https://doi.org/10.1177/11297298211001159 The Journal of Vascular Access 1 –9
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JVA
The Journal ofVascular Access
Introduction
Central venous catheters (CVCs) are essential for the treat-ment of acutely ill newborns. The catheterization of the umbilical vein is the first and best choice for emergency situations in the delivery room, but it is only possible dur-ing the first few days of life.1,2
Epicutaneo cava catheters (ECCs) are routinely used in hospitalized neonates. Because of their small bore they may become insufficient during acute illnesses. US-guided CVC placement has become a standard for health care in hospitalized children and adults, as the procedure has dem-onstrated increased success rate and better safety profile over classical landmark technique.3,4
The placement of CICC in newborns allows for the placement of relatively large bore power injectable cathe-ters (3–4 Fr) inserted in the major veins of cervico thorax district. US-guided IJV cannulation, the most used tech-nique in older children and adults, might be very difficult in
Ultrasound-guided cannulation of
the brachiocephalic vein in newborns:
A novel approach with a supraclavicular
view for tip navigation and tip location
Ferdinando Spagnuolo and Teresa Vacchiano
Abstract
Purpose: Central vascular catheters (CVCs) are frequently used in newborns in NICU. Ultrasound (US) guided
supraclavicular venipuncture of the brachiocephalic vein (BCV) is usually performed with a 12 MHz linear probe and then a catheter tip location is verified with an 8 MHz micro-convex probe or intracavitary ECG (IC-ECG). We explored the feasibility of an US guided puncture using a 7 MHz sector probe, positioned on the clavicular sternal joint. We also explored the opportunity of performing it with a probe tilting tip navigation and tip location.
Design: This is a monocentric retrospective observational study made in the neonatal intensive care unit L. Vanvitelli
University Hospital of Naples, Italy.
Patients: Forty newborns in NICU scheduled for an ultrasound guided CVC.
Interventions: US guided brachiocephalic vein catheterization. We used A long axis in plane supraclavicular approach
to the BCV for real time puncture, for tip navigation and tip location, using a 7 MHz sector transducer. We executed an ultrasound pre-scan of the Y-shape (right and left BCV, superior vena cava (SVC)) and of the right pulmonary artery (RPA), and then we performed a guided sterile puncture on middle third of supraclavicular fossa next to clavicular sternal joint with a 7 MHz. We used the same probe for tip navigation by this supraclavicular short axis of ascending aorta view. Tip location was confirmed with the ultrasound and IC-ECG.
Results: In all infants the ultrasound tip navigation and tip location were successful and were confirmed by IC-ECG. No
misplacement, arterial puncture or pneumothorax occurred.
Conclusions: The supraclavicular view performed with a 7 MHz sector probe has proved to be completely safe and to
be a method with 100% feasibility.
Keywords
Supraclavicular view in newborns, intracavitary ECG, CICC in newborns, tip location, ultrasound guided venipuncture
Date received: 26 January 2021; accepted: 16 February 2021
Neonatal Intensive Care Unit, University of Study “L. Vanvitelli” Naples, Napoli, Italy
Corresponding author:
Ferdinando Spagnuolo, Neonatal Intensive Care Unit, University of Study “L. Vanvitelli” Naples, Largo Madonna delle Grazie,1, Napoli 80138, Italy.
Email: ferdinandospagnuolo33@gmail.com
2 The Journal of Vascular Access 00(0)
the newborns because of the small vein diameter, ease of collapse with the spontaneous breathing and with gentle pressure, and frequent carotid artery overlap.5
A quite new technique may offer advantages over the other approaches in small infants and newborns.6–8
This new technique consists of an US-guided supracla-vicular in plane cannulation of the brachiocephalic vein (BCV), largest-size, superficial location.3,9–13
In the neonatal intensive care venipuncture of BCV in infants is usually performed in a plane with a long axis view with a 12 MHz linear probe or hockey stick.14
Catheter tip location in the cavo atrial junction (CAJ) is usually verified with an 5–8 MHz micro-convex probe15 or IC-ECG, the use of US is not mandatory for tip location.
We have explored the feasibility of an ultrasound guided puncture of BCV using a 7 MHz sector probe posi-tioned on the clavicular sternal joint. We have explored the possibility of performing a tip navigation and tip location with the same probe.
