DISCUSSION prospective, randomized, observational study conducted on

DISCUSSION A central venous catheter is usually inserted into the, internal jugular, subclavian vein or femoral vein. There are both advantages and disadvantages at each puncture site. Therefore, choosing a puncture site depends on the purpose of the central venous catheter. Since 2002, the use of ultrasound guidance for central vein catheterization into the IJV has been recommended for children by the United Kingdom National Institute for Clinical Excellence 19. This study focused on IJV catheterization for several reasons. In the IJV approach, the carotid artery pulse can be easily seen by ultrasound, thus preventing arterial puncture. In addition, the IJV is located close to the skin and is therefore easy to compress by ultrasound 47Present study was prospective, randomized, observational study conducted on 100 patients admitted for cardiac surgery at a tertiary care hospital.

The aim of study was to compare central venous cannulation in pediatric cardiac patients using ultrasound versus landmark technique. Patients were chosen on the basis of previously mentioned eligibility criteria requiring IJV cannulation for undergoing cardiac surgery. The analysis of data was done by comparing ultrasound guided (Group1) cannulation of IJV with landmark technique(Group 2).

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Comparison was done on basis of time taken for IJV cannulation (time from the moment of needle insertion through the skin to the time at which guide wire will be successfully placed within IJV), success rate, number of attempts, complications if any ,arterial puncture ,pneumothorax or hematoma. The cannulation was done by pediatric anesthesiologist who had done more than 50 IJV cannulation by both ultrasound and landmark technique . The median age was 17.5 months (Range: 2 – 144 months) and 21.

0 months (Range: 3 – 120 months) in group 1 and group 2 respectively. Majority of patients were in age group between 2 months-90 months, only 4 patients above 90 months .Also majority of patients were male (60%) and female (40%). In this study, IJV cannulation was possible in all of the 50 (100%) patients in ultrasound group and 46 (92%) in landmark group in this study which is comparable to other studies.

In study of Verghese et al ultrasound-guided catheterization of the IJV was successful in all 43 (100%) infants in the ultrasound group and in 40 of 52 (77%) infants in the landmarks group11. In another study, they also 49 have demonstrated a significantly lower catheterization time and the reduced incidence of carotid artery punctures in infants and children when using the ultrasound technique as compared with the landmark technique. In. Chuan WX et al. study, success rate with ultrasound technique was 100% and with landmark technique was 80% 48 However, study of Grebenik CR et al.

show there is insufficient evidence to support the use of ultrasound-guided catheterization 50  Meta-analysis of Sigaut S et al. in children and infants has shown that ultrasound-guided catheterization has had no effect on the failure rate or incidence of complications as compared with the anatomical landmark technique51Central venous catheterization is more difficult in pediatric patients than in adult patients due to the smaller dimensions of the IJV in infants and children, particularly the size of its diameter. As a result, more insertion attempts are required before successful catheterization can be performed in pediatric patients, and as the number of insertion attempts increases, risk of complications such as carotid artery puncture increases. Although the vascular anatomy of infants has been assessed in only a few studies, study of Cobb LM, et al. and Steinberg Cet al.

demostrated that cervical vessel anatomy in children is more variable than in adults53,54. Thus, the major advantage of the ultrasound-guided technique is its ability to provide a visual of the structures at the puncture site before catheterization is attempted. Ultrasound also allows for the confirmation of anatomical variations related to the IJV-carotid artery relationship. The IJV is located lateral to the carotid artery. The incidence of a posteriorly located carotid artery, which predisposes the patient to accidental carotid artery puncture if the needle transverses the internal jugular vein, has been reported to be as high as 54% 15 There was significant difference in the insertion of catheter on the first attempt, in 36 (72.0%) patients in the group 1 and 24 (48.0%) patients in the group 2 (p-value = 0.

014*). A difference of 24.0% (95% CI 4.8% to 43.2%) was observed which was not significant .

On subsequent attempts also that is 2,3and 4 attempt there was difference but not significant between two groups .In study of Bikash R Ray et al.of IJV cannulation which was comparison of three techniques by anatomical landmark (AL) ,prelocation of IJVwith ultrasound (USG PL ) and ultrasound-guided real-time imaging (USG RT) which included patients aged 15-65 years and 40 in each group. Insertion of catheter with first attempt with AL group was 62.

5% ,with USG PL group75% and with USG RT group 77.5%.Findings of ultrasound group in this study is comparable with our group but landmark group have higher successful rate on first attempt in this study as age group is15-65 years and anatomical landmark are more prominent in adults than our study of pedriatic group 56A successful cannulation in this study was 4 or less than 4 attempts ,after more than 4 attempts other technique was used for central line access.  Most of the studies have not specified the definition of successful cannulation, and it varied from <3 attempts without carotid artery puncture to <7 attempts and some investigators have defined it as access time less than 4 minutes.

48,55 . In our study, when cannulation failed after 4 attempts in landmark group, in 2 children ultrasound guided cannulation was done which was successful and in other2 children subclavian vein was cannulated. The average number of attempts resulting in successful insertion was 1.40 for the Group 1 and 1.

56 for Group 2 in this study which was significant. In study of Eu Jeen Yang et al. average number of attempts for successful insertion with ultrasound technique was 1.57±0.3457 .

Verghese et al. have explained the mean number cannulation attempts with the ultrasound-guided technique (1.3±0.6) was also significantly less than with the landmarks method (3.3±2.8) (P<0.

