Central Vein Cannulation Research Articles

Percutaneous cannulation of central veins in neonates: Its safety and feasibility: Audit of 75 neonatal insertions

Introduction: Central venous catheters (CVC) have become an integral part in the care of children in intensive care settings. However, their use in neonates is limited due to inherent difficulties in insertion and associated complications. Objective: We present our experience in the use of CVC by percutaneous cannulation in neonates. Materials and Methods: A total of 75 cases of neonatal percutaneous central venous cannulation inserted over a period of 6-month from March 2014 to August 2014. Data regarding age, indication for central line insertion, site of insertion, complications related to central line insertion, duration of catheter days, werecollected. Results: Of the 75 neonates, 49 were male and 26 were female. Age group ranged from 14 to 30 days with a median of 21 days. Weight ranged from 750 g to 3.5 kg with an average of 1.9 kg. The internal jugular vein was accessed in 45 (60%), followed by femoral 26 (34.6%) and subclavian in 4 (5.3%) cases. Successful percutaneous cannulation was achieved in all and the median catheter days were 12 days. The longest catheter patency was 46 days in one neonate. The most common indication for placement was failure of peripheral venous access (78%). The main complications encountered were catheter displacement (12%) and catheter malposition (9.3%). Catheter induced sepsis was seen in 7 (9.3%) neonates. Conclusion: Percutaneous cannulation of central veins in neonates is feasible, and safe, with acceptable morbidity. Ultrasound guided central line insertions is becoming the gold standard in neonates, as the entire vascular anatomy is delineated and variations in anatomy clearly identified; hence avoiding multiple attempts and complications.Contrast injected X-rays confirmation even when the catheter is radio-opaque is effective in accurate tip identification and helps in preventing tip related complications.

Coagulopathy in cirrhosis: A prospective study to correlate conventional tests of coagulation and bleeding following invasive procedures in cirrhotics

Conventional tests of coagulation which only measure procoagulant factors do not correctly estimate the actual in vivo hemostatic balance in cirrhosis. This prospective multicenter study was conducted to evaluate safety of various invasive procedures in the presence of abnormal coagulation tests and to correlate conventional coagulation parameters with clinically significant bleeding in cirrhotics. Three hundred and eighty patients (median age 54 years, 287 males) enrolled in the study were divided into two groups (A and B), according to the presence or absence of abnormal coagulation parameters (defined as INR ≥1.5 and/or platelet count ≤50,000/cum). One hundred and twenty-eight patients (33.68%) were qualified in group A. Alcohol was the predominant etiology of cirrhosis (40% and 32% in groups A and B, respectively). The two groups were similar in baseline characteristics other than tests of coagulation and severity of liver disease. Low risk procedures (abdominal paracentesis most common) were carried out in 47% and 53% patients in two groups, respectively. None of the patients in either group had clinically significant bleeding. Similarly, high risk procedures (central vein cannulation, liver biopsy, etc.) were carried out in 14% and 10%, respectively, in two groups. Three patients in group A developed clinically significant bleeding, however, the difference was statistically nonsignificant (p=0.061). None of our patients received periprocedural correction of abnormal coagulation parameters with plasma/platelet concentrate. Deranged conventional coagulation parameters did not predict clinically significant bleeding in cirrhosis. Whenever indicated, any invasive procedure could be safely carried out in patients with cirrhosis without prior correction of coagulation abnormalities.

Cerebral Vein Thrombosis Post Cabg Precipitated by Malposition of Subclavian Central Catheter in Protein C & S Deficiency Patient

Cerebral venous thrombosis is an uncommon disorder in the general population. However, it has a higher frequency among patients younger than 40 years , patients with thrombophilia and patients that have foreign body such as catheter in their veins or arterial system. In this case report, we described the clinical and radiological findings of a patient who developed cerebral vein thrombosis post coronary artery bypass grafting secondary undiagnosed protein C and S deficiency which was precipitated by malposition of subclavian central catheter into internal jugular vein. We emphasis the importance of radiological veiw of central vein catheter position just after or at the time of cannulation of central vein, not at some hours later as in our case.

Subclavian Vein Cannulation Success Rate in Neonates and Children.

