Figure - available from: Frontiers in Pediatrics
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Anatomical identification of the internal jugular vein. (A) The vessel in short axis view in a newborn at term. Notice the diameters. IJV: internal jugular vein; ICA: internal carotic artery. (B) Notice how the vein collapses under a slight pressure, as oppose to the artery. (C) Doppler demonstrating the pulsatile flow in the artery. (D) Doppler demonstrating the laminar flow in the vein. Notice how the flow changes with the respiration.
Source publication
The correct choice of intra vascular access in critically ill neonates should be individualized depending on the type and duration of therapy, gestational and chronological age, weight and/or size, diagnosis, clinical status, and venous system patency. Accordingly, there is an ongoing demand for optimization of catheterization. Recently, the use of...
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The incidence of end-stage renal disease (ESRD) patients is increasing considerably worldwide, and most of the patients start their therapy by hemodialysis (HD). Arteriovenous fistula (AVF) is the best type of vascular access due to its decreased rate of complications followed by arteriovenous graft (AVG) and finally, central venous catheters which...
Citations
... These are small bore silicone or polyurethane catheters (1-2.7 Fr) which may sometimes not completely fulfill the need of a critical ill neonate [4]. In such cases, the placement of a large bore polyurethane catheter (3)(4) in the brachio-cephalic vein, subclavian vein, or internal jugular vein (centrally inserted central catheters = CICC) [4][5][6][7][8][9][10][11][12][13][14][15] or in the femoral vein (femorally inserted central catheter) [16] can be advisable. The emerging role of this new vascular access device in NICU has been also recently highlighted in the neonatal expert algorithm [17]. ...
... There is a growing evidence about the use of US-guided CICC insertion in newborn and infants [5,9,12,17,[24][25][26]; in particular, ultrasound-guided catheterization of the brachio-cephalic vein is currently seen as new standard for the care for critical ill neonates [17]. However, to be performed safely, CICC insertion requires a trained physician in US-guided venipuncture and a competent physician responsible for the administration of drugs for sedation. ...
Critically ill newborns admitted to Neonatal Intensive Care Unit often require a centrally inserted central catheters (CICCs) inserted by ultrasound-guided puncture of the internal jugular or brachio-cephalic vein. Achieving an appropriate level of sedation and analgesia is paramount for procedure success and patient safety, avoiding the potential risks associated with excessive deep sedation. The aim of this study is to evaluate the feasibility of a novel protocol of sedation. Data from 46 patients were prospectively collected. The feasibility was assessed throughout the monitoring of adverse events and the incidence of spontaneous movements. The procedure was completed in 100% of cases. There were no cases of escalation of the baseline ventilatory support despite the procedure and no case of hypotension, and all spontaneous movements were controlled with additional boluses when required.
Conclusion: Our study represents the very first step towards the design of a validated protocol for analgosedation during ultrasound-guided CICC insertion in NICU. What is Known:
• Critically ill newborns admitted to Neonatal Intensive Care Unit often require a centrally inserted central catheter.
• Achieving an appropriate level of sedation and analgesia is paramount for procedure success and patient safety, avoiding the potential risks associated with excessive deep sedation.
What is New:
• The use of this new protocol for analgosedation is able to achieve a good level of sedation and pain control without significant adverse event.
• Ultrasound-guided CICC insertion can be performed even in non-ventilated newborns.
... In addition, neonatologists' expertise in point-of-care ultrasound (POCUS) applications is growing [6]. POCUS techniques include ultrasound (US) guidance for intra-procedural real-time catheter's tip navigation and tip location during ECC, UVC, and CVC placement and post-procedural early recognition of secondary malposition due to tip migration [7]. To assess ECC, UVC, and CVC tips, standard chest and abdomen radiographs (X-ray) have some relevant limitations (e.g., relatively inaccurate and post-procedural methodology), whereas real-time US in experienced hands, using structured protocols such as the "Neo-ECHOTIP" protocol, have several potential advantages (e.g., accurate and intra-procedural methodology appropriate for both navigation and tip location of all CVADs used in NICU) [4]. ...