0001) which was comparable to our stdy11. Such results were directly related to the practitioner’s experience, hand skill, and sample size, all potential confounding factors. The mean time of cannulation of IJV(access time) for the Group 1 was 189 seconds( SD 153) seconds, median (171 seconds); for Group 2, it was 265 seconds(SD 148) seconds, median (208 seconds),(p value .016) which is statistically significant (p-value ; 0.

05) In study of Verghese et al, cannulation time with ultrasound group was 4.2±2.8 minutes and with the landmarks technique was 14.0±15.

1 minutes .In study of Eu Jeen Yang et al. cannulation time with ultrasound technique was 14.07±1.

91 minutes which was more than our study (189 s) . However, meta-analysis found ultrasound guidance to have no influence over the access time as compared to with traditional techniques 51. Since the ultrasound-guided technique requires some preparation time for anatomical screening and equipment preparation, ultrasound-guided central venous catheterization can take more time in practice. As the mean time of cannulation measured in this study with ultrasound was significantly less compared to landmark group, it is clear that ultrasound-guided central venous catheterization is rapid and reliable enough to secure venous access in paedriatric patients also.

The most common complication of central venous catheterization is an arterial puncture or hematoma. In our study, then incidence of carotid artery puncture was (2%) with ultrasound technique (Group 1) as compared to 5 (10%) in landmark technique (Group2) .In study of Bulent Karapinar and Alphan Cura of Complications of central venous catheterization in critically ill children58.

They compared complications in internal juglae vein, femoral vein and subclavian veins. Overall success catherization rate was 92.4%. The success rate was significantly lower in younger patients with subclavian catheterization. Insertion-related complications were noted, including 33 arterial punctures (8.9%), 27 cases of malposition (7.

3%), 19 hematomas (5.2%), 12 cases of minor bleeding (3.3%), and 3 cases of pneumothorax (0.8%), and they were more common in the subclavian vein than in the internal jugular and femoral vein. Complications during IJV cannulation out of 84 children by landmark technique; arterial puncture 6(7.1%), hematomas 5(6%) and no case of pneumothorax which is comparable to our study.

They also concluded that multiple attempts and failed attempts significantly correlated with higher incidence of complications. The incidence of carotid puncture punctures in study of Verghese et al. in the landmarks group was 25%, and no punctures occurred in the ultrasound group (P ; 0.000002). Of the 13 infants sustaining carotid punctures in the landmarks group, seven were younger than 3 months .

In study of Eu Jeen Yang et al. there was one case of arterial puncture out of 44 patients (2.3%) by ultrasound technique. The number of arterial punctures were less in ultrasound group in our study ( 2%) because ultrasound guidance allowed for the visualization and distinction of the patients’ arteries and veins. In the Group 1, there were 6 (12.0%) hematomas and 1 (2.

0%) hemothorax. In the Group 2, there were 11 (22.0%) hematomas, and no cases of hemothorax. More cases of haematomas in Group 2 because no of attempts and carotid puncture were more in this group as concluded by studyof Bulent Karapinar and Alphan Cura. No patient developed pneumothorax in the entire study in both Groups. DISCUSSION REFERENCE Kim KO, Jo JY, Oh AY, Kim HS, Kim CS.

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Anesthesiology 1996;85:1078.Grebenik CR, Boyce A, Sinclair ME, Evans RD, Mason DG, Martin B. NICE guidelines for central venous catheterization in children. Is the evidence base sufficient? Br J Anaesth 2004;92:827-Sigaut S, Skhiri A, Stany I, Golmar J, Nivoche Y, Constant I, et al. Ultrasound guided internal jugular vein access in children and infant: a meta-analysis of published studies. Paediatr Anaesth 2009;19:1199-206.

Sayin MM, Mercan A, Koner O, Ture H, Celebi S, Sozubir S, etal. Internal jugular vein diameter in pediatric patients: are the J-shaped guidewire diameters bigger than internal jugular vein? An evaluation with ultrasound. Paediatr Anaesth 2008;18:745-51Cobb LM, Vinocur CD, Wagner CW, Weintraub WH. The central venous anatomy in infants.

Surg Gynecol Obstet 1987;165:230-4. Steinberg C, Weinstock DJ, Gold JP, Notterman DA. Measurements of central blood vessels in infants and children: normal values.

Cathet Cardiovasc Diagn 1992;27:197-201. Hayashi H, Amano M. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Prospective randomized comparison with landmark-guided puncture in ventilated patients. J Cardiothorac Vasc Anesth. 2002;16:572–5.Bikash R Ray,  HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Mohan%20VK%5BAuthor%5D&cauthor=true&cauthor_uid=24106363” Virender K Mohan,  HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Kashyap%20L%5BAuthor%5D&cauthor=true&cauthor_uid=24106363” Lokesh Kashyap,  HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Shende%20D%5BAuthor%5D&cauthor=true&cauthor_uid=24106363” Dilip Shende,  HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Darlong%20VM%5BAuthor%5D&cauthor=true&cauthor_uid=24106363” Vanlal M Darlong, and  HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Pandey%20RK%5BAuthor%5D&cauthor=true&cauthor_uid=24106363” Ravindra K Pandey,Journal of Anaesthesiology Clinical Pharmocology2013Eu Jeen Yang, MD, Hyeong Seok Ha, MD, Young Hwa Kong, MD, Sun Jun Kim, MD Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea.Bulent Karapinar And Alphan Cura, Pediatric Intensive Care Unit, Ege University Faculty of Medicine, Izmir, Turkey, Pediatrics International (2007) 49, 593–599

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