Background:Central vein cannulation allows the administration of large volumes of fluids in short times and at high osmolarities for rehydration, volume replacement, chemotherapy, and parenteral nutrition. Percutaneous central venous line insertion has replaced peripheral venous cut-down as the primary mode of short-term venous access in children.Objectives:The aim of our study was to delineate some aspects of this procedure as well as its success rate and relative risk in pediatrics.Patients and Methods:Totally, 3264 subclavian vein cannulations in neonates and children were analyzed regarding successful catheterization attempts and early complication rates after the procedure retrospectively in Mofid Hospital (Tehran, Iran).Results:There were 1340 newborn patients (first 28 days of life) in our study population. In these newborns, only 55 cannulations failed; one patient was complicated with pneumothorax; guide wires malfunctioned in 21 cases; and first- attempt cannulation success was reported in only 981 cases. In the remaining 1924 patients, between one month and 8 years old, only 14 attempts at the cannulation of the subclavian vein failed and 1655 cases had first-attempt cannulation success.Conclusions:The cannulation of the central vein in neonates and children in a skilled hand would be performed with great success rate and low complications.

Absence of the Right Internal Jugular Vein During Ultrasound-Guided Cannulation

Cannulation of the internal jugular vein (IJV) may be diffucult because of anatomical variations. A 66-year-old female patient, who was in the intensive care unit, underwent ultrasound-guided cannulation of the right IJV. The right IJV could not be visualized by ultrasonography despite positional changes of the patient and Valsalva maneuvre. The left IJV was easily determined by ultrasonography and cannulated. Although the landmark technique may be sufficient for most of the central vein cannulations, the rate of anatomical variations and related complications is quite high. We point out that even if ultrasound cannot be used in real-time, the ultrasonographic confirmation during the pre-insertion period may be crucial for successful central vein cannulation.

Hemodialysis catheter malposition: How to prevent this fault?

Cannulation of central veins and placement of catheters for temporary hemodialysis is a common procedure in the management of patients with end stage renal failure. The right internal jugular vein is the site of choice for central venous catheter placement, because it provides a more direct route into the right atrium and therefore helps prevent sheath kinking and further catheter secondary shift, being associated with the lowest complication rate. The procedure can be associated with a variety of malpositions of the catheter and rarely, can lead to significant morbidity and even mortality, if this is not recognized and not corrected early [1]. Non-tunneled percutaneous central vein catheter is usually placed at the bedside, while tunneled catheters can be placed in an interventional suite or operating room using fluoroscopic guidance.

Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: a prospective randomized study

Quick-look ultrasound with a skin mark (UM) has been frequently used for central vein cannulation. The aim of this study is to compare this method with landmark (LM) and ultrasound-guided (UG) cannulation of jugular and femoral veins by inexperienced operators. Prospective randomized single-center study. A medical intensive care unit (ICU) of a university medical center. Patients requiring jugular or femoral central cannula placement. Each inexperienced resident randomly inserted a central venous line using the UM, LM or UG technique. The primary outcome was the success rate, and secondary outcomes were the placement time, number of attempts, mechanical complication rate, and catheter colonization rate. A total of 118 patients were randomly assigned to the three groups. The mean age of patients included in the study was 65±15years, and the mean Simplified Acute Physiology Score2 (SAPS2) was 57±20. The success rate was higher in the UG group than in the LM and UM groups (100, 74, and 73%, respectively; p=0.01). The total number of mechanical complications was higher in the LM and UM groups than in the UG group (24 and 36 versus 0%, respectively; p=0.01). The number of attempts and the access time were higher in the LM group than in the UG group, but not compared with the UM group. No difference in terms of catheter colonization was observed between the three groups. Ultrasound-guided cannulation of the internal jugular or femoral vein by inexperienced residents appears to be more reliable than the LM or UM methods and was associated with a lower mechanical complication rate among ICU patients.

Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography

In 210 consecutive patients undergoing emergency central venous catheterization, we studied whether an ultrasonography examination performed at the bedside by an emergency physician can be an alternative method to chest X-ray study to verify the correct central venous catheter placement, and to identify mechanical complications. A prospective, blinded, observational study was performed, from January 2009 to December 2011, in the emergency department of a university-affiliated teaching hospital. Ultrasonography interpretation was completed during image acquisition; ultrasound scan was performed in 5 ± 3 min, whereas the time interval between chest radiograph request and its final interpretation was 65 ± 74 min p < 0.0001. We found a high concordance between the two diagnostic modalities in the identification of catheter position (Kappa = 82 %, p < 0.0001), and their ability to identify a possible wrong position showed a high correlation (Pearson's r = 0.76 %, p < 0.0001) with a sensitivity of 94 %, a specificity of 89 % for ultrasonography. Regarding the mechanical complications, three iatrogenic pneumothoraces occurred, all were correctly identified by ultrasonography and confirmed by chest radiography (sensitivity 100 %). Our study showed a high correlation between these two modalities to identify possible malpositioning of a catheter resulting from cannulation of central veins, and its complications. The less time required to perform ultrasonography allows earlier use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patients.