Background: Centrally inserted central catheters (CICCs) are increasingly used in neonatal care. CICCs have garnered attention and adoption owing to their advantageous features. Therefore, achieving clinical competence in ultrasound-guided CICC insertion in term and preterm infants is of paramount importance for neonatologists. A safe clinical training program should include theoretical teaching and clinical practice, simulation and supervised CICC insertions. Methods: We planned a training program for neonatologists for ultrasound-guided CICCs placement at our level III neonatal intensive care unit (NICU) in Modena, Italy. In this single-centre prospective observational study, we present the preliminary results of a 12-month training period. Two paediatric anaesthesiologists participated as trainers, and a multidisciplinary team was established for continuing education, consisting of neonatologists, nurses, and anaesthesiologists. We detail the features of our training program and present the modalities of CICC placement in newborns. Results: The success rate of procedures was 100%. In 80.5% of cases, the insertion was obtained at the first ultrasound-guided venipuncture. No procedure-related complications occurred in neonates (median gestational age 36 weeks, IQR 26–40; median birth weight 1200 g, IQR 622–2930). Three of the six neonatologists (50%) who participated in the clinical training program have achieved good clinical competence. One of them has acquired the necessary skills to in turn supervise other colleagues. Conclusions: Our ongoing clinical training program was safe and effective. Conducting the program within the NICU contributes to the implementation of medical and nursing skills of the entire staff.
... In addition, monitoring of central venous pressure and pulmonary artery pressure is accomplished via central veins. [2] The indirect measurement of venous pressure (VP) by the physical examination of blood arteries in the neck is one of the most important components of assessment, but it is not without its problems. The jugular vein is difcult to palpate in more than 20% of patients; hence, measures of normal, low, and high levels of VP are erroneous, particularly in critically ill patients. ...
... Consequently, the direct assessment of VP is frequently necessary for patients with hemodynamic instability and those undergoing major surgery. [2,3] On the other hand, the use of central venous cannulation can be associated with adverse effects that are both hazardous to patients and can increase costs. Mechanical complications have been observed in 5% to 9% of patients, infectious complications in 5% to 26%, and thrombotic complications in 2% to 26% of patients. ...
In surgery, the implantation of a central venous catheter through the internal jugular or subclavian vein is crucial.[1] Typically, uids, blood, or inotropic medications are delivered through the catheter's numerous passageways. In addition, monitoring of central venous pressure and pulmonary artery pressure is accomplished via central veins. [2] The indirect measurement of venous pressure (VP) by the physical examination of blood arteries in the neck is one of the most important components of assessment, but it is not without its problems. The jugular vein is difcult to palpate in more than 20% of patients; hence, measures of normal, low, and high levels of VP are erroneous, particularly in critically ill patients. [3] These difculties also occur in individuals who are scheduled for surgery; sometimes, even dramatic changes in VP are not identied. Consequently, the direct assessment of VP is frequently necessary for patients with hemodynamic instability and those undergoing major surgery. [2,3]
... The subclavian vein is a continuation of the axillary vein [6]. The axillary vein is a continuation of the Brachial vein. ...
... The extra thoracic segment of the subclavian vein lies on top of the first rib. The extra-thoracic part ends at the medial margin of the fisrt rib [6,7]. The extra thoracic segment continues from the medial margin of the first rib till it joins the internal jugular vein to form the Brachiocephalic vein. ...
... The extra thoracic segment continues from the medial margin of the first rib till it joins the internal jugular vein to form the Brachiocephalic vein. The left and right brachiocephalic vein join at the conference of Pirogoff to form the superior vena cana [6,7]. The brachiocephalic veins also called innominate veins. ...
The success of any trans-venous procedure involves the rate liming step, which is the access. The procedure cannot be performed without the access site. It is the key that open the success of the procedure. There are many procedures that require extra-thoracic subclavian vein. These procedures may include: central venous pressure monitoring, administration of multiple medications and drips, high volume/flow resuscitation, emergency venous access, inability to obtain peripheral venous access, repetitive blood sampling, administering hyperalimentation, vasopressors, caustic agents, or other concentrated fluids; insertion of transvenous cardiac pacemakers, hemodialysis or plasmapheresis and insertion of pulmonary artery catheters. In this review, we discuss the various techniques of accessing the vein and it tips and tricks..
