PEDIATRIC ANESTHESIA Section Editor Paul R. Hickey
Internal Jugular Vein Catheterization in Infants Undergoing Cardiovascular Surgery: An Analysis of the Factors Influencing Successful Catheterization Yukio Hayashi, MD, Osamu Uchida, MD, Osamu Takaki, MD, Yoshihiko Ohnishi, Toshito Nakajima, MD, Hiroto Kataoka, MD, and Masakazu Kuro, MD
MD,
Department of Anesthesiology, National Cardiovascular Center, Osaka, Japan
Central venous catheterization for pressure monitoring and drug administration is often important in the anesthetic management of infants undergoing cardiovascular surgery. We examined the effects of patient age, weight, and central venous pressure and the experience of the anesthesiologist on the rate of successful catheterization and catheterization time of the internal jugular vein (IJV) in a prospective study. We studied 106 infants undergoing IJV catheterization for cardiovascular surgery over a 7-mo period at our institution. We catheterized the IJV by the high approach. The direct venipuncture or the Seldinger method was used according to the patient's weight. Overall successful catheterization rate was 97.2%, and the average catheterization time was 353 ? 21 s (mean ? SEM). Complications included arterial puncture in 12 cases (11.3%)'hematoma formation in four
C
entral venous catheterization for vascular pressure monitoring a nd drug therapy is often used for pediatric patients undergoing cardiovascular surgery (1). Several sites, including the internal or external jugular, antecubital, femoral, a n d subclavian veins, have been used for catheter placement. Among them, despite the several complications reported (2-9), the internal jugular vein (IJV) is a useful an d reliable site in children (10-13). The IJV technique is more difficult in infants than in adults (ll),although successful catheterization in children has been shown not to be related to age, weight, height, o r central venous pressure (11). Because many patients with congenital heart disease also suffer from hypoxia or congestive heart failure, central venous catheterization should be performed speedily in such cases. However, the time required Accepted for publication December 6 , 1991. Address correspondence to Dr. Hayashi, Anesthesiology Service, VA Medical Center, 3801 Miranda Avenue, Palo Alto, CA 94304.
cases (3.8%),and catheter malposition in two cases (1.9%),but pneumothorax was not observed. When a patient was younger than 3 mo or weighed less than 4.0 kg, successful catheterization rate decreased significantly to 81.3%and 78.6%, respectively. Catheterization time was inversely correlated with both age and weight, whereas central venous pressure did not affect either successful catheterization rate or catheterization time. We were unable to demonstrate that the experience of the anesthesiologist plays a significant role in the success or complication of the catheterization procedure. Our results indicate that IJV catheterization by the high approach is a reliable and useful technique in infants, and that the weight and age of the patient significantly influence the rate of successful catheterization. (Anesth Analg 1992;74:688-93)
for catheterization in infants and the factors influencing it have not previously been examined. Furthermore, the experience of the person inserting the catheter may have a role (12-14). We sought to examine the time required for IJV catheterization in infants undergoing cardiovascular surgery and to determine whether patient factors such a s age, weight, and central venous pressure influence catheterization time. We also analyzed the effect of operator experience with this technique.
Methods The protocol of this study was approved by our Human Ethical Committee and parental consent was obtained. One hundred six patients weighing less than 20 kg w h o underwent cardiovascular surgery from June 1990 through January 1991 were included in this study. The patients were aged between 10 days and 7 yr (mean age, 25.5 mo). After induction of anesthesia and tracheal intubation, IJV catheterization was performed. The catheterization technique 01992 by the International Anesthesia Research Society
688
Anesth Analg 1992;74:688-93
0003-2999/92/$5.00
ANESTH ANALG 1992;74:68693
Figure 1. Schematic representation of the landmarks used to locate the internal jugular vein and the puncture point. A, carotid artery; B , suprasternal notch; C, clavicle; D, mastoid process; E , the puncture point.