Emergency medicine techniques and the forensic autopsy

Emergency medicine measures often have to be carried out under suboptimal conditions in emergency situations and require invasive patient treatment. In the case of a fatal outcome these measures have to be evaluated at autopsy, regarding indications, correct implementation and possible complications. As well, alongside the more familiar procedures--such as endotracheal intubation, insertion of chest drains, external cardiac massage and cannulation of central and peripheral veins--there are alternative techniques being increasingly applied, that include new tools for the management of hemorrhagic shock, drug delivery and alternative airway management devices. On the one hand, all of these measures are essential for the survival and appropriate treatment of the injured and/or sick patient, but on the other hand they can damage the patient and thus contain a significant risk of both medical and forensic relevance for the patient and the physician. In the following review we provide an overview of established, new and alternative techniques for emergency airway management, administration of drugs and management of hemorrhagic shock. The aim is to facilitate the understanding and autopsy evaluation of current emergency medicine techniques.

Ultrasound Guided Supraclavicular Central vein Cannulation in Adults: A Technical Report

Ultrasound-guided (USG) central vein cannulation has become very popular among anesthesiologists and critical care physicians in the last decade and it has been advocated as the gold standard practice for internal jugular vein (IJV) catheterization. We report a technique used at our second level hospital for cannulating either subclavian vein or innominate vein using a supraclavicular (SCV) approach under real time ultrasound guidance for elective positioning of long, medium or short-term central venous catheters (CVC). We report one year of practice. A total of 347 intravascular devices were positioned; successful USG SCV cannulation with no complication, failure or malposition was reported in 119 cases. The SCV approach under ultrasound guidance is feasible and safe.

Is Head Rotation Preferred During Right Internal Jugular Vein Cannulation in Obese Asians?

Background: Obese subjects are considered to be a difficult group for central vein cannulation. We investigated the optimal position for right internal jugular vein (IJV) cannulation in relation to BMI in Asians. Methods: 102 subjects were divided into three groups; 34 with a BMI of less than 25 kg/aŽi (Group â ), 34 with a BMI from 25 to 30 kg/aŽi (Group II), and 34 with a BMI of 30 kg/aŽi or above (Group III). Using a 5-12 MHz linear probe of an ultrasound system, the IJV depth, the diameter of the IJV and common carotid artery (CCA) and overlap length between them were measured at six positions: 0°, 30°, and 60° of head rotation to the contralateral side combined with 0° and 10° of Trendelenburg tilt. Results: The IJV depth was deepest in Group III and significantly shorter at 10° Trendelenburg tilt compared to 0° Trendelenburg tilt. The IJV diameter increased by 10 to 20% with 10° Trendelenburg tilt and there were not significant change by head rotation or BMI. The overlap of the IJV and CCA was significantly increased in Group III compared to Group I and in Group III, there were significant increases of the overlap according to the degree of head rotation, regardless of Trendelenburg tilt.

