Internal Jugular Venous Catheter Research Articles

Complications of femoral access for hemodialysis: A surgical perspective

Background: Vascular access, especially arteriovenous fistula (AVF), is critical for patients requiring haemodialysis. Due to delayed diagnosis, late referral, poverty and limited availability of competent access surgeons, many patients commence haemodialysis without an AVF, hence the frequent use of venous catheters. Objectives: To assess the pattern of complications associated with repeated femoral punctures for haemodialysis. Materials and Methods: This is a multicentre prospective study conducted at the Cardiovascular units of the University of Port Harcourt Teaching Hospital, Port Harcourt and Federal Medical Centre, Umuahia between January 2017 and December 2022. 66 patients were recruited for the study. Data obtained were patients’ demography, complications of femoral access, surgical approach and outcome. Results: 15 patients presented with severe lower limb pains and inability to walk, 10 with fibrosis/ hardening of the skin of both groins, 8 with skin infection at the repeated puncture sites, 12 had Pseudoaneurysm of the superficial femoral artery (SFA), 6 had iatrogenic femoro-femoral Arteriovenous Fistula (AVF) of the SFA and superficial femoral vein (SFV), 5 had groin abscess. All the patients had internal jugular venous catheters inserted. Some patients had Fogarty catheter thrombectomies and interposition Great Saphenous Vein (GSV) graft repairs, while some others had successful takedown of the AVF, Fogarty thrombectomy and direct prolene 6/0 repair of the vein & arterial wall defects. All those that underwent surgical treatment had successful recovery. Conclusion: Femoral vein cannulation, apparently easy to perform, should not be used as the vascular access of choice for chronic haemodialysis.

POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care.

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

Inadvertent catheter misplacement into the subclavian artery during ultrasound-guided internal jugular venous catheterization: a case report

BackgroundUltrasound-guided central venous catheterization has become a standard procedure. However, mechanical complications are still reported.Case presentationAn 85-year-old woman presented with coagulopathic bladder tamponade. Ultrasound-guided right internal jugular venous catheterization was planned because of difficult peripheral venous access. A guidewire was advanced through a needle inserted at the midpoint of the right carotid triangle. The guidewire was identified in the short axis, but not in the long-axis ultrasound view, leading to inadvertent insertion of the catheter into the right subclavian artery through the internal jugular vein. Stent graft insertion was performed for perforation closure. The patient exhibited no symptoms of cerebral ischemia following stent graft insertion.DiscussionThis case demonstrated that the needle-sticking site should not be placed close to the clavicle for ultrasound-guided internal jugular venous catheterization, as it may not confirm the position of guidewire in the long-axis ultrasound view.

Persistent left SVC: Can nephrologist use it for dialysis

Persistent left sided superior vena cava (PLSVC), though rare, is the most common congenital anomaly of thoracic venous circulation. Most of the times, it gets incidentally detected during left internal jugular venous hemodialysis catheter insertion.

Comparative evaluation between external jugular and internal jugular venous catheterization through landmark technique.

Cannulation of a central vein is crucial in patients for hemodynamic management and when insertion of a peripheral line is not possible. The internal jugular vein is the preferred access site; however, in the case of not being accessible, the second cannulation site of choice is still unclear. The study aimed to access the feasibility of external jugular vein cannulation versus internal jugular vein cannulation in terms of success, cannulation time, number of attempts and complications. In this prospective, randomised double-blinded study, 100 patients received 7Fr size triple-lumen central vein catheter either in the internal jugular vein (n = 50) or external jugular vein (n = 50) through the landmark technique as a part of anaesthetic care in the operation theatre. The number of attempts, cannulation time and incidence of complications in both the techniques were observed and recorded. The success rate in internal jugular vein cannulation was 88%, while in the external jugular vein, it was 78% (p = 0.17). The external jugular vein cannulation was comparatively quicker in our study (p = 0.01). Similarly, elevated body mass index did not affect the success rate in the number of cannulations attempts in either group (p = 0.08). In terms of complications, the internal jugular vein group had a total of 20% and the external jugular vein group had 28% complications; however, the complications were more severe in the internal jugular vein group. Anaesthetists should rethink alternate routes for the insertion of central vein cannulation. The external jugular cannulation route is one of them.