... 6. In the paper by Van Rens et al. [3], the authors do not consider the use of ultrasound-guided central VADs, which represents probably the most important novelty in the care of critically ill neonates [6,7,[9][10][11][12][13][14][15][16]. ...
... Giovanni Barone 1 · Vito D'Andrea 2 · Gina Ancora 1 · Francesco Cresi 3 · Luca Maggio 4 · Antonella Capasso 5 · Rossella Mastroianni 6 · Nicola Pozzi 7 · Carmen Rodriguez-Perez 8 · Maria Grazia Romitti 9 · Francesca Tota 10 · Ferdinando Spagnuolo 11 ...
In most NICUs, the choice of the venous access device currently relies upon the operator's experience and preferences. However, considering the high failure rate of vascular devices in the neonatal population, such clinical choice has a critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems in line with the current scientific evidence. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in the neonatal population. After a systematic review of the available evidence, the panel of the consensus (which included Italian neonatologists specifically experts in this area) has provided structured recommendations answering four sets of questions regarding (1) umbilical venous catheters, (2) peripheral cannulas, (3) epicutaneo-cava catheters, and (4) ultrasound-guided centrally and femorally inserted central catheters. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice. Conclusion: The goal of the present consensus is to offer a systematic set of recommendations on the choice of the most appropriate vascular access device in Neonatal Intensive Care Unit.
... Tunnelling is a powerful technical tool for obtaining the best exit site independently from the venepuncture site. A good example of its usefulness is the insertion of ultrasound guided CICCs in neonates, where the brachiocephalic vein (BCV) represents the safest and easiest access to the central veins, as has been proven by several papers [44][45][46][47][48][49][50][51]; however, when the BVC is used for the cannulation, it is mandatory to tunnel the catheter in order to move the exit site into the infraclavicular area, which is more stable and has cleaner skin [26]. This technique can be used in virtually any central CVCs as long as a modified Seldinger technique is used for the placement of the device. ...
Unlabelled:
Dialkylcarbamoylchloride dressing is a fatty acid derivative that has been shown in vitro to bind a number of pathogenic microorganisms. The purpose of this prospective study was to evaluate the safety and the efficacy of this technology in the care of the exit site of central venous catheter in a paediatric and neonatal population.
Methods:
The study was conducted from September 2020 to December 2022 at the Infermi Hospital in Rimini. Central venous catheters were placed using the SIC bundle for insertion. Dialkylcarbamoylchloride dressing was placed below the subcutaneous anchoring at the time of CVC placement and at each dressing change. Data about the catheters and the exit site were recorded and then compared with an historical cohort.
Results:
118 catheters were placed during the studied period. The dialkylcarbamoylchloride dressing was well-tolerated. No case of systemic or local infection was recorded. The comparison with the historical cohort showed a reduction in the rate of exit site infection (p value 0.03).
Conclusion:
Dialkylcarbamoylchloride dressing is well-tolerated in paediatric and neonatal population. It represents a promising tool as a strategy for infection prevention.
... They can be placed even in preterm infants by ultrasound-guided puncture of the internal jugular vein or brachio-cephalic vein (centrally inserted central catheter or CICC) or femoral vein (femorally inserted central catheter or FICC) (1, 2); they are power-injectable 3-4Fr polyurethane catheters. Ultrasound-guided placement of CICC and FICC is feasible at any gestational age and birth weight (3)(4)(5)(6)(7), but is a painful procedure and it's mandatory to keep the babies still at the time of the venipunture in order to ensure the safety of the patients. Furthermore, pain has negative long-term neurodevelopmental consequences, such as cognitive impairment, learning disabilities, attention deficits, behavioral problems and motor abnormalities (8,9). ...