Yet another cause of guidewire impaction during central vein cannulation

yet another cause of guidewire impaction during central vein cannulation

Traumatic injuries in pregnant women: Anesthesiology aspects

Among the most common predisposing factors that increase the anesthetic-related risks in the management of traumatic injuries are; patients presenting with depressed level of consciousness, full stomach, hypothermia, major blood loss, and screening positive for alcohol or drug abuse. Such patients, therefore, are more likely to respond differently to anesthetic agents. In reference to the current case,1we do not have any data to show patient’s blood pressure, heart rate, respiratory rate and urine output. However, according to her medical chart, we do know that her estimated blood lost was 10-15%. In such circumstances it seems logical to start the patient with intravascular fluid replacement with crystalloids infusion.2In all cases of multiple traumatic injuries, patients are at high risk for cervical spine trauma even when the related signs or symptoms are not present. This is especially important to consider when patient is transported by ambulance, or is transferred between different diagnostic wards, or during the time when rapid sequence induction is mandatory in anesthesia induction time.3,4Safety measures and precautions that are recommended for such cases include; use of appropriately sized Philadelphia collar, placing sand bags on each side of the patient’s head and neck, and resting the patient on a hard board with the forehead taped and secured to the board. These considerations however are often neglected in our practice. Other major risk factors in the management of multiple traumas include; tension pneumothorax, occult blood loss and occult long bone fractures, all requiring vigilance of emergency department physicians and personnel. For anesthesiologists, the choice of selecting a particular anesthetic agent is not as crucial as is deciding what does is more appropriate to use. Thiopental and propofol are appropriate drugs for trauma patients with minor blood loss (below 15%) if given in reduced doses.5Ketamine may be used in the hypovolemic patients. Of note, however, is that occasionally trauma patients, while under emergency care, may endure intracranial injuries with no prominent symptoms. Synthetic opioids, such as fentanil and sufentanil are preferable options for maintenance of anesthesia, but when used alone they carry the risk of awareness during anesthesia, which is quite prevalent in trauma patients. Therefore, anesthesiologist are recommended to use these drugs with some adjutants like benzodiazepines, scopolamine and/or nitrous oxide, if possible.6 Furthermore, management of pregnant women with traumatic injuries calls for immediate consultation and coordinated care with an obstetrician. This is to ascertain the viability and proper care of the fetus. My question in reference to the present case is why the pregnancy was terminated by hysterectomy despite the fact that the fetus was alive and active and had normal fetal heart rates. Also, there was enough amniotic fluid; and there was no laceration or hematoma to the placenta or other solid organs. It is advisable, however, that some anesthetic agents should be avoided in the first trimester of pregnancy to guard against teratogenicity, such as chlordiazepoxide and nitrous oxide.7In hemodynamically unstable trauma patients invasive hemodynamic monitoring is mandatory. This usually consists of continuous intra-arterial blood pressure measurement and central vein cannulation. In addition, patient’s temperature should be monitored regularly and in cases where patient's temperature is below 36oC active warming should be applied. The following care and precautions should be considered while the patient is in the postoperative care unit:, providing sufficient analgesia, balancing of intravascular volume and acid-base status, blood products replacement, identifying strategy for pulmonary emboli prevention due to the long bones fractures and prolonged bed rest, identifying methods of preventing hypothermia, and performing thorough physical exams for detection of any hidden injuries. Presence of lung contusion due to blunt chest trauma is a warning sign that the patient may need postoperative mechanical ventilation and intensive care therapy for several days. Continuous monitoring of the fetus heart rate for detecting fetal distress and unexpected abortion is also highly advised during the management of such patient.

Ultrasound-Guided Central Venous Cannulation in Infants Weighing Less than 5 Kilograms

Recent reports suggest that ultrasound-guided central venous cannulation may also be safe and effective in infants. This study aimed to evaluate the success and complications rate of this technique in infants weighing less than 5 kg. We studied 45 infants, weighing less than 5 kg (mean weight: 2.9 ± 1.1 kg, median: 3.1) needing a central venous access for intensive care treatment. In all patients, venous access was obtained by ultrasound-guided cannulation of the internal jugular vein (IJV). Central venous cannulation was successful in all 45 infants. The right internal jugular vein (IJV) was used in most cases (92%). The IJV was antero-lateral to the carotid artery in 66% of patients, lateral in 28% and anterior in 6%. Although we recorded 10 complications (22.2%), only one was clinically relevant (one pneumothorax). The other complications were repeated venipunctures (n=4), kinking of the guidewire (n=3) and local venous hematomas (n=2). The time required for completing the procedure was 7 ± 4.3 min, while the mean time of central venous catheter permanence was 5.5 ± 8 days. There was a negative correlation between the patient's weight and the time needed for cannulation (p<0.01). Complications occurred in infants with a lower body weight (p<0.01). Our experience suggests that ultrasound-guided central vein cannulation can be performed by well-trained physicians in infants weighing less than 5 kg without relevant risks.

Vascular Access on the 21st Century Military Battlefield

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It allows the administration of emergency drugs, analgesics and rapid replacement of...

A national clinical scenario‐based survey of clinicians' attitudes towards fresh frozen plasma transfusion for critically ill patients

It is known that 20-30% of fresh frozen plasma (FFP) is used in intensive care units (ICUs), but little is known about variations in decision making between clinicians in relation to coagulopathy management. Our aim was to describe ICU clinicians' beliefs and practice in relation to FFP treatment of non-bleeding coagulopathic critically ill patients. Two patient-based scenarios were developed and sent to 2700 members of two UK intensive care professional societies. Scenario 1 was a non-bleeding septic patient with coagulopathy; scenario 2 was a non-bleeding critically ill patient with hepatic cirrhosis and coagulopathy. Responses were sought in relation to FFP prophylaxis, and prior to central venous cannulation. A supplementary question asked clinicians' view of prophylaxis in relation to other ICU procedures. Two-thousand-and-seven-hundred clinicians were surveyed from whom 601 responses were received (22·3% response rate). For scenario 1 52% of respondents stated that they would never routinely administer prophylactic FFP, but this decreased to 9% when central venous cannulation was planned (P < 0·01). There was wide variation in the 'trigger' INR (international normalised ratio) value used prior to central vein cannulation, the most common range being 2·0-2·4. For scenario 2, responses were very similar. More than 80% of clinicians stated that they would routinely treat coagulopathy prior to lumbar puncture, epidural catheterisation, intracranial pressure monitoring and tracheostomy; and 54% prior to chest drain insertion. Our survey demonstrated a wide range of responses consistent with important variations in clinical practice and substantial clinical uncertainty in relation to FFP treatment for non-bleeding ICU patients.