Determination of Central Venous Catheter Complications: Internal Jugular Vein versus Femoral Vein Catheterization

Aim: This research aimed to compare the mechanical, thrombotic, and infectious complication ratio of the internal jugular vein with those of femoral vein catheterization. Materials and Methods: It is a single-center retrospective study. One hundred seventy-nine pediatric patients undergoing central venous catheter insertion in the intensive care unit were selected from February 2020 to August 2021. The patients were divided into 2 groups based on catheter type; internal jugular versus femoral venous catheterization. Procedure complications rates were assessed. However, jugular catheterization was performed under ultrasound guidance, and femoral venous catheterization was inserted via an original landmark-based technique. Thromboprophylaxis was performed on all patients without coagulopathy. Results: The overall rate of procedural complications was 20%. The subcutaneous hematoma was the most common mechanical complication and higher in femoral attempts (p= 0.001), followed by arterial injury (p= 0.002). Thrombotic complications were similar between the two groups (p= 0.053). Infections complications were higher in femoral venous catheterization (p= 0.016). Conclusion: Femoral venous catheterization is associated with a greater risk of mechanical and infectious complications than internal jugular venous catheterization. Usage of ultrasound during catheterization procedures decreases mechanical complications.

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

Preparing for the lasting effects of COVID-19 on medical training: The design and pilot study of a low-fidelity virtual reality prototype for Central Venous Catheterization training.

Over the last several decades we have seen a shift from in-person to online training that has been exasperated by the COVID-19 pandemic. Researchers believe that many of these effects will be lasting which makes it even more important that the Human Factors community seek to step back and understand how to best train complex skills in a virtual world. The current paper is focused on understanding the utility of Virtual Reality (VR) in medical education for a hands-on procedural heavy procedure - ultrasound-guided Internal Jugular Central Venous Catheterization. Specifically, the objective of this study is to identify the potential utility of VR in US-IJCVC training through the design of a low-fidelity prototype and user interviews with three subject-matter experts. Results showed that the VR prototype designed is useful and provides a depth of knowledge and educational value which can be used to design innovative VR training approaches.

Optimal positioning of right internal jugular venous catheter: A randomised study comparing modified Peres' height formula and distance between insertion point and right third intercostal space.

ABSTRACTBackground and Aims:The position of the tip of the central venous catheter (CVC) is important to minimise complications. The aim of our study was to compare modified Peres’ height formula and landmark method using distance between puncture site and right third intercostal space (PS-RTICS) and to develop a reliable formula for correct positioning of tip of the CVC.Methods:This prospective, randomised study was conducted on 400 patients of either gender, of age 18 years and older, scheduled to undergo right internal jugular venous cannulation. Depending on the technique used for deciding the length of CVC to be inserted, the patients were randomly allocated into two groups: Group A, using modified Peres’ height formula, that is, height of patient (cm)/10-2 and Group B, using distance between PS-RTICS and subtracting one from it, that is (PS-RTICS)-1. The carina was taken as the landmark for optimum insertion of CVC, which was confirmed on postprocedure chest X-ray. Data so obtained were tabulated and analysed. P<.05 was considered statistically significant for correlation and regression coefficients.Results:In group A, the mean length of catheter inserted was 15.18 ± 0.73 cm and the catheter tip was found to be 2.41 ± 0.85 cm distal to carina (P =0.001). Over-insertion was found in 98.45% patients in group A. In group B, the mean length of catheter inserted was 14.12 ± 0.85 cm and the catheter tip was found to be 0.20 ± 1.18 cm distal to carina.Conclusion:Though both landmark and modified Peres’ height formula has low accuracy, landmark technique is superior in predicting correct depth of right internal jugular venous cannulation catheter.

Internal jugular central venous catheterization: a focus on the procedure

Central venous catheterization (CVC) is very common procedure in the emergency department and intensive care unit. Although patients undergoing CVC may have various indications and contraindications for this catheterization, the procedure is typically similar, regardless of the route. However, site-specific precautions also exist. This report describes the overall procedure for CVC with access by the internal jugular vein. Neurologic complications such as stroke and cranial air embolism, as well as mechanical complications such as hemopneumothorax and hematoma, can occur related to the internal jugular venous approach to CVC. Clinicians should be aware of these concerns for these patients population.

Effectiveness of Using a Gelatine-Based Model in Ultrasonography-guided Jugular Central venous Catheter Placement Training: A Randomised Clinical Trial.