Ethics approval: Ethical approval for this study of
University Hospital of Campania Vanvitelli—register number. 0018889/i date 30/07/2020
Study design: This is a monocentric retrospective
observational study made by neonatologists from Hospital University of Campania “Luigi Vanvitelli” in Naples.
We have evaluated the feasibility and safety of an ultra-sound guided puncture of BCV using a 7 MHz sector probe positioned on the clavicular sternal joint and we have also evaluated the chance of performing a tip navigation and tip location with the same probe tilting. Tip location was con-firmed by intracavitary ECG. Misplacements and compli-cations were excluded by ultrasound.
Study protocol: The indication for a CICC was based
on the following criteria: expected duration of parenteral
nutrition longer than 14 days; need of surgery; hemody-namic instability; other conditions requiring a central cath-eter (Figure 1). Ultrasound Guided venipuncture was performed after adequate information consensus. Data col-lection is done after consensus for privacy.
Patients: From November 2016 to July 2020 we
enrolled 40 newborns (1–28 days of postnatal age or cor-rect age lower than 42 weeks), who underwent CICC in right or left BCV.
Inclusion criteria were newborns who needed CVC with:
– postnatal age 1–28 d or correct age lower than 42 ws – BCV diameter ⩾ 3 mm
– sinusal rytmus on ECG Exclusion criteria were:
– correct age ⩾ 42 weeks – severe coagulation disorders – right or left BCV diameter < 3 mm – thrombosis of BCV or SVC
Ultrasound guided CICC placement
All cannulations were performed by the same trained oper-ator following the same insertion bundle for neonatal cen-tral lines according to Barone et al.4: preoperative ultrasound scan of all central veins Rapid Central Vein Assessment (RaCeVa),16 maximal barrier precautions, skin antisepsis with 2% chlorhexidine in 70% isopropyl alcohol, ultra-sound guided venipuncture of the brachiocephalic vein bythe supraclavicular approach (visualization in long axis: in-plane puncture); vein cannulation using the modified Seldinger technique and a tear away introducer 3.5 Fr × 7 cm; ultrasound assessment of the direction of the guidewire into the vasculature (ultrasound based tip navi-gation); tip location by intracavitary ECG; tunneling of the catheter to the infraclavicular area; securement by suture-less device; cyanoacrylate glue for the closure of the punc-ture site and for the sealing of the exit site; coverage of the exit site with semipermeable transparent membrane. All procedures were performed in the infant incubator or infant radiant warmer. Each baby lining on the back, with a roll placed under the shoulders, in a slightly Trendelenburg position and the head turned 30°–45° to the side opposite to the puncture site. The operator stands on the same side as the selected puncture site.
A long axis in plane right and left supraclavicular approach to the BCV was performed using a 7 MHz sector transducer Logic 7 General Electrics machine Little Chalfont, United Kingdom. The depth was adjusted as needed according to the depth of the vein.
Prior to the cannulation procedure the size and visibility of both BCVs were determined by an ultrasound prescan. The better sonographic visibility and larger size made us eventually aim for either the left or right BCV. The choice of the catheter was based on the diameter of the vein as well as on the clinical complexity of the patients. The mean diameter was 3.4 mm SD 0.29 and of the range was from 3.1 to 4.2 mm. We used radiopaque polyurethane power injectable catheter 3 Fr single lumen (Blucath, Delta
Med S.p.A., Viadana (MN), Italy), the echogenic needle (Sharps Safety) the 21 G × 7 cm. We prefer the right BCV because the diameter was larger and the best position of the probe.
The procedure was performed under mild sedation with nebulized endonasal fentanyl citrate (3 γ/kg) and nebulized endonasal midazolam 0.5 mg/kg 15 min before puncture, while just before, the operative field was infiltrated with 1% lidocaine buffered 0.2 ml/kg according to recent guidelines.17–20
A 7 MHz sectorial probe was positioned on the middle third of the supraclavicular fossa next clavicular sternal joint with tail toward the left shoulder for right BCV and vice versa for left BCV (Figure 2(a) and (b)). After having executed an ultrasound pre-scan of the Y-shape (right and left BCV, SVC) and of the RPA (Figure 3) a sterile
Figure 2. (a) Probe was positioned on the middle third of the supraclavicular fossa next to the clavicular sternal joint with tail
toward the left shoulder in order to inspect the right BCV, the confluence with left BCV and SVC and (b) probe was positioned on the middle third of the supraclavicular fossa next to the clavicular sternal joint with tail toward the left shoulder in order to inspect the right BCV, the confluence with left BCV and SVC.
