Letters to Editor Page | 141
A simple technique to avoid difficulty in guide wire insertion during pediatric central venous cannulation Sir, Percutaneous central venous cannulation (CVC) using Seldinger technique is a routinely performed procedure both in the operation theatre and intensive care unit. But a frequently encountered problem particularly during pediatric CVC is displacement of introducer needle (after localization of vein) before or during insertion of J-tip guide wire. Here we describe a simple technique to avoid this problem. A 2-year 9-kg child was scheduled to undergo resection of a parieto-temporal glioma under general anesthesia (GA). In our patient, we tried an ultrasonography (USG) guided right internal jugular vein (IJV) cannulation under GA with a 5 Fr triple lumen central venous catheter (Certifix Trio® B. Braun, Melsungen AG). Venous puncture and introducer needle placement was made in first attempt, but in spite of our best efforts we were unable to introduce the guide wire into the IJV due to the frequent displacement of the introducer needle either during detachment of the syringe or during introduction of guide wire. So we used a 22G intravenous cannula (IC) instead of the introducer needle for IJV cannulation and after locating the IJV under USG guidance we passed the total length of sheath of the IC into IJV and withdrew its stylet. However, as there was difficulty in passage of the guide wire into the IC sheath through its curve end we had to introduce the guide wire through its straight end [Figure 1] very gently keeping
a close watch on the electrocardiogram (ECG). We are now following this technique routinely for all pediatric IJV cannulations (using 22G and 24G IC in infants and neonates respectively) with 100% first attempt successful placement of the guide wire and the central venous catheter without any complication. Use of USG is now considered as a standard of care for IJV cannulation.[1] Real-time US guidance has been shown to improve the technical efficiency and efficacy of internal jugular venous and has also decreased the frequency of procedure related complications.[2] We agree that use of USG has advantage in terms of identification of the local anatomy, but our problem of displacement of introducer needle persisted in spite of use of USG. So we used the IC to deal with the problem. However, there are two problems with our techniques. First, there is chance of distortion of the IVC sheath during guide wire insertion which can cause extra-vascular migration of the IC sheath (especially during use of smaller IC) and secondly, there is chance of injury to the surrounding structures during introduction of straight end of the guide wire. However, the advancement of sheath of IC completely into the central vein will prevent the distortion and/or extra-vascular migration of the IVC sheath[3] and we introduced the guide wire very gently keeping a close watch on ECG so as to avoid injury to the surrounding structures during guide wire insertion. Our report highlights a common problem encountered during USG guided pediatric IJV cannulation and a simple technique to deal with it. Surya Kumar Dube, Arvind Chaturvedi Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Arvind Chaturvedi, Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi - 110 029, India. E-mail: [email protected]
REFERENCES Figure 1: Sheath of 22G intravenous catheter (with straight end of J tip guide wire) inside right internal jugular vein
Saudi Journal of Anesthesia
1.
Milling TJ Jr, Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove JJ, et al. Randomized, controlled clinical trial of
Vol. 8, Issue 1, January-March 2014
Letters to Editor Page | 142
2. 3.
point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med 2005;33:1764-9. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72:823-6. Nakayama S, Takahashi S, Toyooka H. Curved-end guidewire for central venous cannulation in neonate. Anesth Analg 2003;97:917-8.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.125980
Anatomical variations of interscalene brachial plexus block: Do they really matter? Sir, Ultrasound inter-scalene brachial plexus block (ISBPB) is one of the most common procedures carried out for upper limb surgery. However, anatomical variations in brachial plexus anatomy with respect to scalene muscles are common.[1] With ultrasound guided interscalene block, the commonly described anatomical position of the brachial plexus lying between the anterior and middle scalene muscle is seen in 60% of cases only. These variations may pose a problem for nerve stimulation-based approaches to brachial plexus blocks above the clavicle. We report a brachial plexus anomaly at inter-scalene level that was uncommon in our experience. A 55-year-old male who presented to our operation theater at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences with fracture radius was scheduled for open reduction and internal fixation. After patient’s consent, we planned to give ultrasound guided supraclavicular brachial plexus block. Since the brachial plexus imaging is most consistent in supraclavicular region, we routinely practice to scan supraclavicular region first and trace the plexus to inter-scalene groove. In our patient, brachial plexus anatomy at the level of supraclavicular region was near normal, but as we traced the plexus cranially toward inter-scalene groove, we noticed that the plexus was missing from inter-scalene groove. All ventral rami were seen stacked medial to the anterior scalene muscle (ASM) and lateral to internal jugular vein [Figure 1]. We confirmed these roots by stimulating with nerve stimulator. We gave supraclavicular nerve block to patient and surgery was uneventful with no complications and complete paresthesia with motor blockade. Sonography Vol. 8, Issue 1, January-March 2014
of the opposite side of the brachial plexus revealed no such anomaly and the ventral rami were all stacked between the two scalene muscles. The upper nerve roots of the brachial plexus in the interscalene region have been reported with 13-35% anomalies involving their relation to the ASM. The C5 and C6 nerve roots either course through or anterior to the ASM before assuming a normal position in the inter-scalene groove posterolateral to the subclavian artery.[1-3] There have been not many studies and a few case reports only on scalene muscle anomaly. In a study performed on cadavers by Harry et al., it was found that the most common variation was the penetration of the ASM by the C5 and/or C6 ventral rami.[1]
Figure 1: Inter-scalene brachial plexus anomaly (1) Internal jugular vein, (2) roots of brachial plexus, (3) sternocleidomastoid, (4) scalene ant, (5) scalene med
Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A simple technique to avoid difficulty in guide wire insertion during pediatric central venous cannulation Sir, Percutaneous central venous cannulation (CVC) using Seldinger technique is a routinely performed procedure both in the operation theatre and intensive care unit. But a frequently encountered problem particularly during pediatric CVC is displacement of introducer needle (after localization of vein) before or during insertion of J-tip guide wire. Here we describe a simple technique to avoid this problem. A 2-year 9-kg child was scheduled to undergo resection of a parieto-temporal glioma under general anesthesia (GA). In our patient, we tried an ultrasonography (USG) guided right internal jugular vein (IJV) cannulation under GA with a 5 Fr triple lumen central venous catheter (Certifix Trio® B. Braun, Melsungen AG). Venous puncture and introducer needle placement was made in first attempt, but in spite of our best efforts we were unable to introduce the guide wire into the IJV due to the frequent displacement of the introducer needle either during detachment of the syringe or during introduction of guide wire. So we used a 22G intravenous cannula (IC) instead of the introducer needle for IJV cannulation and after locating the IJV under USG guidance we passed the total length of sheath of the IC into IJV and withdrew its stylet. However, as there was difficulty in passage of the guide wire into the IC sheath through its curve end we had to introduce the guide wire through its straight end [Figure 1] very gently keeping
a close watch on the electrocardiogram (ECG). We are now following this technique routinely for all pediatric IJV cannulations (using 22G and 24G IC in infants and neonates respectively) with 100% first attempt successful placement of the guide wire and the central venous catheter without any complication. Use of USG is now considered as a standard of care for IJV cannulation.[1] Real-time US guidance has been shown to improve the technical efficiency and efficacy of internal jugular venous and has also decreased the frequency of procedure related complications.[2] We agree that use of USG has advantage in terms of identification of the local anatomy, but our problem of displacement of introducer needle persisted in spite of use of USG. So we used the IC to deal with the problem. However, there are two problems with our techniques. First, there is chance of distortion of the IVC sheath during guide wire insertion which can cause extra-vascular migration of the IC sheath (especially during use of smaller IC) and secondly, there is chance of injury to the surrounding structures during introduction of straight end of the guide wire. However, the advancement of sheath of IC completely into the central vein will prevent the distortion and/or extra-vascular migration of the IVC sheath[3] and we introduced the guide wire very gently keeping a close watch on ECG so as to avoid injury to the surrounding structures during guide wire insertion. Our report highlights a common problem encountered during USG guided pediatric IJV cannulation and a simple technique to deal with it. Surya Kumar Dube, Arvind Chaturvedi Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Arvind Chaturvedi, Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi - 110 029, India. E-mail: [email protected]
REFERENCES Figure 1: Sheath of 22G intravenous catheter (with straight end of J tip guide wire) inside right internal jugular vein
Saudi Journal of Anesthesia
1.
Milling TJ Jr, Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove JJ, et al. Randomized, controlled clinical trial of
Vol. 8, Issue 1, January-March 2014
Letters to Editor Page | 142
2. 3.
point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med 2005;33:1764-9. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72:823-6. Nakayama S, Takahashi S, Toyooka H. Curved-end guidewire for central venous cannulation in neonate. Anesth Analg 2003;97:917-8.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.125980
Anatomical variations of interscalene brachial plexus block: Do they really matter? Sir, Ultrasound inter-scalene brachial plexus block (ISBPB) is one of the most common procedures carried out for upper limb surgery. However, anatomical variations in brachial plexus anatomy with respect to scalene muscles are common.[1] With ultrasound guided interscalene block, the commonly described anatomical position of the brachial plexus lying between the anterior and middle scalene muscle is seen in 60% of cases only. These variations may pose a problem for nerve stimulation-based approaches to brachial plexus blocks above the clavicle. We report a brachial plexus anomaly at inter-scalene level that was uncommon in our experience. A 55-year-old male who presented to our operation theater at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences with fracture radius was scheduled for open reduction and internal fixation. After patient’s consent, we planned to give ultrasound guided supraclavicular brachial plexus block. Since the brachial plexus imaging is most consistent in supraclavicular region, we routinely practice to scan supraclavicular region first and trace the plexus to inter-scalene groove. In our patient, brachial plexus anatomy at the level of supraclavicular region was near normal, but as we traced the plexus cranially toward inter-scalene groove, we noticed that the plexus was missing from inter-scalene groove. All ventral rami were seen stacked medial to the anterior scalene muscle (ASM) and lateral to internal jugular vein [Figure 1]. We confirmed these roots by stimulating with nerve stimulator. We gave supraclavicular nerve block to patient and surgery was uneventful with no complications and complete paresthesia with motor blockade. Sonography Vol. 8, Issue 1, January-March 2014
of the opposite side of the brachial plexus revealed no such anomaly and the ventral rami were all stacked between the two scalene muscles. The upper nerve roots of the brachial plexus in the interscalene region have been reported with 13-35% anomalies involving their relation to the ASM. The C5 and C6 nerve roots either course through or anterior to the ASM before assuming a normal position in the inter-scalene groove posterolateral to the subclavian artery.[1-3] There have been not many studies and a few case reports only on scalene muscle anomaly. In a study performed on cadavers by Harry et al., it was found that the most common variation was the penetration of the ASM by the C5 and/or C6 ventral rami.[1]
Figure 1: Inter-scalene brachial plexus anomaly (1) Internal jugular vein, (2) roots of brachial plexus, (3) sternocleidomastoid, (4) scalene ant, (5) scalene med
Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