To evaluate the effectiveness of using a gelatine-based model, that can be prepared easily and at a low cost, compared to training without a model in ultrasonography (USG) guided internal jugular venous catheter placement training. An open-label, randomised clinical trial. (UHS) Izmir Bozyaka Training and Research Hospital, Izmir, Turkey, from 1st to 30th July 2019. Analysis was conducted with the data of 48 participants (resident physicians-RP). Group 1 (n: 26) received imaging training with USG on a human subject and then performed needle insertion training on the gelatine-based jugular vein model with the USG guidance. Group 2 (n: 22) received the same imaging training with USG but did not perform needle insertion training. Evaluation of the participants included successful long axis vein imaging time, successful in-plane needle imaging, number of changes in needle angles, the total number of punctures, successful vein puncture time, successful catheterization time, and catheterization success with the gelatine-based test manikin. Comparison of the rates of successful in-plane needle imaging (Group 1: 92.3%, Group 2: 59.1%; p = 0.006), catheterization success (Group 1: 92.3%, Group 2: 59.1%; p = 0.006), successful catheterisation time (Group 1: 77.5 sec, Group 2: 152.5 sec; p = 0.026), and total complications (Group 1: 3.8%, Group 2: 31.8%; p = 0.010) demonstrated that the model-trained RPs were significantly more successful. The study results suggest that the use of a gelatine-based model in USG-guided central jugular vein catheterisation training can be an effective method to reduce complications. Central venous catheter, Medical training, Simulation-based training, Ultrasonography.

Going the (social) distance: Comparing the effectiveness of online versus in-person Internal Jugular Central Venous Catheterization procedural training

BackgroundThis study compares surgical residents’ knowledge acquisition of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) between in-person and online procedural training cohorts before receiving independent in-person Dynamic Haptic Robotic Simulation training. MethodsThree surgical residency procedural training cohorts, two in-person (N = 26) and one online (N = 14), were compared based on their performance on a 24-item US-IJCVC evaluation checklist completed by an expert physician completed after training. Pre- and post-training US-IJCVC knowledge was also compared for the online cohort. ResultsNo significant change in the pass rates on the US-IJCVC checklist was found between in-person and online cohorts (p = 0.208). There were differences in the Economy of Time and Motion between in-person and online cohorts (p < 0.005). The online cohort had significant increases in US-IJCVC knowledge pre-to post-training (p < 0.008). ConclusionOnline training with independent simulation practice was as effective as in-person training for US-IJCVC.

Unintentional common carotid artery cannulation during attempted internal jugular venous catheter insertion

Purpose: Insertion of a central venous catheter is a common procedure, performed by anesthesiologists and other medical professionals. The preferred site for central venous cannulation is the right internal jugular vein.&#x0D; Case Report: We present the case of a male patient who underwent renal transplantation for end-stage renal disease. During preparation for surgery, the right common carotid artery was cannulated instead of the right internal jugular vein. The situation was immediately recognized and managed by a vascular surgeon. The patient recovered completely without neurological deficit.&#x0D; Conclusion: Central venous cannulation is usually performed using the landmark technique. Incidental cannulation of the common carotid artery is a rare complication that can have serious consequences if not immediately recognized and properly managed.

Evaluation of Surface Landmarks and C-length as Predictors of the Depth of Right Internal Jugular Venous Catheter Insertion: A Transesophageal Echocardiography-Guided Study

