According to studies, the success rate of IJV cannulation in infants can be 100% as long as certain measures are taken and catheter insertion is ultrasound-guided. 1
WHAT CAN YOU FIND IN THIS ARTICLE?
- Pediatric patients: the challenges of central venous cannulation
- Internal jugular vein
- What should we consider when choosing the ideal central venous access for our patient?
- How to explore the internal jugular vein?
- Complications related to internal jugular vein cannulation in paediatrics
- How to avoid complications? 10 keys
Do you want to know more about internal jugular vein cannulation in pediatrics? Stay on this page and read the full entry.
Internal jugular vein cannulation is a common procedure, however, it is not without risks, which are accentuated in children and neonates due to the technical difficulty of these patients. How can we avoid possible complications during internal jugular vein cannulation in pediatrics?
According to studies, the success rate of IJV cannulation in infants can be 100% as long as certain measures are taken and catheter insertion is ultrasound-guided. 1
PAEDIATRIC PATIENTS: THE CHALLENGES OF CENTRAL VENOUS CANNULATION
In general, internal jugular vein cannulation is usually chosen due to greater experience and more conclusive scientific evidence in adults, however, this extrapolation is not always applicable in pediatrics due to a series of peculiarities specific to the pediatric population:
- Smaller vessel calibre.
- Closer proximity of structures.
- Collapse with respiration or minimal pressure.
For this reason, there is currently no clear recommendation as to which access is the access of choice in children. For this reason, we recommend the most thorough examination possible and assessment of the most suitable access for our patient, always based on the patient’s individual characteristics and the scientific evidence on the pediatric population.
INTERNAL JUGULAR VEIN
The IJV is located anterolateral or anterior to the internal carotid artery (ICA), with the transducer at the level of the cricoid cartilage. In adults and older children, the right internal jugular vein is longer than the contralateral one. 4
While short axis cannulation is the technique most commonly used by professionals, experts in the field warn that the long axis technique remains safer for the patient and allows 100% verification of correct catheter placement.
So much so that, in infants, a particularly complicated population due to their small size and the characteristics of their veins, we can go from a 75% success rate using a traditional palpation method to 100% when cannulation of the internal jugular vein is performed under ultrasound guidance. In addition, the incidence of carotid artery punctures is reduced from 25% to 0%. 1
Precisely, accidental puncture of the carotid artery is the most common serious complication in jugular venous access.
The pre-puncture examination with ultrasound (US) will allow us to visualise the anatomical relationship between the vein and the artery in order to obtain the best plane.
In addition, the positional relationship of the vessels will also vary according to the position of the head and neck.
Moreover, the diameter of the internal jugular vein can also be significantly affected during respiration and after various maneuvers to increase intravascular filling and pressure. 1
WHAT SHOULD WE CONSIDER WHEN CHOOSING THE IDEAL CENTRAL VENOUS ACCESS FOR OUR PATIENT?
Although the recommendation places the internal jugular vein (IJV) as the first choice for placement of a central venous catheter, there are a number of other factors that may play a role such as:
- Interindividual variability in vein size.
- Significant distortion of IJV during cannulation attempts.
- Internal jugular vein catheter-related infection rate compared to subclavian or brachiocephalic venous lines in some patients.
To identify an optimal insertion site for VYI, Schindler et al. described the combination of a ‘sweep’ and ‘swing’ technique:
- ‘Sweep technique”: helps to assess the size and quality of the vessel.
- ‘Swing technique”: serves to follow the progress of the needle using the long-axis view.
HOW TO EXPLORE THE INTERNAL JUGULAR VEIN?
In this case we are going to focus on the right internal jugular vein, as it is the vein with the most experience in its exploration and cannulation:
- We will position ourselves at the patient’s bedside.
- We will slightly rotate the head towards the contralateral side, no more than 45º (the rotation will be less the smaller they are, to avoid the overlapping of the carotid vein and artery). If necessary, we can perform a slight cervical extension or place the patient in Trendelenburg at -15º and up to -30º (this increases capillary filling).
- Place the lubricated high frequency linear probe perpendicular to the neck, at the vertex of the triangle formed by the sternocleidomastoid, the clavicle and the line that joins the mastoid process with the sternal manubrium; with the notch pointing to approximately 21:00. From this position, slide the probe in a caudal direction until the most suitable position for cannulation is located. In the case of children, the more proximal to the clavicle, the more the vein overlaps the carotid artery; this increases the risk of incidental arterial puncture.
Generally speaking, the right internal jugular vein has a larger calibre and also flows directly into the superior vena cava, and is therefore considered the preferred laterality for cannulation.
COMPLICATIONS RELATED TO INTERNAL JUGULAR VEIN CANNULATION IN PAEDIATRICS
When choosing the central venous access, it is also necessary to take into account the complications associated with each access, as well as the peculiarities of our patient, as there is no ideal access for all cases.
