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Central venous cannulation in children: further evidence
- Kenneth Pickett, [Oliver Dearlove], and [Michael Pollard] (10 October 2008)
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Kenneth Pickett, ST5 Anaesthesia Royal Manchester Children's Hospital, [Oliver Dearlove], and [Michael Pollard]
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To the Editor of the BJA . Dear Sir, The difficulties of insertion of central lines in children exercises doctors the world over (1) and even regulators show unnatural interest in them (2). Very little is written about these difficulties but this does not preclude the production of guidelines, perhaps from those who have not published their own results. In 2003, we audited the insertion of central lines as part of a Trust-wide audit including adults and paediatric patients. During the six month audit period, 37 lines were inserted in children and this represented 12% of the total in the Trust in that period; 6 (16%) were in infants, 10 (27%) in the one-to-five age-group and 21(57%) in children aged 6 to 16. All lines were inserted in theatre, critical care or A+E with the exception of the 2 that were inserted on a general ward. The majority of paediatric central lines were inserted using a landmark technique. There were three arterial punctures (8%). Five years on, the subjected was re-audited and readers may be interested in the shifts of practice. 22 central lines were inserted in an identical period. Four (18%) were in children under one year of age, four (18%)in children between one and five and 11 (64%) in those aged six to sixteen. The majority (17) were inserted by anaesthetists in the anaesthetic room. Paradoxically this means we were in a good position to check our results from a small approachable group. The internal jugular vein was used in fourteen of the lines (64%) and the rest elsewhere. Ultrasound was used in 15 (68%) insertions and landmarks in seven, although it was not noted if the Ultrasound was used in ‘real-time’ or as an adjunct to a landmark technique. There was a successful insertion in 91% with 9% of attempts abandoned. However all ultrasound guided insertions (15) were successful with no arterial punctures. In seven landmark insertions only half were successful. In fact two landmark attempts were converted to ultrasound after initial difficulty. All lines inserted by trainees were supervised and 90% of the supervising consultants had inserted more than 50 lines. Discussion: These are small numbers; as would be expected in paediatric population. Neonatal catheters are much more commonly used (3). Our results show a large shift towards the use of ultrasound in children, reflecting its increased use across the board, and show successful results at par with the previous predominant landmark technique. Previously there was little or no evidence base on the use of ultrasound in children. Finally, the landmark method is becoming much less commonly used and much less successful than previously published. Perhaps this is an example of methods that are occasionally used are less successful or as the old adage holds, practice makes perfect. K. Peckitt MB ChB, FRCA O. Dearlove MB FRCA M. Pollard MB ChB, FRCA References: 1. Cardiac perforation and tamponade: The deadly duo of central venous catheters. International Journal of Trauma Nursing, Volume 7, Issue 3 , Pages 108 - 112 D . Yoder 2.http://runningahospital.blogspot.com/2007/05/central-line-infection -report.html 3. Central venous lines in neonates: a study of 2186 catheters Cartwright Arch. Dis. Child. Fetal Neonatal Ed..2004; 89: F504-F508 Conflict of Interest:None declared |
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