Abstract Background Central venous catheterization is a standard clinical practice for infusion of fluids, blood products, or vasoactive drugs to the central circulation and to monitor central venous pressure during perioperative periods. However, this procedure can lead to significant complications, including cardiac arrhythmia, vascular injury, hydrothorax, hemothorax, hydromediastinum, and cardiac tamponade. Such complications can occur when the catheter tip is inserted within the heart chamber or when it abuts the vascular wall at a steep angle. Objectives The primary aim of the current study is to examine the accuracy of the C-distance or surface landmarks in determining the length of CVC that is required to place the catheter tip at the mid-SCV as confirmed by transesophageal echocardiography (TEE). A secondary aim is to derive an equation or formula to calculate the depth of the CVC that is required in order to have the catheter tip placed at the mid-SVC. Patients and Methods After obtaining the approval from research ethical committee of Ain Shams University and obtaining informed consent from patients the study was conducted in The Academic Institute for Cardiothoracic and Vascular Surgery, Ain Shams University hospitals. 30 adult patients scheduled for elective cardiac surgeries were enrolled in the study after being selected by random simple method. Results We used the TEE to visualize the CVC tip 3 cm above SVC-RA junction and use this actual depth to compare between the accuracy of the expected depth by C-length method and expected measured depth by surface landmarks method; we found out that the two methods were nearly the same to the actual depth guided by TEE. The mean ± SD surface landmarks distance was 142 ± 12 mm (range, 120 - 162 mm) and the mean ± SD by C-length was 128 ± 18 mm (range, 95 - 174 mm). The mean ± SD TEE-guided CVC length needed to place CVC tip at mid-SVC was140 ± 13 mm (range, 110 - 162 mm). Also in none of the patients was the CVC tip placed below the carinal level on postoperative plain AP chest x-ray. The CVC tip was placed at a mean ± SD height of 12 ± 2 mm (range, 5 to 16 mm) above the carinal line, which concludes that the mid SVC region lies above the carina level by 0.5-1.5 cm and it’s a reliable landmark for postoperative confirmation of optimum placement of CVC tip. Conclusion TEE can be used to effectively determine the proper fixed catheter insertion depth for a patient through the right internal jugular vein. This study showed that both C-length and surface landmarks methods are accurate to determine the depth of the central venous catheter in the mid SVC region (3-3.5 cm) above SVC-RA junction above pericardial reflection. Another conclusion is that the mid SVC region is above carinal level in all cases by 5 mm -15 mm. From this study we formulated two regression equations depending on the expected surface landmarks and C-length with an accuracy of ± 11.662 mm and ± 10.643 mm respectively.

Brachial Plexopathy Following High-Dose Melphalan and Autologous Peripheral Blood Stem Cell Transplantation for AL Amyloidosis

Brachial plexopathy (also known as neuralgic amyotrophy or Parsonage-Turner syndrome) is a rare, self-limited condition characterized by bilateral or unilateral shoulder pain followed by weakness. The pathogenesis is unknown, but is believed to be an immune-mediated disorder that is treated conservatively with analgesics and physical therapy (PT). It has been described following viral infections, surgeries, and immunosuppression. There has never been a reported case following high dose melphalan and stem cell transplantation (HDM/SCT) for immunoglobulin light chain (AL) amyloidosis.Here we report two cases of brachial plexopathy following HDM/SCT for AL amyloidosis. These cases were prospectively identified from a population of 42 patients who underwent HDM/SCT at Boston Medical Center between January 2014 and June 2017.The first patient was a 68-year-old woman with AL amyloidosis with renal involvement with a lambda clonal plasma cell dyscrasia. She was diagnosed with AL amyloidosis three months prior to HDM/SCT. She had no history of peripheral neuropathy or other neurologic disorder. Neutrophil engraftment post-SCT occurred on day +9. On day +12, she developed acute onset bilateral shoulder pain and weakness, left greater than right. Neurologic evaluation at the time was notable for 4/5 strength in the left deltoid, triceps, and biceps muscles. Sensation to pinprick was decreased on the dorsum of the left hand. Deep tendon reflexes were normal. These deficits were consistent with C5-8 motor and sensory dysfunction. Magnetic resonance imaging (MRI) of the cervical spine and brachial plexus and electromyography/nerve conduction study were consistent with bilateral brachial plexopathy. Doppler ultrasounds of the upper extremities were negative for deep venous thrombosis. Lyme disease and West Nile virus testing were negative. She began treatment with PT and her symptoms completely resolved at two years following HDM/SCT.The second patient was a 58-year-old woman with Waldenström's macroglobulinemia (WM) and associated AL amyloidosis with renal involvement with an underlying lambda clonal plasma cell dyscrasia. She was initially diagnosed with WM eight years prior to her diagnosis of AL amyloidosis. She received eight cycles of rituximab, cyclophosphamide, vincristine, and prednisone for treatment of WM, and then four cycles of rituximab, bortezomib, and dexamethasone after diagnosis of AL amyloidosis. She then underwent HDM/SCT. She had a history of lower extremity peripheral neuropathy secondary to prior treatments, but had no other neurologic symptoms. Neutrophil engraftment occurred on day +10 post-SCT. On day +13, she developed acute onset left shoulder pain and weakness. MRI of the cervical spine and left brachial plexus was consistent with brachial plexopathy. Her symptoms completely resolved by one year post-SCT with PT.These two cases of brachial plexopathy following HDM/SCT are, to our knowledge, the first reported cases in association with AL amyloidosis. Previously, a handful of cases of brachial plexopathy with similar time courses have been described after both autologous and allogeneic PBSCT in association with multiple myeloma, non-Hodgkin's lymphoma, myelodysplastic syndrome, diffuse large B-cell lymphoma, and multiple sclerosis.1-3 An autoimmune process has been postulated, especially given the known phenomenon of immune dysregulation following SCT with immune reconstitution. Direct trauma was not a contributing factor in these cases, and both patients had an internal jugular tunneled venous catheter on the right side. We conclude that brachial plexopathy is an uncommon, but potential early complication of HDM/SCT for AL amyloidosis that should be considered in patients with new onset shoulder pain or weakness. PT may be beneficial to patients with this self-limited disorder.