we used was the high approach, which is similar to that reported by English et al. (12). A rolled towel was placed under the shoulders to extend the neck, and the patient was placed in the 15”-20” Trendelenburg position with the head turned away from the site of catheterization. Catheterization was performed at a site immediately lateral to the intersection of the carotid artery with a line running between the suprasternal notch and the mastoid process (Figure 1). After antiseptic preparation of the neck, catheterization of the right IJV was attempted first. However, the left IJV was tried first in patients with dextrocardia or a right aortic arch. Catheterization was performed using one of two techniques, i.e., the direct venipuncture method (10) or the Seldinger method (11).Patients weighing more than 8 kg were generally catheterized by the direct venipuncture method; if the weight was under 8 kg, we usually used the Seldinger method. However, the final choice was made by the anesthesiologist managing the patient. In fact, eight patients weighing less than 8 kg were catheterized by direct venipuncture, and 13 patients weighing more than 8 kg were treated by the Seldinger method. For the direct venipuncture method, we used an 18-gaugeMedicubUK-IIadoublelumen catheter kit (‘Japan Shenvood, Tokyo, Japan). After pilot venipuncture with a 23-gauge needle to locate the IJV, we inserted a 16-gauge cannula over a needle attached to a 3-mL syringe and advanced it caudally while maintaining continuous negative pressure with the syringe. When return of blood was observed or the cannula was thought to have advanced deeply enough to enter the IJV, the needle was removed and the cannula was attached to the syringe. Then the cannula was withdrawn slowly while maintaining continuous negative pressure with the syringe. When a satisfactory blood reflux was obtained, the double-lumen catheter was threaded through the cannula into the IJV and the cannula was withdrawn. For the Seldinger method,
PEDIATRIC ANESTHESIA HAYASHI ET AL. INTERNAL JUGULAR VEIN CATHETERIZATION
689
we used an Arrow 4F double-lumen catheter kit (Arrow, Reading, Pa.). After pilot venipuncture as described above, the IJV was entered with a 22-gauge Angiocath cannula (Deseret, Sandy, Utah), a J-tipped guidewire was passed through the cannula, and then the cannula was removed. An 8-cm, 4F, doublelumen catheter was advanced over the guidewire into the IJV, and then the wire was removed. In both techniques, the catheter tip was advanced into a satisfactory position, and the catheter was sutured to prevent dislodgment. The catheter position was checked by a postoperative roentgenogram of the chest. Catheterization was performed by the anesthesiologists in our institution, who were divided into three groups based on their clinical experience: (a) staff physician (SP) (six doctors, mean age = 34 yr) who had more than 6 yr of clinical experience; (b) senior resident (SR) (two doctors, mean age = 32 yr) who had undergone 1 yr of residency in our institution after more than 2 yr of clinical experience; and (c) junior resident (JR) (four doctors, mean age = 29.5 yr) who had more than 2 yr of clinical experience and were familiar with the IJV catheterization in adults but had little experience in infants. Catheterization by a JR was always performed under the supervision of an SP. Age, weight, initial central venous pressure, catheterization time, the number of attempts until successful catheterization, and complications were recorded. The catheterization time was defined as the time from pilot venipuncture to suturing of the catheter. When arterial puncture occurred, when the catheterization site was changed, when 10 min of pilot venipuncture failed to locate the IJV, or when another anesthesiologist took over, the attempt was defined as abandoned and a new attempt was started. However, multiple percutaneous punctures at a single site were considered as a single attempt. In the case of arterial puncture, up to 5 min of compression time was allowed before a new attempt was initiated. When the anesthesiologist was changed, a more experienced doctor always made the next attempt. In the present study, we examined the effect of the patient’s age, weight, and central venous pressure as well as the experience of the anesthesiologists on the rate of successful catheterization and the catheterization time in infants. Data were expressed as the mean +- SEM. The results of multiple groups were analyzed by one-way analysis of variance (ANOVA) or repeated measures analysis of variance as appropriate, and comparisons between groups were assessed by Scheffgs test. The ,$ test or Student’s t-test for unpaired data was used as appropriate. P < 0.05 was considered statistically significant.
