US Vascular Access

Introduction

Ultrasound-guided central venous cannulation in children

In neonates, infants and young children central venous catheters are of vital importance during surgery as well as postoperative care. The benefit of ultrasonography seems to be very important for vascular access of the internal jugular (IJV), subclavian (SCV), brachiocephalic (BCV) and femoral vein (FV). Ultrasonography enables the view of structures below the skin surface. In addition to the location of the vein and the determination of its patency prior to the puncture it makes the cannulation procedure visible to the operator under real time control. At that complications e.g. wrong guide wire migration, pneumothorax and pericardial effusion can be diagnosed quickly. Ultrasound-guided cannulations have been described in children for the IJV, infraclavicular approach to the SCV , supraclavicular approach to the SCV/BCV and FV. Studies comparing the landmark vs. ultrasound-guided technique only exist for the IJV and FV. All in all they show a clear trend in favour of the ultrasound-guided technique in terms of a higher and quicker success and lower complication rate.

This presentation is to demonstrate the current practice of the ultrasound-guided cannulation of the IJV, infraclavicular approach to the SCV , supraclavicular approach to the SCV/BCV and FV in children in terms of the sonoanatomy, cannulation technique and expert opinion including figues and videoclips.

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Brachiocephalic vein

veins1

Sono-Anatomy BCV

By placing the US (ultrasound) probe perpendicular to the skin at the level of the cricoid cartilage a cross-sectional view of the internal jugular vein (IJV) is obtained. The probe is then moved caudally following the IJV until the junction of the subclavian vein (SCV) and IJV is reached. After that the probe is tilted slightly medially and caudally until a good longitudinal view of the brachiocephalic vein (BCV) beginning at the junction of the IJV and SCV is obtained (BCV-Figure 1, see below).

 fig 1_BCV
22-gauge i.v. cannula (Abbocath) within the left BCV of a 3 kg infant. Small picture: Right-handed operator maneuvering the i.v.cannula without attached syringe 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.

Technique BCV

Children are placed in a light head-down position. A standard sized towel roll is placed under the shoulders. The patient’s head is turned 45° to the side opposite to the cannulation (BCV-Clip 2).

The operator positions himself next to the left side of the child’s body while facing the head of the patient when attempting to cannulate the left brachiocephalic vein (BCV). The ultrasound (US) screen is placed next to the infant’s head on the left hand side. This enables an almost concomitant view of both the patient’s anatomy as well as the US image while holding the US probe in the one hand and maneuvering the needle or i.v. cannula without attached syringe with the other hand. For the cannulation of the right BCV the operator is positioned at the child’s head while facing the body of the patient and the US screen is placed next to the right side of the infant’s body.  An US device with a 13-6 MHz, 25-mm broadband linear array transducer (M-Turbo, Sonosite, Inc., Botholl, WA, USA) and a depth of 1.9 cm can be used. Depending on the operator’s preference a 4 cm 21-gauge needle (Arrow; Arrow international, Inc.; Reading, PA) or 32 mm, 22-gauge i.v. cannula (Abbocath; Arnsino Medical (Shanghai) Co., Ltd; Shanghai, China) or 25 mm, 22-gauge i.v. cannula (Jelco; Smiths Medical International Ltd, Rossendale, Lancashire, UK) are chosen. The US probe is placed in the supraclavicular region so as to obtain a good longitudinal view of the BCV (BCV-Figure 1xxx) (1). Using a strict in-plane technique the needle or i.v. cannula is then guided from lateral to medial under direct US vision into the BCV (BCV fig.1xxx, BCV-clip 1xxx,  BCV-clip 2xxx, BCV-clip3xxx). If there is a good spontaneous return of blood flow via the needle the US probe is withdrawn and a J-shaped 0.018 inch (0.46 mm) guide-wire (Arrow or Cook inc.; Bloomington, In, USA) is introduced into the vein. In the case of an i.v. cannula the needle is withdrawn as soon as a spontaneous return of blood flow is noted and the cannula advanced over the needle into the vein. If according to the US image the tip of the needle or i.v. cannula is believed to be inside the vein without a spontaneous return of blood flow, a syringe is attached in order to try to aspirate blood while slowly withdrawing the needle or i.v. cannula. After successful blood aspiration the guide-wire is introduced into the vein. If blood cannot be aspirated the US probe is replaced and the tip of the needle is redirected into the vein under direct US vision. Finally a 2-French single lumen catheter (Seldiflex; Plastimed; Saint-Leu-La-Foret, France) or 4-French double lumen catheter (Arrow) is threaded into the vein via the guide-wire and fixed on the patients’ shoulder.

Expert Opinion BCV

It cannot always be clearly distinguished whether it is the BCV or in fact the SCV which is being punctured via this access (2). However, clinically it does not matter as the puncture of any of these veins at this site provides a rather direct line to the superior caval vein. Both veins are fixed to the clavipectoral fascia avoiding anterior vessel wall collapse under the pressure of the approaching needle. It seems to be easier to cannulate the left BCV. This could be related to the different anatomy (3). The right BCV is in most cases much shorter than the left one. The right BCV also quickly takes a sharp angled, caudad turn whereas the left one runs first in a significantly less caudally directed, more horizontal way (BCV-Figure 2, 3xxx).

