Optimal site for ultrasound-guided venous catheterisation in paediatric patients: an observational study to investigate predictors for catheterisation success and a randomised controlled study to determine the most successful site

Abstract

IntroductionVenous catheterisation in paediatric patients can be technically challenging. We examined factors affecting catheterisation of invisible and impalpable peripheral veins in children and evaluated the best site for ultrasound-guided catheterisation.MethodsSystolic pressure, age, sex, and American Society of Anaesthesiologists (ASA) physical status were determined in 96 children weighing less than 20 kg. Vein diameter and subcutaneous depth were measured with ultrasound. Logistic regression was used to evaluate the contribution of these factors to cannulation success with (n = 65) or without (n = 31) ultrasound guidance. Thereafter, we randomly assigned 196 patients for venous catheter insertion in the dorsal veins of the hand, the cephalic vein in the forearm, or the great saphenous vein. Success rates and vein diameters were evaluated by using Dunn tests; insertion time was evaluated by using Kaplan-Meier cumulative incidence analysis.ResultsIndependent predictors of catheterisation were ultrasound guidance (odds ratio (OR) = 7.3, 95% confidence interval (CI) 2.0 to 26.0, P = 0.002), vein diameter (OR = 1.5 per 0.1 mm increase in diameter, 95% CI 1.1 to 2.0, P = 0.007), and ASA physical status (OR = 0.4 per status 1 increase, 95% CI 0.2 to 0.9, P = 0.03). Cephalic veins were significantly larger (cephalic diameter 1.8 mm, P = 0.001 versus saphenous 1.5 mm, P <0.001 versus dorsal 1.5 mm). Catheterisation success rates were significantly better at the cephalic vein than either the dorsal hand or saphenous vein (cephalic 95%, 95% CI 89% to 100%, P <0.001 versus dorsal 69%, 95% CI 56% to 82%, P = 0.03 versus saphenous 75%, 95% CI 64% to 86%).ConclusionsThe cephalic vein in the proximal forearm appears to be the most appropriate initial site for ultrasound-guided catheterisation in invisible and impalpable veins of paediatric patients.Trial registry numberUMIN Clinical Trials Registry as UMIN000010961. Registered on 14 June 2013.

Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA)

“…In a motionless anesthetized child, a very high success rate can be achieved, such as that reported in the saphenous vein . In clinical practice, the brachiocephalic vein in the forearm may be even larger and, therefore, a preferable vessel …”

“…84 In clinical practice, the brachiocephalic vein in the forearm may be even larger and, therefore, a preferable vessel. 85 Central venous access increases not only the risk of failure but also the potential for relevant complications, eg, hemato-and pneumothorax or arterial lacerations. The use of ultrasound has been shown to enable a successful puncture in the internal jugular vein in less time with fewer complications, 86 and undoubtedly, ultrasound should be mandatory for central venous access in children.…”

Ultrasound-guided peripheral vascular catheterization in pediatric patients: a narrative review

“…However, veins here are sometimes invisible and impalpable in pediatric patients, and 8-50% of catheterization attempts are associated with difficult venous access [17]. Venous diameter is an important independent predictor of catheterization success [18]. Thus, the saphenous vein at the level of the medial malleolus [16] or cephalic vein at the forearm [18] has been suggested as a more preferable site for ultrasound guidance than the dorsum of the hands and feet due to its larger diameter.…”

Getting to know a familiar face: Current and emerging focused ultrasound applications for the perioperative setting

“…These probes are capable of producing much more detailed views of superficial structures than traditional linear probes, allowing for a greater selection of vessels for cannulation. Most pediatric studies regarding difficult peripheral venous access in the emergency department setting demonstrated a higher first attempt success rate and faster time to cannulation when performed by skilled providers . There is a theoretical concern for more frequent and severe soft tissue infiltration with ultrasound‐guided PIVs since such lines are often placed in deeper vessels, resulting in shorter intravascular segments of catheter .…”