Central venous lines insertion is one of the commonest procedures in major tertiary-level pediatric hospitals. Current practice in the utilization of CVC for patients receiving care in the NICU is not well elucidated. CVC often involves a dedicated surgical team, and serious complications, while rare, do exist [6,7,8,9].
In 2009, Kaji et al. began to perform US-guided central venous catheterization into the IJV. Providing the US probe is placed at the summit of the triangle formed by the two subdivisions of the sternocleidomastoid muscle and the clavicular bone, the IJV and common carotid artery can be identified. Real-time US imaging might cause operators to assume that the IJV puncture is easy. The continuous visualization of the needle tip during needle advancement is quite difficult. Kaji et al. conducted US-guided catheterization, with the probe placed in the short axis. Previous studies have compared the short- and long-axis approaches to vascular access, and have reported that needle tip visibility at the time of vessel puncture was higher with the long-axis approach (62%) than with the short-axis approach (23%) . Thus, the short-axis approach is difficult, and the long-axis approach might be recommended. However, because the cervical space in children is not wide enough for the placement of the US probe, the long-axis approach is not acceptable for small children. Additionally, Blaivas reported that US-guided vascular access using the short-axis approach regularly penetrated the posterior wall of the IJV [11,12,13].
In our institution, as a tertiary center for neonatology and pediatric surgery, we adopted modified Seldinger technique for open central venous lines insertion in neonates (hybrid technique), as our anesthesia team had no experience with neonates in the ultrasound-guided percutaneous insertion of the central venous catheter.
Our intraoperative complications were arrhythmia in 9 cases (7.5%), and blood oozing in 5 cases 4.1%. We had no events of arterial puncture, or failure of cannulation. We assume that this was due to direct vision, and good control of the internal jugular vein. With regard to our postoperative complications, there were 3 cases of Pneumothorax (2.5%), neck hematoma in 2 cases (1.6%), IJV thrombosis in 6 cases (5%) and dislodging of the catheter in 3 cases (2.5%). There were no cases of haemothorax, as we did not insert in the subclavian veins, and we had good control of the internal jugular vein during insertion. Breaking or leaking of the catheter was detected in 2 cases (1.6%), no cases had leak from the tunnel, and 5 cases developed infection (4.1%) that was treated by antibiotics according to culture sensitivity.
The new technique saves time of venous dissection, venotomy, and control of bleeding and closure of venotomy. We faced less risk of bleeding as we avoid the vascular dissection and venotomy (which is the main steps of the routine open technique). For these reasons, it is easily to be learned and performed with short time learning curve. Postoperatively, this technique minimizes vein thrombosis and give chance for reinsertion in the same site over a guide wire like the advantage of closed method, this advantage is lacked in the routine open technique.
According to international literature, the overall complication rate in U/S-guided PCVC insertion in pediatric age ranges between 2.4 and 4.6%. Avanzini et al. observed the complication rate in U/S-guided insertion per 1,000 catheter days. Their complications included 15 (7.7%) mechanical incidents and 7 (3.6%) cases of infection; however, the remaining 5 (2.6%) were classified as intraoperative complications. However, this study only included pediatric cases, and did not specifically study the procedure in neonates. They explained their high rate of complications due to the learning curve of U/S-guided procedur e.
Basford et al, in their comparison of complication rates between surgical and radiologic placement, found higher rates of infectious and mechanical complications among surgically placed catheters, than those placed radiologically (47.1% vs 16.7% and 50.0% vs 16.7%, respectively). Mean complications per 1000 days reflected this trend, but just failed to reach significance .
Arul G.S. et al. reported that many UK pediatric surgeons use open surgical cutdown (OSC) as the technique of choice; even those with an interest in using percutaneous landmark technique (LT) often prefer (OSC) in smaller babies requiring central venous cannulation .
This current study has limitations, which we recommend future studies to try to overcome. These include retrospective study design, single-center experience, and a small sample size. We recommend the adoption of our technique on a multicenter prospective scale, with a control group of closed percutaneous technique or ultrasound-guided group.
Our adopted technique (modified Seldinger maneuver) is safe, and feasible especially in neonates, and provides easy and accurate detection of the internal jugular vein.