BCV-Figure 2

fig 2_BCV
BCV-Figure 3

fig 3_BCV

Both the usually shorter distance as well as the sharp angled, caudally orientated right BCV could explain its more difficult ultrasonographic imaging in the longitudinal axis (BCV-Figure 2,3xxx) . Delineating the longitudinal axis of these veins via US requires a slightly more caudally orientated US probe placement for the right BCV (BCV-Figure 2, 3xxx). This apparently makes a good view of the needle advancement in the in-plane technique more difficult for the right BCV above all in neonates. In addition the left BCV is apparently larger than the right one in preterm babies (4). The major advantage of the supraclavicular in-plane technique is the view of the advancing needle over more or less its entire distance and directing it under real time US control into the longitudinally imaged BCV without any disturbing US shadow caused by the clavicle (1, 2).

The major disadvantages of this method is that the in-plane technique requires that the needle be located inside a 1-mm longitudinal area (1). This necessitates excellent hand-eye coordination which may be even more difficult for the right BCV due to the slightly more caudally orientated US probe placement.

Literature BCV

  • Breschan C, Platzer M, Jost R, et al. Ultrasound-guided Supraclavicular Approach to the Brachiocephalic Vein in Children: a Consecutive, Prospective Case Series of a New Method. Br J Anaesth 2011; 106: 732 – 7
  • Rhondali O, Attof R, Combet S, et al. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Pediatr Anesth 2011; 21: 1136 – 41
  • Breschan C, Platzer M, Jost R, et al. Ultrasound-guided Supraclavicular Cannulation of the Brachiocephalic Vein in Infants: a Retrospective Analysis of a Case Series. Pediatr Anesth 2012; 22: 1062-67
  • Eifinger F, Brisken B, Roth B, et al. Topographical Anatomy of Central

Subclavian Vein

veins1

Sono-Anatomy SCV

By placing the US (ultrasound) probe perpendicular to the skin at the level of the cricoid cartilage a cross-sectional view of the internal jugular vein (IJV) is obtained. The probe is then moved caudally following the IJV until the junction of the subclavian vein (SCV) and IJV is reached. After that the probe is tilted slightly laterally across the clavicle until a good longitudinal view of the subclavian vein (BCV) beginning at the US shadow of the clavicle to the junction of the IJV and SCV is obtained (SCV-Figure 1) (SCV-Clip1)

Technique SCV

Children are placed in a light head-down position. A standard sized towel roll is placed under the shoulders. The patient’s head is turned slightly to the side opposite to the cannulation. Positioning should enable the operator to see the entire US picture and the patient’s landmarks. Linear US probes are to be preferred. The US unit is settled on its highest resolution with a depth of 1.9 cm. Depending on the operator’s preference a 4 cm 21-gauge needle (Arrow; Arrow international, Inc.; Reading, PA) or 32 mm, 22-gauge i.v. cannula (Abbocath; Arnsino Medical (Shanghai) Co., Ltd; Shanghai, China) or 25 mm, 22-gauge i.v. cannula (Jelco; Smiths Medical International Ltd, Rossendale, Lancashire, UK) can be chosen. The i.v. cannula is slightly bent in its centre. The US probe is placed in the supraclavicular region so as to obtain a good longitudinal view of the SCV (SCV-Figure 1). The US probe is held in the one hand while the needle or i.v. cannula without attached syringe is maneuvered with the other hand. Using a strict in-plane technique the needle or i.v. cannula pierces the skin at the infraclavicular region (1). It is then guided from lateral to medial under direct US vision into the SCV (SCV-Figure 1; SCV-Clip 2). If there is a good spontaneous return of blood flow via the needle the US probe is withdrawn and a J-shaped 0.018 inch (0.46 mm) guide-wire (Arrow or Cook inc.; Bloomington, In, USA) is introduced into the vein. In the case of an i.v. cannula the needle is withdrawn as soon as a spontaneous return of blood flow is noted and the cannula advanced over the needle into the vein. If according to the US image the tip of the needle or i.v. cannula is believed to be inside the vein without a spontaneous return of blood flow, a syringe is attached in order to try to aspirate blood while slowly withdrawing the needle or i.v. cannula. After successful blood aspiration the guide-wire is introduced into the vein. If blood cannot be aspirated the US probe is replaced and the tip of the needle is redirected into the vein under direct US vision. Finally a 2-French single lumen catheter (Seldiflex; Plastimed; Saint-Leu-La-Foret, France) or 4-French double lumen catheter (Arrow) is threaded into the vein via the guide-wire and fixed on the patients’ shoulder.

Expert Opinion SCV

The SCV is fixed to the clavipectoral fascia avoiding anterior vessel wall collapse under the pressure of the approaching needle. In infants the SCV runs more cephalad than in older children having a nearly extrathoracic position before reaching the brachiocephalic vein (2). The whole length is therefore more easily visualised by US. Moreover the place where the SCV passes over the first rib has been identified as a safe spot for its cannulation (3). At that place, the first rib protects the lung from accidental puncture and from this place on the subclavian artery passes behind the anterior scalene muscle whereas the vein remains in front of it. The major disadvantage of this technique is that needle or i.v. cannula cannot be imaged via US while it is advanced under the clavicle due to the US shadow caused by the clavicle.

Literature SCV

  1. Pirotte T, Veyckemans F. Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. Br J Anaesth 2007 Apr;98(4):509-14.
  2. Groff DB, Ahmed N. Subclavian vein catheterization in the infant. J Pediatr Surg1974 Apr;9(2):171-4.
  3. Cobb LM, Vinocur CD, Wagner CW, Weintraub WH. The central venous anatomy in infants. Surg Gynecol Obstet 1987 Sep;165(3):230-4.

Jugular vein

Available soon…