Comparison of dynamic needle tip positioning versus conventional long-axis in-plane techniques for ultrasound-guided internal jugular venous catheterization: a randomized controlled trial.

Continuous visualization of the needle tip is essential for successful ultrasound-guided central venous catheterization, and the dynamic needle tip positioning (DNTP) technique enables it. The aim of this randomized, dual-center trial was to compare the first-attempt success rate of ultrasound-guided internal jugular catheterization between the DNTP and conventional long-axis in-plane (LAX-IP) techniques. Patients undergoing cardiac surgery at two tertiary teaching hospitals were randomly allocated to either the DNTP or LAX-IP group. Internal jugular venous catheterization was performed by four anesthesiologists. The primary outcome was the first-attempt success rate of central venous catheterization. Procedural time and complications related to catheterization were compared as secondary outcomes. In total, 142 patients were analysed. The first-attempt success rate was significantly higher in the DNTP group (59/72, 81.9%) than in the LAX-IP group (46/70, 65.7%; odds ratio, 2.37; 95% confidence interval 1.09-5.15; P=0.028). In addition, the needle was redirected less frequently in the DNTP group than the LAX-IP group (P=0.026). Procedural time was comparable between the groups. No significant differences were observed in complications related to catheterization, including posterior wall puncture, carotid artery puncture, or hematoma. The DNTP technique resulted in a significantly higher success rate on the first attempt at internal jugular venous catheterization and required less frequent redirection of the needle during the procedure than the conventional LAX-IP technique.

Comparison of Peres' Formula and Radiological Landmark Formula for Optimal Depth of Insertion of Right Internal Jugular Venous Catheters.

BackgroundCentral venous catheterization is a vital procedure for volume resuscitation, infusion of drugs, and for central venous pressure monitoring in the perioperative period and intensive care unit (ICU). It is associated with position-related complications like arrhythmia's, thrombosis, tamponade, etc. Several methods are used to calculate the catheter insertion depth so as to prevent these position-related complications.ObjectiveTo compare Peres’ formula and radiological landmark formula for central venous catheter insertion depth through right internal jugular vein (IJV) by the anterior approach.Materials and methodsA total of 102 patients posted for elective cardiac surgery were selected and divided into two equal groups—Peres’ group (group P) and radiological landmark group (group R). Central venous catheterization of right IJV was done under ultrasound (USG) guidance. In group P, central venous catheter insertion depth was calculated as height (cm)/10. In group R, central venous catheter insertion depth was calculated by adding the distances from the puncture point to the right sternoclavicular joint and on chest X-ray the distance from the right sternoclavicular joint to carina. After insertion, the catheter tip position was confirmed using transesophageal echocardiography (TEE) in both the groups.ResultsAbout 49% of the catheters in group P and 74.5% in group R were positioned optimally as confirmed by TEE, which was statistically significant. No complications were observed in both the groups.ConclusionRadiological landmark formula is superior to Peres’ formula for measuring optimal depth of insertion of right internal jugular venous catheter.How to cite this articleManudeep AR, Manjula BP, Dinesh Kumar US. Comparison of Peres’ Formula and Radiological Landmark Formula for Optimal Depth of Insertion of Right Internal Jugular Venous Catheters. Indian J Crit Care Med 2020; 24(7):527–530.