690
PEDIATRIC ANESTHESIA HAYASHI ET AL. INTERNAL JUGULAR VEIN CATHETERIZATION
Table 1. Subject Data Age (mo) Weight (kg) Height (cm) BSA (m’) Diagnosis Tetralogy of Fallot Ventricular septa1 defect Single ventricle Endocardia1 cushion defect Transposition of great arteries Tricuspid atresia Double-outlet right ventricle Other
25.5 ? 8.76 2 76.6 0.42 2
*
(n
2.2 0.42 1.7 0.02
Table 3. Effect of Age on the Rate of Successful Catheterization and Catheterization Time Age (mo) (n
24 = 16) ( n = 24) ( n = 22) ( n = 44)
Success rate (70)” 81.3 100 100 100 Catheterization time (s)” 448 5 49 410 t 47 373 48 284 27
22) 22) (n = 9) ( n = 8) (11 = 8) ( 1 1 = 6) (11 = 6 ) ( n = 25) =
*
(tl =
Values arc expressed as mean 2 SEM “Significant correlahon with age multiples (P < 0.05).
Table 4. Effect of Weight on the Rate of Successful Catheterization and Catheterization Time
BSA, body surface area. Values are expressed as mean
Weight (kg) 2 SEM.
5. 3. Cook TL, Dueker CW. Tension pneumothorax following internal jugular cannulation and general anesthesia. Anesthesiology 1976;45:554-5. 4. Morgan RNW, Morrell DF. Internal jugular catheterization. A review of a potentially lethal hazard. Anaesthesia 1981;36: 512-7. 5 McEnanv MT, Austen WG. Life-threatening hemorrhage from inadvertent cervical arteriotomy. Ann Thorac Surg 1977;24: 23M. 6. Vest JV, Pereira MB, Senior RM. Phrenic nerve injury associated with venipuncture of the internal jugular vein. Chest 1980;78:777-Y . 7. Mason MS, Wheeler JR, Jaffe AH, Gregory RT. Massive bilateral hydrothorax and hydromediastinum: an unusual complication of percutaneous internal jugular vein cannulation. Heart Lung 1980;9:883-6. 8 Forestner JE. lpsilateral mydriasis following carotid-artery puncture during attempted cannulation of the internal jugular vein. Anesthesiology 1980;52:438-9. 9. Stock MC, Downs JB. Transient phrenic nerve blockade during internal jugular vein cannulation using the anterolateral approach. Anesthesiologv 1982;57:230-3. 10. Prince SR, Sullivan RL, Hackel A. Percutaneous cathetenzation of the internal jugular vein in infants and children. Anesthesiology 1976;44:17M. 11. Cote CJ, Jobes DR, Schwartz AJ, Ellison N. Two approaches to cannulation of a child’s internal jugular vein. Anesthesiology 1979;50:371-3. 12. English ICW, Frew RM, Pigott JF, Zaki M. Percutaneous catheterization of the internal jugular vein. Anaesthesia 1969; 24521-31. 13. Rao TLK, Wong AY, Salem MR. A new approach to percutaneous catheterization of the internal jugular vein. Anesthesiology 1977;46:3624. 14. Sznajder Jl, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by
ANESTH ANALG 1992;74:68%93
three percutaneous approaches. Arch Intern Med 1986;146: 259-61. 15. Belani KG, Buckley JJ, Gordon JR, Castaneda W. Percutaneous cervical central venous line placement: a comparison of the internal and external jugular vein routes. Anesth Analg 1980; 59:4(3-4. 16. Escarpa A, Gomez-Arnau J. Internal jugular vein catheterization: time required with several techniques under different clinical situations. Anesth Analg 1983;62:97-9.
PEDIATRIC ANESTHESIA HAYASHI ET AL. INTERNAL JUGULAR VEIN CATHETERIZATION
693
17. Cucchiara RF, Messick JM, Gronert GG, Michenfelder JD. Time required and success rate of percutaneous right atrial catheterization: description of a technique. Can Anaesth SOCJ 1980;27572-3. 18. Bazaral M, Harlan S. Untrasonographic anatomy of the internal jugular vein relevant to percutaneous cannulation. Crit Care Med 1981;9:307-10. 19. Troianos CA, Savino JS. Internal jugular vein cannulation guided by echocardiography. Anesthesiology 1991;74:787-9.
