removal Yes Yes Yes Yes Died before removal Yes

C D E F

G H

MD RD AKI UCD

AKI UCD

26 17 25 19 15 8 80 27 30

Complication

Puncture failure

Cardiac tamponade

R/L, right/left; UCD, urea cycle defect; MD, mitochondrial disease; AKI, acute kidney injury; RD, renal dysgenesis.

Please cite this article as: Oh C, et al, Ultrasound guided percutaneous internal jugular vein access in neonatal intensive care unit patients, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.09.019

C. Oh et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx

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seven cases were examined after catheter removal for venous patency. All cases showed patent IJV and four cases had successful reinsertions on the same site. 4. Conclusion Ultrasound guided percutaneous IJV access in NICU patients can be performed safely and is associated with preserved venous patency after catheter removal. With accumulation of further evidence, this procedure may replace the traditional open cut-down method for IJV access in neonates. References

Fig. 1. Patient F’s internal jugular vein shows patency under ultrasonography after the removal of the catheter inserted during case 10.

The diameter and depth from the skin of IJV is not well known. We only proceeded when the diameter of the IJV measured by ultrasonography was greater than 150% of the diameter of the catheter. All patients’ IJV diameter was greater than 3 mm on ultrasonography. Ybarra et al. claimed that the Trendelenburg position with the head in neutral position is the best position for IJV puncture in pediatric patients [17]. Sulek et al. also showed that head rotation in IJV puncture increases the risk of arterial puncture [18]. However, neutral position has the disadvantage of restricting the operating field. Therefore, we positioned the patients with their heads tilted contralaterally from the side of procedure, not rotating more than 40 degrees to avoid arterial puncture because of anatomical alteration. One thing to point out is that percutaneous approach seemed to show advantage compared to open cut-down procedure in patients with acute kidney injury who have generalized edema. Because of edematous subcutaneous tissue, open procedure becomes difficult, while percutaneous approach is not affected and even easier with increased venous volume. Two cases were successfully performed on severely edematous patients with acute kidney injury in this series. Many neonates require central venous catheterization for various reasons besides the diseases that were included in this study. When a catheter is no longer needed, it should be removed promptly to prevent catheter related infection. However, these neonates may require more catheter insertions during their life time. Therefore, preserving as many patent venous access sites as possible is critical in the journey of their treatment. Traditionally, open technique for insertion of central venous catheters has been the standard in NICU patients. However, occlusion rate was reported to be as high as 25% in open method [19]. Venous occlusion after landmark technique was 40% in the literature of Koksoy et al. [20]. In comparison, in a recent study by Wragg et al., occlusion rate was only 3% after removal of Hickman catheter which was inserted percutaneously under ultrasound guidance [21]. In our study,

[1] Verghese ST, McGill WA, Patel RI, et al. Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999;91:71–7. [2] Leyvi G, Taylor DG, Reith E, et al. Utility of ultrasound-guided central venous cannulation in pediatric surgical patients: a clinical series. Paediatr Anaesth 2005;15:953–8. [3] Hosokawa K, Shime N, Kato Y, et al. A randomized trial of ultrasound image-based skin surface marking versus real-time ultrasound-guided internal jugular vein catheterization in infants. Anesthesiology 2007;107:720–4. [4] Bruzoni M, Slater BJ, Wall J, et al. A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population. J Am Coll Surg 2013;216:939–43. [5] Verghese ST, McGill WA, Patel RI, et al. Comparison of three techniques for internal jugular vein cannulation in infants. Paediatr Anaesth 2000;10:505–11. [6] Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361. [7] Hayashi T. Transcutaneous observations of the internal jugular venous flow in atrial septal defect by ultrasonic Doppler flowmeter. Jpn Circ J 1978;42:1069–70. [8] Tercan F, Oguzkurt L, Ozkan U, et al. Comparison of ultrasonography-guided central venous catheterization between adult and pediatric populations. Cardiovasc Intervent Radiol 2008;31:575–80. [9] Lobato EB, Sulek CA, Moody RL, et al. Cross-sectional area of the right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999;13:136–8. [10] Di Nardo M, Tomasello C, Pittiruti M, et al. Ultrasound-guided central venous cannulation in infants weighing less than 5 kilograms. J Vasc Access 2011;12:321–4. [11] Goldstein SD, Pryor H, Salazar JH, et al. Ultrasound-guided percutaneous central venous access in low birth weight infants: feasibility in the smallest of patients. J Laparoendosc Adv Surg Tech A 2015;25:767–9. [12] McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123–33. [13] Shah PM, Babu SC, Goyal A, et al. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management. J Am Coll Surg 2004;198:939–44. [14] Maietta PM. Accidental carotid artery catheterization during attempted central venous catheter placement: a case report. AANA J 2012;80:251–5. [15] Haass C, Sorrentino E, Tempera A, et al. Cardiac tamponade and bilateral pleural effusion in a very low birth weight infant. J Matern Fetal Neonatal Med 2009;22:137–9. [16] Weil BR, Ladd AP, Yoder K. Pericardial effusion and cardiac tamponade associated with central venous catheters in children: an uncommon but serious and treatable condition. J Pediatr Surg 2010;45:1687–92. [17] Ybarra LF, Ruiz H, Silva MP, et al. Ultrasound evaluations of internal jugular vein punction techniques in children: the easiest method to reach the target area. Pediatr Surg Int 2009;25:99–104. [18] Sulek CA, Gravenstein N, Blackshear RH, et al. Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996;82:125–8. [19] Willetts IE, Ayodeji M, Ramsden WH, et al. Venous patency after open centralvenous cannulation. Pediatr Surg Int 2000;16:411–3. [20] Koksoy C, Kuzu A, Erden I, et al. The risk factors in central venous catheter-related thrombosis. Aust N Z J Surg 1995;65:796–8. [21] Wragg RC, Blundell S, Bader M, et al. Patency of neck veins following ultrasoundguided percutaneous Hickman line insertion. Pediatr Surg Int 2014;30:301–4.

Please cite this article as: Oh C, et al, Ultrasound guided percutaneous internal jugular vein access in neonatal intensive care unit patients, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.09.019