Basics of Tunneled Dialysis Catheter Placement for Haemodialysis – Single Centre Experience

/non tunneled dialysis catheters or through arteriovenous fistulas/grafts. The tunneled dialysis catheters act as bridge dialysis devices during maturation period of arteriovenous fistulas/grafts and also serve as the last option for end stage renal disease patients who have exhausted all the other dialysis accesses. The aim and objective is to review the basic key concepts of internal Jugular, External Jugular and Subclavian tunneled venous catheter placement, techniques utilized, complications encountered, issues of suboptimal functioning and their management. Subjects and Methods: This was a prospective observational study done in department of Radio diagnosis, Narayana medical college, Nellore. About 54 cases were performed in our institution from December 2018 to Mar 2020 (including three pediatric patients). The age range of these patients is 10 to 75 years. Results: Out of 54 cases, one case had failed, as the guide wire didn’t pass across the brachiocephalic vein. Venogram revealed high grade stenosis of right brachiocephalic vein. There were major complications in two cases, minor complications in five cases with delayed complications in two cases. Conclusion: Tunneled catheters play a key role in serving as bridging devices during maturation of AVF/AVG or as the last option in chronic kidney disease patients in whom all other options have exhausted. Intervention radiologist should have good experience and an overall knowledge of the issues involved in placement of tunneled dialysis catheters, knowledge about the complications, technical issues of suboptimal functioning, for optimal catheter placement and also for improving catheter function.

Shallow-angle needle guide for ultrasound-guided internal jugular venous catheterization: A randomized controlled crossover simulation study (CONSORT).

Needle guides for ultrasound-guided internal jugular venous catheterization facilitate successful cannulation. The ability of a needle guide to prevent a posterior vein wall injury which may secondarily induce lethal complications, is unknown. Previous studies showed that a shallow angle of approach may reduce the incidence of posterior wall injuries. We developed a novel needle guide with a shallow angle of approach for ultrasound-guided venous catheterization and examined whether this needle guide reduces the incidence of posterior wall injuries compared to a conventional needle guide and free-hand placement in a simulated vein. This study was a randomized crossover-controlled trial. The primary outcome was the rate of posterior vein wall injuries. Participants had a didactic lecture about three ultrasound-guided techniques using the short-axis out-of-plane approach, including free-hand (P-free), a commercial needle guide (P-com), and a novel needle guide (P-sha). The view inside a simulated vein was recorded during venipuncture. Thirty-five residents participated in this study. Posterior vein wall injuries occurred in 66% using P-free, 60% using P-com, and 0% using P-sha (p< 0.01). There was no significant difference in the incidence of posterior vein wall injuries between P-free and P-com. Use of a shallow angle of approach needle guide resulted in a lower rate of posterior vein injuries during venipuncture of a simulated vein compared with other techniques using a steeper angle techniques.

Impact of the superior cavopulmonary anastomosis on cerebral oxygenation.

Patients with univentricular heart disease may undergo a superior cavopulmonary anastomosis, an operative intervention that raises cerebral venous pressure and impedance to cerebral venous return. The ability of infantile cerebral autoregulation to compensate for this is not well understood. We identified all patients undergoing a superior cavopulmonary anastomosis (cases) and compared metrics of cerebral oxygenation upon admission to the ICU with patients following repair of tetralogy of Fallot or arterial switch operation (controls). The primary endpoint was cerebral venous oxyhaemoglobin saturation measured from an internal jugular venous catheter. Other predictor variables included case-control assignment, age, weight, sex, ischemic times, arterial oxyhaemoglobin saturation, mean arterial blood pressure, and superior caval pressure. A total of 151 cases and 350 controls were identified. The first post-operative cerebral venous oxyhaemoglobin saturation was significantly lower following superior cavopulmonary anastomosis than in controls (44 ± 12 versus 59 ± 15%, p < 0.001), as was arterial oxyhaemoglobin saturation (81 ± 9 versus 98 ± 5%, p < 0.001). Cerebral venous oxyhaemoglobin saturation correlated poorly with superior caval pressure in both groups. When estimated by linear mixed effects model, arterial oxyhaemoglobin saturation was the primary determinant of central venous oxyhaemoglobin saturation in both groups (β = 0.79, p = 3 × 10-14); for every 1% point increase in arterial oxyhaemoglobin saturation, there was a 0.79% point increase in venous oxyhaemoglobin saturation. In this model, no other predictors were significant, including superior caval pressure and case-control assignment. Cerebral autoregulation appears to remain intact despite acute imposition of cerebral venous hypertension following superior cavopulmonary anastomosis. Following superior cavopulmonary anastomosis, cerebral venous oxyhaemoglobin saturation is primarily determined by arterial oxyhaemoglobin saturation.