طب انتظامی (Jan 2022)
Evaluation of Complications of Central Venous Catheterization into Subclavian Vein with Supraclavicular Approach in Critically Children Admitted to Pediatric Intensive Care Unit in A Referral Center in the South of Iran
Abstract
INTRODUCTION Central venous catheter can be performed through various sites such as a femoral vein, internal jugular vein, and subclavian vein, but it seems choosing the best route depends on skill, clinical situation, and physician judgment. [1]. Subclavian vein catheterization is mostly used with infraclavicular approach. However, this approach is associated with complications such as perforation of the subclavian artery, pneumothorax, and Hemothorax [2, 3]. ... [4]. Because of the potentially life-threatening complications, physicians, especially anesthesiologists, had no interest in performing subclavian vein catheterization [5]. If we compare the supraclavicular approach with the infraclavicular approach, the presence of a specific location (landmark) and fully defined (clavisternomastoid angle), shorter skin-to-vein distance; A larger target area, a more direct path to the subclavian vein, less proximity of this method to the lung, and fewer complications of pleural or artery rupture are some of the advantages of the supraclavicular approach; in addition, there is less need to stopping resuscitation performing this method during cardiopulmonary resuscitation [6, 7]. Because of the small spots to place the probe (especially in children) during needle insertion, supraclavicular approach in children in ultrasound-guided subclavian vein placement is technically difficult; however, in recent years, many advantages of this method have been shown [8-10]. Although data from studies on adults suggest a lower risk and fewer complications from the subclavian region, there is less information about children [3]. Also, there are not many studies on the complications of the supraclavicular approach in intubated patients treated with positive pressure ventilation, especially in children [11, 12]. AIM(s) Although ultrasound is a great advance in the placement of central catheters, and with ultrasound guidance, in the supraclavicular method, the rate of catheter failure and its complications are reduced, ultrasound is not always available in all ICUs or is not easily used in children. Therefore, the catheterization method based on landmarks can be used as a safe method by physicians even among children. Since we use this method at Namazi Hospital in Shiraz, Iran without the help of ultrasonography; we conducted this study to investigate the complications and success rate of this method, especially in intubated patients, and compare our results with other studies. RESEARCH TYPE This is a retrospective observational study. RESEARCH SOCIETY, PLACE & TIME This study was conducted from January 2019 to August 2020 in the pediatric intensive care unit (PICU) in Namazi Hospital, Shiraz, Iran, and patients less than 18 years old for whom central venous catheterization in the subclavian vein was performed with a supraclavicular approach because of various reasons (lack of suitable peripheral vessels, need for inotrope, etc.), were included in the study. METHOD In this study, patients who were extubated were given appropriate anesthesia and the skin was anesthetized with lidocaine, but patients who were intubated under mechanical ventilation, received sedation and painkillers, and lidocaine was used according to the level of consciousness and sensation. All procedures were performed in aseptic conditions with continuous cardiac monitoring and oxygen saturation. The size of the catheters was chosen according to the weight and size of the patients and the reason for their placement (hemodialysis or plasmapheresis). Catheters were operated through the skin using the Seldinger technique, after catheter placement, to confirm its position and detect its primary complications (hemothorax, pneumothorax); a chest radiograph was taken (Figure 1). During and after the procedure, the injection site and the patient's condition were closely monitored for possible immediate complications (such as bleeding, and pneumothorax), and patients were also monitored daily for other late complications such as thrombosis, dysfunction, and infection. All of them were examined by a doctor and the ICU nurses recorded the complications in the symptom registration form in the patient's medical records. Insertion of central venous catheters was performed by a cardiac anesthesiologist (first author), and another colleague collected data by reviewing medical records and checklists filled by ICU physician and nurses regarding the complications of central venous catheter insertion. ETHICAL PERMISSIONS This study was approved by the ethics committee of the university and registered with the approval ID IR.sums.med.rec.1398.255. FINDING by TEXT During the 20 months of conducting this study, 282 patients were included in the study 153 of whom (54.3%) were girls and 129 patients (45.7%) were boys. The average age of the patients in this study was five years and one month with a standard deviation of 5.4 years (Chart 1), the youngest of whom was one month old and the oldest was 18 years old. The minimum weight of the studied samples was 2400 grams and their maximum weight was 124 kg. Out of the total number of patients, 14 people were extubated and 268 (95%) were intubated under mechanical ventilation. In 275 patients (97%), the lumen was placed on the right side (versus 7 patients). In 7 cases (2.48%), a size 12 lumen was placed for hemodialysis or plasmapheresis. Catheterization failed in 2 patients (0.7%) and the success rate of this method in our study was 99.3%. The two cases, in which central venous catheter placement was unsuccessful, included a 57-day-old boy with a large ventricular septal defect (VSD) with heart failure and pleural