Centrally inserted central catheters (CICCs) are placed by ultrasound guided puncture of the internal jugular or brachio-cephalic vein. It is crucial to achieve a good level of sedation and analgesia in order to keep the babies still thus reducing the risk of procedural failure. The aim of this study is to evaluate the efficacy of the combination of ketamine and fentanyl during the CICC placement procedure. We retrospectively collected data from 72 infants who underwent CICC insertion after sedation with KetaFent protocol. The primary outcome was to assess the success of the procedure defined as CICC placement. Secondary outcome was intubation during the procedure in non-ventilated infants (noninvasive ventilation or spontaneous respiration), need for repeat doses of study medications to complete the procedure, time to complete the procedure, the level of analgesia assessed using vital parameters. The procedure was completed in 100% of cases. There were no cases of hypotension during and at the end of the procedure. No intubation was performed on non-ventilated infants. The combination of ketamine and fentanyl for sedation and analgesia in infants requiring insertion of a CICC is 100% successful. It is associated with a low risk of side effect like apnea and intubation. Insertion of a central venous catheter is a painful procedure for infants. Adequate sedation is mandatory to keep the baby still thus reducing the risk of procedural failure.
... The subclavian vein is a continuation of the axillary vein [6]. The axillary vein is a continuation of the Brachial vein. ...
... The extra thoracic segment of the subclavian vein lies on top of the first rib. The extra-thoracic part ends at the medial margin of the fisrt rib [6,7]. The extra thoracic segment continues from the medial margin of the first rib till it joins the internal jugular vein to form the Brachiocephalic vein. ...
... The extra thoracic segment continues from the medial margin of the first rib till it joins the internal jugular vein to form the Brachiocephalic vein. The left and right brachiocephalic vein join at the conference of Pirogoff to form the superior vena cana [6,7]. The brachiocephalic veins also called innominate veins. ...
Citation: Edafe EA, Sotonye D-MT. Extra-thoracic subclavian vein access: The tips and tricks. Med Clin Sci.
... La exploración con US en la fosa supraclavicular permite la visualización de tal confluencia venosa en el eje largo de la vena y permitirá más cómodamente la punción en el plano de esta, como ventaja adicional se puede observar muy bien el avance de la guía y su correcta dirección hacia VCS (Figura 4A). Existe numerosa evidencia que demuestra el uso de esta técnica de punción en niños y neonatos (inclusive de muy bajo peso) con un éxito superior al 95%, una tasa de complicaciones baja y una curva de aprendizaje rápida [12]. Además, ha demostrado mejores resultados al primer intento que la punción de la VYI [13]. ...
... This procedure is performed in the newborn intensive care unit (NICU) and pediatric intensive care unit (PICU) on a daily basis (3). The correct choice of intravenous access depends on the type and duration of treatment, gestational age, weight, diagnosis, clinical condition, and the state of the patient's venous system (4,5). ...
Objectives
Ultrasound is currently utilized to locate the internal jugular vein (IJV), reduce the complications of catheter placement, and increase the likelihood of accessing IJV. Therefore, the aim of the present study was to evaluate the effectiveness of ultrasound in reducing complications during catheter placement in children weighing less than 5 kg.
Materials and methods
The current randomized clinical trial was performed on 111 children weighing less than 5 kg who required a central venous catheter (CVC). Children were divided into two groups: in the first group (Seldinger group; n = 55), a CVC was inserted using the Seldinger wire method under ultrasound guidance, and in the second group (open surgical cutdown (OSC); n = 56), the catheter was inserted via the open method. Two weeks after catheter placement, patients were evaluated for thrombosis, catheter occlusion, catheter tip migration, infection, catheter removal, and catheter dysfunction.
Results
The success rate of catheter placement in the ultrasound-guided method was 85.5%. The incidence of thrombosis (3.6% vs. 5.4%), infection (1.8% vs. 7.4%), and bleeding (zero vs. 3.6%) was lower in the Seldinger group, but the difference was not significant (p ˃ 0.05). Hematoma (7.3% vs. 3.6%) occurred less frequently in the patients of the OSC group (p = 0.33). Hemothorax, pneumothorax, catheter migration, and occlusion did not occur in any of the patients. In the OSC group, two deaths (3.6%) occurred due to underlying diseases.
Conclusion
When ultrasound is used to insert a CVC in children weighing less than 5 kg, the incidence of complications is not significantly different compared to when the open method is employed.