Internal Jugular Vein Catheterization in Infants Undergoing Cardiovascular Surgery: An Analysis of the Factors Influencing Successful Catheterization Yukio Hayashi, MD, Osamu Uchida, MD, Osamu Takaki, MD, Yoshihiko Ohnishi, Toshito Nakajima, MD, Hiroto Kataoka, MD, and Masakazu Kuro, MD
MD,
Department of Anesthesiology, National Cardiovascular Center, Osaka, Japan
Central venous catheterization for pressure monitoring and drug administration is often important in the anesthetic management of infants undergoing cardiovascular surgery. We examined the effects of patient age, weight, and central venous pressure and the experience of the anesthesiologist on the rate of successful catheterization and catheterization time of the internal jugular vein (IJV) in a prospective study. We studied 106 infants undergoing IJV catheterization for cardiovascular surgery over a 7-mo period at our institution. We catheterized the IJV by the high approach. The direct venipuncture or the Seldinger method was used according to the patient's weight. Overall successful catheterization rate was 97.2%, and the average catheterization time was 353 ? 21 s (mean ? SEM). Complications included arterial puncture in 12 cases (11.3%)'hematoma formation in four
C
entral venous catheterization for vascular pressure monitoring a nd drug therapy is often used for pediatric patients undergoing cardiovascular surgery (1). Several sites, including the internal or external jugular, antecubital, femoral, a n d subclavian veins, have been used for catheter placement. Among them, despite the several complications reported (2-9), the internal jugular vein (IJV) is a useful an d reliable site in children (10-13). The IJV technique is more difficult in infants than in adults (ll),although successful catheterization in children has been shown not to be related to age, weight, height, o r central venous pressure (11). Because many patients with congenital heart disease also suffer from hypoxia or congestive heart failure, central venous catheterization should be performed speedily in such cases. However, the time required Accepted for publication December 6 , 1991. Address correspondence to Dr. Hayashi, Anesthesiology Service, VA Medical Center, 3801 Miranda Avenue, Palo Alto, CA 94304.
cases (3.8%),and catheter malposition in two cases (1.9%),but pneumothorax was not observed. When a patient was younger than 3 mo or weighed less than 4.0 kg, successful catheterization rate decreased significantly to 81.3%and 78.6%, respectively. Catheterization time was inversely correlated with both age and weight, whereas central venous pressure did not affect either successful catheterization rate or catheterization time. We were unable to demonstrate that the experience of the anesthesiologist plays a significant role in the success or complication of the catheterization procedure. Our results indicate that IJV catheterization by the high approach is a reliable and useful technique in infants, and that the weight and age of the patient significantly influence the rate of successful catheterization. (Anesth Analg 1992;74:688-93)
for catheterization in infants and the factors influencing it have not previously been examined. Furthermore, the experience of the person inserting the catheter may have a role (12-14). We sought to examine the time required for IJV catheterization in infants undergoing cardiovascular surgery and to determine whether patient factors such a s age, weight, and central venous pressure influence catheterization time. We also analyzed the effect of operator experience with this technique.
Methods The protocol of this study was approved by our Human Ethical Committee and parental consent was obtained. One hundred six patients weighing less than 20 kg w h o underwent cardiovascular surgery from June 1990 through January 1991 were included in this study. The patients were aged between 10 days and 7 yr (mean age, 25.5 mo). After induction of anesthesia and tracheal intubation, IJV catheterization was performed. The catheterization technique 01992 by the International Anesthesia Research Society
688
Anesth Analg 1992;74:688-93
0003-2999/92/$5.00
ANESTH ANALG 1992;74:68693
Figure 1. Schematic representation of the landmarks used to locate the internal jugular vein and the puncture point. A, carotid artery; B , suprasternal notch; C, clavicle; D, mastoid process; E , the puncture point.