Internal Jugular Vein Cannulation; Anatomical Surface Markings Versus Ultrasound Guidance: A Case Report.

Central venous cannulation is a common procedure in anaesthesia and intensive care which has traditionally been performed using anatomical surface landmarks. Recently, the use of ultrasound guidance was introduced and has been shown to be associated with better success rates and fewer complications. We report the case of a female patient scheduled for skin grafting of chronic Burulli ulcers who had a history of difficult peripheral vein cannulation. She had undergone numerous central venous cannulations and unsuccessful peripheral vein cut-downs in the past. On two separate occasions she had central venous catheters (CVCs) inserted in theatre using the surface landmark technique and ultrasound-guided technique. This paper describes these procedures and highlights the advantages of the ultrasound-guided technique over the external anatomical landmark technique in this patient. Keywords: Central vein cannulation, ultra sound guidance

Real‐Time Ultrasound‐Aided Central Vein Cannulation Failure Rate: Establishing a Benchmark

The use of real-time two-dimensional B-mode ultrasound (RTUS)-aided central venous access device (CVAD) insertion has been recommended by health-care agencies, but a realistic failure rate for bedside attempts is unknown. The failure rate of RTUS-aided CVAD insertion is estimated using data from adult inpatients and outpatients referred to a tertiary referral radiology department for a new CVAD insertion during the 2.5-year period ending February 29, 2008. Cannulation failure, complications, and additional fluoroscopic interventions per central vein cannulation attempt and per patient encounter were retrospectively collected and evaluated. Of the 2456 consecutive patient encounters, the index central vein cannulation failure rate using only RTUS and fluoroscopy was 4.8%; ultimate failure rate was 0.3%. The procedural mortality rate was 0.04%. If the index upper-body central vein cannulation failed, an ipsilateral upper-body attempt through a different central vein failed in 63.6%, whereas a contralateral upper-body attempt failed in 26.7% (p=0.11) and a common femoral vein attempt failed in 11.5% (p=0.0039). The minimum bedside failure rate of RTUS-aided CVAD insertion is 4.8% for the index central vein cannulated. The ultimate failure rate of 0.3% and the mortality rate of 0.04% are due to RTUS, fluoroscopy, and the additional equipment available in an IR suite. If the upper-body index central vein cannulation fails, cannulation of the common femoral vein is more likely to succeed than additional attempts in other ipsilateral upper-body central veins.

A review of the nursing role in central venous cannulation: implications for practice policy and research

The aim of this article is to review published studies about central vein cannulation to identify implications for policy, practice and research in an advanced practice nursing role. Modified integrative literature review. Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Medline, Embase, and the World Wide Web were undertaken using MeSH key words. Hand searching for relevant articles was also undertaken. All studies relating to the nurses role inserting central venous cannulae in adult populations met the search criteria and were reviewed by three authors using a critical appraisal tool. Ten studies met the inclusion criteria for the review, all reported data were from the UK. There were disparate models of service delivery and study populations and the studies were predominantly non experimental in design. The results of this review need to be considered within the methodological caveats associated with this approach. The studies identified did not demonstrate differences in rates of adverse events between a specialist nurse and a medical officer. There were only a small number of studies found in the literature review and the limited availability of clinical outcome data precluded formal analysis from being generated. Central vein cannulation is potentially an emerging practice area with important considerations for policy practice and research. Training specialist nurses to provide such a service may facilitate standardising of practice and improving surveillance of lines, and possibly improve the training and accreditation process for CVC insertions for junior medical officers. For this to occur, there is a need to undertake well-conducted clinical studies to clearly document the value and efficacy of this advanced practice nursing role.

Respiratory Distress Requiring Surgical Intervention Following Traumatic Central Internal Jugular Vein Cannulation: Review Of 2 Cases

Acute upper airway obstruction may occur secondary to hematoma formation following traumatic internal jugular vein (IJV) cannulation. Though uncommon, hematoma after central access can be a life-threatening event that requires early and prompt intervention. We present two different cases of airway obstruction caused by hematoma formation following IJV central line placement and discuss key management strategies. INTRODUCTION