4 The Journal of Vascular Access 00(0) ultrasound guided puncture (Figure 4) was performed according to the insertion bundle for neonatal central lines. One hand of the operator held the probe whereas the other hand guided the 21 G echogenic needle with attached a syringe filled with NaCl 0.9%. After gentle blood aspira-tion the syringe was removed, on the same coronal plane the probe tail was tilted to the chin and 0.018” floppy straight tip nitinol guidewire was advanced through the needle in BCV while viewing the SVC from the supracla-vicular fossa (Figure 5). Tip navigation and tip location was performed using the same ultrasound view after slightly adjusting the depth of field: the SVC was imaged entering the right atrium with the beam angled to the right of the ascending aorta. The transducer sometimes needs to be moved toward the left and be angled back to the right to avoid shadowing by the overlying right lung. After con-firming the correct guidewire position the introducer advanced intravenously. The guidewire was then with-drawn and the catheter finally advanced till the tip was imaged at the end of SVC in the right atrium. Tip location
Figure 4. Needle tip in BCV-SVC.
was confirmed and documented by intracavitary ECG, using a standard monitor and dedicated sterile ECG cable (Vygocard, Vygon). In the end tunneling the catheter through a 16 G needle cannula the exit site was placed in the infraclavicular area (Figures 6 and 7). Closure of exit site was performed with Octyl-cyanoacrylate glue (Dermabond Ethicon) and securement of catheter with sutureless device subcutaneously anchored (Securacath, Interrad Medical). Exit site was covered by semipermeable transparent membrane (Tegaderm Diamond 3 M). All CVADs, whose tips were within a target zone correspond-ing to the lower third of the SVC or at the cavoatrial
junction (CAJ) or in the upper third of the RA, were con-sidered as correctly positioned (Figure 8)
Intracavitary ECG
Within this study, we used the IC ECG technique with liq-uid columns. We used a transducer (Vygocard -Vygon) to shift from surface ECG tracing to IC ECG tracing on a monitor Taurus. When P is at its peak (P max), the catheter tip is near the CAJ (Figure 9).
Thoracic ultrasound: After the sterile phase, we
per-formed a thoracic ultrasound using a linear 10 MHz probe,
6 The Journal of Vascular Access 00(0)
in order to exclude pneumothorax, hemothorax and misplacement
Diagnosis of CRBSI: Diagnosis of CRBSI was
per-formed with delayed time to positivity method (DTP)
Outcome measurements: The primary outcome was
the feasibility of an ultrasound guided puncture using a 7 MHz sector probe positioned on the clavicular sternal joint and the possibility to perform a tip navigation and tip location with the same probe. Secondary outcome was the safety of the procedure.
Statistical analysis: The X square test was performed.
Variables were expressed as mean ± SD
Results: A total of 40 infants in NICU were enrolled in
this study (Table 1).
There were 17 male and 23 female, of which 25 at term newborns and 15 preterm newborns, with mean gestational age 36.53 weeks (range: 26.41–41 weeks SD 4.59). Mean weight at the time of insertion was 2691.28 g. SD 968,95 (range: 629–4450 g).The mean diameter was 3.4 mm and SD 0.29 and the range was from 3.1 to 4.2 mm. The right BCV was chosen in 36 cases.
The feasibility was 100%.
Catheters’ mean life was 10.88 ± 6.41 (4–29) days. Incidence of CRBSI was 4.5 infections per 1000 catheter days. Two catheters had to be removed prematurely due to CRBSI16 (5%). Tip location was in the target zone in 100% of cases assessed by US and IC ECG (Table 2). In two patients (5%) the guide wire had to be redirected under
Figure 7. Closure of exit site was performed with Octyl-cyanoacrylate glue and securement of catheter with sutureless device
real time US guidance from left BCV to SVC. No compli-cations such as arterial puncture, pleural injury occurred.
Discussion
The most recent guidelines have supported the ultra-sound-guided puncture of the cervical thoracic vessels in adults and children. Over the years, NICUs that use
CICCs with a caliber greater than 2 Fr in critical infants have increased.21,22
Our study focused on a promising awareness in the world of neonatal vascular access.