we used was the high approach, which is similar to that reported by English et al. (12). A rolled towel was placed under the shoulders to extend the neck, and the patient was placed in the 15”-20” Trendelenburg position with the head turned away from the site of catheterization. Catheterization was performed at a site immediately lateral to the intersection of the carotid artery with a line running between the suprasternal notch and the mastoid process (Figure 1). After antiseptic preparation of the neck, catheterization of the right IJV was attempted first. However, the left IJV was tried first in patients with dextrocardia or a right aortic arch. Catheterization was performed using one of two techniques, i.e., the direct venipuncture method (10) or the Seldinger method (11).Patients weighing more than 8 kg were generally catheterized by the direct venipuncture method; if the weight was under 8 kg, we usually used the Seldinger method. However, the final choice was made by the anesthesiologist managing the patient. In fact, eight patients weighing less than 8 kg were catheterized by direct venipuncture, and 13 patients weighing more than 8 kg were treated by the Seldinger method. For the direct venipuncture method, we used an 18-gaugeMedicubUK-IIadoublelumen catheter kit (‘Japan Shenvood, Tokyo, Japan). After pilot venipuncture with a 23-gauge needle to locate the IJV, we inserted a 16-gauge cannula over a needle attached to a 3-mL syringe and advanced it caudally while maintaining continuous negative pressure with the syringe. When return of blood was observed or the cannula was thought to have advanced deeply enough to enter the IJV, the needle was removed and the cannula was attached to the syringe. Then the cannula was withdrawn slowly while maintaining continuous negative pressure with the syringe. When a satisfactory blood reflux was obtained, the double-lumen catheter was threaded through the cannula into the IJV and the cannula was withdrawn. For the Seldinger method,
PEDIATRIC ANESTHESIA HAYASHI ET AL. INTERNAL JUGULAR VEIN CATHETERIZATION
689
we used an Arrow 4F double-lumen catheter kit (Arrow, Reading, Pa.). After pilot venipuncture as described above, the IJV was entered with a 22-gauge Angiocath cannula (Deseret, Sandy, Utah), a J-tipped guidewire was passed through the cannula, and then the cannula was removed. An 8-cm, 4F, doublelumen catheter was advanced over the guidewire into the IJV, and then the wire was removed. In both techniques, the catheter tip was advanced into a satisfactory position, and the catheter was sutured to prevent dislodgment. The catheter position was checked by a postoperative roentgenogram of the chest. Catheterization was performed by the anesthesiologists in our institution, who were divided into three groups based on their clinical experience: (a) staff physician (SP) (six doctors, mean age = 34 yr) who had more than 6 yr of clinical experience; (b) senior resident (SR) (two doctors, mean age = 32 yr) who had undergone 1 yr of residency in our institution after more than 2 yr of clinical experience; and (c) junior resident (JR) (four doctors, mean age = 29.5 yr) who had more than 2 yr of clinical experience and were familiar with the IJV catheterization in adults but had little experience in infants. Catheterization by a JR was always performed under the supervision of an SP. Age, weight, initial central venous pressure, catheterization time, the number of attempts until successful catheterization, and complications were recorded. The catheterization time was defined as the time from pilot venipuncture to suturing of the catheter. When arterial puncture occurred, when the catheterization site was changed, when 10 min of pilot venipuncture failed to locate the IJV, or when another anesthesiologist took over, the attempt was defined as abandoned and a new attempt was started. However, multiple percutaneous punctures at a single site were considered as a single attempt. In the case of arterial puncture, up to 5 min of compression time was allowed before a new attempt was initiated. When the anesthesiologist was changed, a more experienced doctor always made the next attempt. In the present study, we examined the effect of the patient’s age, weight, and central venous pressure as well as the experience of the anesthesiologists on the rate of successful catheterization and the catheterization time in infants. Data were expressed as the mean +- SEM. The results of multiple groups were analyzed by one-way analysis of variance (ANOVA) or repeated measures analysis of variance as appropriate, and comparisons between groups were assessed by Scheffgs test. The ,$ test or Student’s t-test for unpaired data was used as appropriate. P < 0.05 was considered statistically significant.
