Anesth Analg 2003;97:917-918
© 2003 International Anesthesia Research Society
LETTERS TO THE EDITOR
Curved-End Guidewire for Central Venous Cannulation in Neonate
Shin Nakayama, MD,
Shinji Takahashi, MD, and
Hidenori Toyooka, MD
Department of Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan
To the Editor:
Central venous cannulation is routinely performed in pediatric cardiovascular anesthesia. The internal jugular vein (IJV) is the preferred access site for this procedure and has a reasonably infrequent incidence of complications. The majority of the catheters are placed via the Seldinger technique that includes a guidewire with a J-shaped tip.
Because of a smaller target vein diameter and the variable position of the vein to the artery, catheterization of infants and children is more technically challenging than when performed in adults (1). Several studies have demonstrated improved rate of successful cannulation using an ultrasound-guided technique (2–4). While the ultrasound has great advantage in identification of the local anatomy, our problems with cannulation of small target veins in neonates and infants have persisted despite the use of the ultrasound device. Specifically, we encountered difficulties in advancing the J-shaped tip guidewire through the needle into the vein.
The radius of the curvature of the wire’s J-shaped tip is often identical to or larger than the diameter of the neonate vessel. For example, the guidewire provided in the kits of a 4F, 8-cm double-lumen catheter (Arrow International, Reading, PA), has a curved-end radius approximately 5 mm (Fig. 1). In our own study, small diameters of the IJV (5 mm) were mainly seen in infants whose body weight was <5 kg (5). Therefore, the guidewire architecture is not well suited to neonate vein size.
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Figure 1. Curved end of the guidewire provided in the kits of a 4F, 8-cm double-lumen catheter (Arrow International, Reading, PA).
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The properties of the needle also affect the success rate of the procedure. A sharp, short and small-gauged needle has advantage of easy handling and lower incidence of hematoma. The IJV can usually be accessed within a depth of 20 mm from skin in most of the infants (5–7). Thus, we used a 24-gauge, 19-mm needle-catheter assembly (Insyte-W, Becton Dickinson, Sandy, UT) for central venous cannulation rather than the introducer catheter provided in the kit. However, this smaller-gauged introducer catheter is more compliant and bends excessively with J-shaped tip guidewire insertion (Fig. 2). This distortion of the introducer catheter may lead to misplacement of the wire into the extravascular space. Advancement of the introducer catheter completely into the vein or the use of a flexible straight end wire would prevent this problem.
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Figure 2. Distal end of the catheter in which the guidewire is inserted. (A) 22-gauge, 44.5-mm introducer catheter (Arrow International). (B) 24-gauge, 19-mm needle-catheter assembly (Insyte-W, Becton Dickinson, Sandy, UT).
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In conclusion, small-diameter introducer catheter distortion by curved-end guidewire is a significant problem that affects the success of central venous cannulation in infants and neonates, so clinicians should pay particular attention to this phenomenon.
References
- Hayashi Y, Uchida O, Takaki O, et al. Internal jugular vein catheterization in infants undergoing cardiovascular surgery: an analysis of the factors influencing successful catheterization. Anesth Analg 1992; 74: 688–93.[Abstract/Free Full Text]
- Verghese ST, McGill WA, Patel RI, et al. Ultrasound-guided internal jugular vein cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999; 91: 71–7.[ISI][Medline]
- Verghese ST, McGill WA, Patel RI, et al. Comparison of three techniques for internal jugular vein cannulation in infants. Paediatr Anaesth 2000; 10: 505–11.[ISI][Medline]
- Asheim P, Mostad U, Aadahl P. Ultrasound-guided central venous cannulation in infants and children. Acta Anaethesiol Scand 2002; 46: 390–2.[ISI][Medline]
- Nakayama S, Yamashita M, Osaka Y, et al. Right internal jugular vein venography in infants and children. Anesth Analg 2001; 93: 331–4.[Abstract/Free Full Text]
- Alderson PJ, Burrows FA, Stemp LI, et al. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Br J Anaesth 1993; 70: 145–8.[Abstract/Free Full Text]
- Cote CJ, Jobes DR, Schwartz AJ, et al. Two approaches to cannulation of a child’s internal jugular vein. Anesthesiology 1979; 50: 371–3.[ISI][Medline]
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June 1, 2004;
98(6):
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