effusion, and an 18-month-old girl with septic shock and low blood pressure. Among 282 patients, pneumothorax was diagnosed in two patients (0.7%) after catheter placement (a three-month-old and an 11-month-old), and both of them were intubated and under mechanical ventilation, so a chest tube was implanted for them. In our study, hemothorax and arterial perforation were not observed (Table 1). In our study, no patient died intraoperatively due to complications from catheter placement (Table 1). MAIN COMPARISION to the SIMILAR STUDIES The success rate of catheter placement in our study was 99.3%. In other studies, success rates for jugular vein catheterization have been reported as up to 90% [13, 14] and for subclavian vein, catheterization varied from 71 to 100% in the infraclavicular approach [15-17]. In a study that Finck C et al. performed without using ultrasound, the success rate in the age group below 6 months was 78% and in the age group above 6 months was reported at 96% [15]. Lu WH and colleagues in another study done without using ultrasound; have reported a success rate of about 96% [18]. In another study conducted by Byon et al. on 98 children less than 3 years old to compare two supraclavicular and infraclavicular methods for subclavian vein catheterization, ultrasound was used in all patients that were in general anesthesia for congenital heart surgery or neurosurgery and required central venous catheter placement; they performed subclavian cannulation in all patients with 100% success and without complications, but the supraclavicular method was faster and associated with fewer attempts to perform [17]. In another study by Nardi N et al. performed on 615 patients with the supraclavicular method with the help of ultrasound, the success rate was 98% [19]. It seems that in the two cases in which central vein catheterization was unsuccessful in our study, besides the small size and low weight of the patients, severe pleural effusion in one patient, which disturbed the anatomy of that area, and severe hypotension in another patient, were possible causes of failure. The complication rate of subclavian vein catheterization in our study was 0.7% (Table 1). In other studies, the complication rate of central venous catheter operation in the jugular vein has been reported up to 9% [13, 14] and in the subclavian vein up to 58% [6]. In our study, the rate of complications, especially pneumothorax, was observed in two patients, both of whom were intubated (0.7%). Other studies have reported the incidence of complications between 0 and 3 percent [4, 16]. In the present study, we did not have any arterial perforation following catheterization, but the rate of arterial perforation during catheterization has been reported in other studies between 1.9-12.8% [18-23]. In our study, no local infection or systemic infection was detected. Czarnik et al published a study on 370 adult patients in which 78.4% of their patients were intubated on a mechanical ventilator with a subclavian success rate of 92% during the procedure, and the overall complication rate was 1.7%, including three subclavian artery perforations and three subclavian vein catheterizations in the opposite vein [12]. Pneumothorax is one of the complications of central vein catheterization (internal jugular and subclavian), and this complication can even cause the death of the patient if diagnosed late. The incidence of this complication has been reported between 0.2% and 2.4% in various studies [15, 22]. In our study, this rate was 0.7%, which was comparable to other studies. Among the things that are effective in the occurrence of pneumothorax, we can mention the existence of sufficient experience and the use of sedatives in central vein cannulation [3], but in another study conducted on 1257 children, there was no relation between the level of experience of people and the incidence of pneumothorax, but 99% of the patients in this study had received appropriate sedation and anesthesia [16]. In our study, this work was done by an experienced person, but none of the patients were under deep anesthesia, especially in the patients who were not intubated, only local anesthesia and a low dose of sedation were used, and the two cases that suffered from this complication; both were intubated and less than one year old and had received anesthesia, but due to severe pneumonia and lung involvement, the ventilator positive end-expiratory pressure (PEEP) was more than 10. LIMITATIONS The main limitation in conducting our study was the impossibility of performing a comparison of this method in another group using ultrasound, and the reason for that was the lack of a suitable ultrasound probe for small-sized children in the studied hospital. SUGGESTIONS It is suggested that in the next research, the results of patients in whom catheterization was performed using ultrasound be compared with the results of this study. CONCLUSIONS Based on the results of this study, considering the low rate of complications and high success rate, compared to the more common methods of central vein cannulation in children, the supraclavicular approach for subclavian vein cannulation can be considered as a safe and fast method for central vein catheterization among children. CLINICAL & PRACTICAL TIPS in POLICE MEDICINE The catheterization method based on landmarks can be used as a fast and safe method for the treatment staff of military and police headquarter who cannot use ultrasound devices in places close to conflict or remote areas. ACKNOWLEDGMENTS The authors of this article are grateful for the efforts of the pediatric ICU nurses of Shiraz Namazi Hospital. CONFLICT of INTEREST The authors of the article state that there is no conflict of interest in the present study. FUNDING SOURCES The authors of this article did not receive financial support.
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