690
PEDIATRIC ANESTHESIA HAYASHI ET AL. INTERNAL JUGULAR VEIN CATHETERIZATION
Table 1. Subject Data Age (mo) Weight (kg) Height (cm) BSA (m’) Diagnosis Tetralogy of Fallot Ventricular septa1 defect Single ventricle Endocardia1 cushion defect Transposition of great arteries Tricuspid atresia Double-outlet right ventricle Other
25.5 ? 8.76 2 76.6 0.42 2
*
(n
2.2 0.42 1.7 0.02
Table 3. Effect of Age on the Rate of Successful Catheterization and Catheterization Time Age (mo) (n
24 = 16) ( n = 24) ( n = 22) ( n = 44)
Success rate (70)” 81.3 100 100 100 Catheterization time (s)” 448 5 49 410 t 47 373 48 284 27
22) 22) (n = 9) ( n = 8) (11 = 8) ( 1 1 = 6) (11 = 6 ) ( n = 25) =
*
(tl =
Values arc expressed as mean 2 SEM “Significant correlahon with age multiples (P < 0.05).
Table 4. Effect of Weight on the Rate of Successful Catheterization and Catheterization Time
BSA, body surface area. Values are expressed as mean
Weight (kg) 2 SEM.
5. 3. Cook TL, Dueker CW. Tension pneumothorax following internal jugular cannulation and general anesthesia. Anesthesiology 1976;45:554-5. 4. Morgan RNW, Morrell DF. Internal jugular catheterization. A review of a potentially lethal hazard. Anaesthesia 1981;36: 512-7. 5 McEnanv MT, Austen WG. Life-threatening hemorrhage from inadvertent cervical arteriotomy. Ann Thorac Surg 1977;24: 23M. 6. Vest JV, Pereira MB, Senior RM. Phrenic nerve injury associated with venipuncture of the internal jugular vein. Chest 1980;78:777-Y . 7. Mason MS, Wheeler JR, Jaffe AH, Gregory RT. Massive bilateral hydrothorax and hydromediastinum: an unusual complication of percutaneous internal jugular vein cannulation. Heart Lung 1980;9:883-6. 8 Forestner JE. lpsilateral mydriasis following carotid-artery puncture during attempted cannulation of the internal jugular vein. Anesthesiology 1980;52:438-9. 9. Stock MC, Downs JB. Transient phrenic nerve blockade during internal jugular vein cannulation using the anterolateral approach. Anesthesiologv 1982;57:230-3. 10. Prince SR, Sullivan RL, Hackel A. Percutaneous cathetenzation of the internal jugular vein in infants and children. Anesthesiology 1976;44:17M. 11. Cote CJ, Jobes DR, Schwartz AJ, Ellison N. Two approaches to cannulation of a child’s internal jugular vein. Anesthesiology 1979;50:371-3. 12. English ICW, Frew RM, Pigott JF, Zaki M. Percutaneous catheterization of the internal jugular vein. Anaesthesia 1969; 24521-31. 13. Rao TLK, Wong AY, Salem MR. A new approach to percutaneous catheterization of the internal jugular vein. Anesthesiology 1977;46:3624. 14. Sznajder Jl, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by
ANESTH ANALG 1992;74:68%93
three percutaneous approaches. Arch Intern Med 1986;146: 259-61. 15. Belani KG, Buckley JJ, Gordon JR, Castaneda W. Percutaneous cervical central venous line placement: a comparison of the internal and external jugular vein routes. Anesth Analg 1980; 59:4(3-4. 16. Escarpa A, Gomez-Arnau J. Internal jugular vein catheterization: time required with several techniques under different clinical situations. Anesth Analg 1983;62:97-9.
PEDIATRIC ANESTHESIA HAYASHI ET AL. INTERNAL JUGULAR VEIN CATHETERIZATION
693
17. Cucchiara RF, Messick JM, Gronert GG, Michenfelder JD. Time required and success rate of percutaneous right atrial catheterization: description of a technique. Can Anaesth SOCJ 1980;27572-3. 18. Bazaral M, Harlan S. Untrasonographic anatomy of the internal jugular vein relevant to percutaneous cannulation. Crit Care Med 1981;9:307-10. 19. Troianos CA, Savino JS. Internal jugular vein cannulation guided by echocardiography. Anesthesiology 1991;74:787-9.