1. Ultrasound guided venipuncture of BCV in neo-nates of low weight
2. Use of power injectable catheters for CICC in neonates
3. Use of a novel approach with a supraclavicular view for tip navigation and tip location
4. Procedures X Ray free
5. Use of ultrasound for tip location, tip navigation and exclusion of complications
6. Use of IC ECG for tip location in newborns 7. Tunneling of the catheter to the infraclavicular area 8. Use of tissue glue and subcutaneously anchored
device in order to fix catheters also in low birth weight newborns
In the NICU of the Vanvitelli hospital we have abandoned the use of the ECCs on acutely ill infants. We adopt high performance power injectable polyurethane catheters for the needs of high flows and the possibility of longer dura-tion especially when tunneled.
Table 1. Patient’s and catheters’ data, expressed as
mean ± standard deviation (SD) and range or number and percentage.
Total 40
Sex (male/female) (23/17) Gestational age, mean ± SD
(range) (weeks) 36.58 ± 4.54 (26.5–41.2) Weight, mean ± SD (range) (g) 2691.28 ± 988.96 (629–4450) Days of life at the time of
insertion, mean ± SD (range) (days)
7.58 ± 8.24 (1–29) Catheters dwell time,
mean ± SD (range) (days) 10.88 ± 6.41 (4–29) Catheters elective removal 38 (95%)
CRBSI 1000 catheter days 4.5 Catheter related thrombosis 0
Figure 8. Target zone corresponding to the lower third of
the SVC or at the cavoatrial junction (CAJ) or in the upper third of the RA.
Figure 9. When p is at its peak (p max), the catheter tip is
near the CAJ.
Table 2. Results expressed as number and percentage.
Total 40
Feasibility 40 (100%)
Tip location 40 (100%) target zone (CAJ, upper 3 atrium, SCV) Match between
ECHO and IC ECG 40 (100%) Pleural effusion 0
8 The Journal of Vascular Access 00(0) Using our insertion bundle we reduced complications
and completely abandoned the x-ray.
The venipuncture of the BCV is usually carried out with a 12 MHz linear probe while in order to obtain the tip loca-tion it was necessary to use a sectoral probe. Recently Babalan reported brachiocephalic vein catheterization by combining the syringe-free in-plane technique and Y shape visualization of IJV, subclavian vein (SV) and brachioce-phalic vein (BCV) under a micro-convex US probe imag-ing in 12 children.23 In our study we explore a different Y shape: right BCV, the conjunction with the contralateral BCV and SVC.
The great innovation of this study consisted precisely in demonstrating the feasibility and safety of a new supracla-vicular view that allows to obtain tip navigation and tip location simultaneously with the angular movement and the tilt of the same probe using a single sterile ultrasound probe cover kit and without translation of probe in differ-ent acoustic windows far from the sterile operative field. Thanks to the 18 mm tight footprint, and from 8.0 to 4.0 MHz multifrequency, it is possible to use a 7 MHz sec-tor probe at the junction between the clavicle and sternum to visualize the ipsilateral BCV and its conjunction with the contralateral BCV up to the confluence in the SVC. The advantage of using a single sectorial probe for all ster-ile phases of the procedure is clear. The venipuncture proved to be easy and safe while tip location was 100% accurate. The operator can easily puncture the vessels and follow the guide wire, redirecting the catheter in case of incorrect progression and with the same sectorial probe in a sterile way to perform the tip location from the same position. Only later on, at the end of the procedure, when sterility is no longer required, the sector probe is replaced with a linear probe to detect the complications. Unfortunately, the catheter tip visualization at cavo atrial junction can be difficult in certain patients and therefore an alternative tip location technique is needed. An almost similar view had previously been introduced in the adult patient with the limits related to the size of the body sur-face.24 The tip location was confirmed by the IC-ECG.
Recent studies have shown that the IC-ECG represents an accurate and safe method for tip location in children and newborns.4,22,25,26
In our infants, there was a 100% agreement between the tip location with the US and that via IC ECG. The presence of the P max wave was always associated with the position of the tip of the catheter in the target area.
Conclusions
The supraclavicular view performed with a 7 MHz sector probe has proved to be completely safe and to be a method with 100% feasibility. Once again, ultrasound has com-pletely replaced traditional radiography. The use of an inser-tion bundle has proved to be an effective strategy for reducing complications related to CICC placement in newborns.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Ferdinando Spagnuolo https://orcid.org/0000-0002-4850-406X
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