COMPLICATIONS RELATED TO INSERTION
- Anterior wall collapse: frequently observed when ultrasound is used for internal jugular vein puncture in infants and can lead to: accidental puncture of the artery, hematoma or failure of catheter placement in small veins.
- Accidental carotid artery puncture.1,2,3
- Subclavian artery puncture.3
- Incorrect positioning of the catheter.2
- Hematoma. 2,3
- Bleeding. 2
- Pneumothorax. 2,3
- Hemothorax. 2,3
- Extravasation.2,3
Some of these risks can be prevented or significantly reduced by ultrasound. One reason is that as we increase the number of puncture attempts, the likelihood of complications increases and it has been shown that when catheterisation is ultrasound-guided, the number of attempts is reduced. 6
Other post-puncture complications may also be encountered, including: obstruction, accidental withdrawal, central venous thrombosis, subcutaneous extravasation or extravascular infusion. 2
HOW TO AVOID COMPLICATIONS?
1. ECHOGUIDED CANNULATION
As mentioned above, whenever possible, ultrasound-guided puncture should be performed. Its use will allow us to reduce the number of insertion attempts, as well as possible mechanical complications.5,6
2. CHOICE OF VESSEL
Although internal jugular vein cannulation is generally chosen due to greater experience and stronger scientific evidence in adults, this extrapolation is not always applicable in pediatrics or to the individual peculiarities of our patient.
It will be important to adjust the gain and depth according to the patient’s characteristics in order to achieve the highest quality image.
3. PRELIMINARY EXPLORATION OF THE AREA
Whenever possible, prior to cannulation, we should assess the central venous capital: size, patency, respiratory variation in calibre and proximity to the artery, pleura or other structures at risk.
4. DETERMINE THE CALIBRE OF THE VEIN
Calibre determination is essential, not only because it increases the likelihood of a successful single puncture, but also because the calibre will determine the size of the catheter.
Generally speaking, most guidelines recommend that the catheter should not be thicker than 1/3 of the vein diameter (1 French equals 0.33 mm) to prevent the risk of thrombosis.
To determine the calibre, the 2D mode and the function ‘ruler’, ‘diameter’ or its equivalent depending on the model of ultrasound scanner shall be used.
5. THROMBUS AND HAEMATOMA DETECTION
The detection of thrombi and hematomas before and after cannulation avoids puncturing vessels that are already damaged, and avoids opting for other more suitable and normally functioning vessels.
In terms of technique, the high-frequency linear probe is also used. In this case, colour Doppler is preferred, which is also useful for determining patency, although 2D mode can also be used.
6. IN-PLANE CHANNELLING
In-plane cannulation, although more complex than out-of-plane cannulation, provides a good view of both the needle and the vein, thus reducing the number of attempts and potential complications associated with the cannulation technique.4
7. CATHETER ADAPTED TO THE PATIENT
The material, length and size (Fr) of the catheter must be adapted to the patient’s characteristics; a good choice of catheter will reduce or eliminate some of the problems mentioned above.
8. NITINOL SLIDES PREFERABLE TO METAL SLIDES
Nitinol guides will allow smoother passage through the vein and reduce the likelihood of vein perforation.
9. CHOICE OF DILATOR
The short or long dilator should be selected according to the patient’s characteristics, so that it allows us to reach the vein wall in a gentle, progressive manner and ensure effective dilatation.
10. BACTERAEMIA ZERO PROTOCOL
Un mantenimiento adecuado nos permitirá reducir la incidencia de infección y obstrucción del catéter.
The internal jugular vein is the first choice for the cannulation of central venous catheters, however, as we have seen, in order to select the vessel, we must take into account the individual characteristics of our patients, this will avoid possible complications. In addition, there are certain strategies, including the use of ultrasound, that will help us to reduce the number of attempts as well as possible risks to the patient’s health.
BIBLIOGRAPHIE
1. Haas, N. A. (2004). Clinical review: Vascular access for fluid infusion in children. Critical Care, 8(6). https://doi.org/10.1186/cc2880
2. KARAPINAR, B., & CURA, A. (2007b). Complications of central venous catheterization in critically ill children. Pediatrics International, 49(5), 593-599. https://doi.org/10.1111/j.1442-200x.2007.02407.x
3. Murillo, C. S. (2023b, febrero 6). Hemotórax masivo iatrogénico durante canalización de vía venosa central yugular interna izquierda. AnestesiaR. https://anestesiar.org/2022/hemotorax-masivo-iatrogenico-durante-canalizacion-de-via-venosa-central-yugular-interna-izquierda/
4. Sociedad Española de Cuidados Intensivos Pediátricos (SECIP). Protocolo de canalización vascular ecoguiada en pediatría
5. de Souza, T. H., Brandão, M. B., Santos, T. M., Pereira, R. M., & Nogueira, R. J. N. (2018). Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial. Archives of Disease in Childhood, 103(10), 952-956. https://doi.org/10.1136/archdischild-2017-314568
6. Menéndez Suso JJ. Canalización vascular ecoguiada: opción u obligación. Evid Pediatr. 2018;14:1.
