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Indian Pediatr 2013;50:
749-752 |
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Appropriate Length and Position of the
Central Venous Catheter Insertion via Right Internal Jugular
Vein in Children
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L Witthayapraphakorn, A Khositseth, *T Jiraviwatana, *S Siripornpitak,
*R Pornkul,
N Anantasit and J Vaewpanich
From the Department of Pediatrics and *Department of Radiology,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok
10400, Thailand.
Correspondence to: Dr Anant Khositseth, 270 Rama VI Road,
Ratchathewi, Bangkok 10400, Thailand.
Email: [email protected]
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Design: Observational study.
Setting: Tertiary University Hospital.
Participants/patients: Patients, aged 6 days to
19 years, who underwent contrast enhancement computerized tomography
imaging of the thorax (CT-thorax).
Main outcome measures: We measured three lengths
consisting of length A in axial plane at the level of the lower border
of the 6th C-spine from the skin to RIJV at its mid lumen, length B and
C in sagittal plane from the RIJV at the level of the lower of the 6th
C-spine to the superior vena cava (SVC) at carina and from carina to
SVC-right atrium junction, respectively. Lengths A plus B represented
the length of CVC where the tip was expected in the SVC at carina (CVCcarina).
Lengths A plus B and C represented the length of CVC when the tip was
expected in the SVC at SVC-right atrium junction (CVCSVC-RA).
Results: One hundred and sixty-five cases with
mean age of 8.1 ± 4.7 years were reviewed. The CVCSVC-RA and CVC carina
were significantly correlated with age and body surface area (BSA).
Using multiple regression analysis, CVCSVC-RA (cm) was equal to 6.4 +
2.8[BSA (m2)] + 0.022[age (month)] and CVCcasina (cm) equal to 4.9
+2.7[BSA (m2)] +0.013[age (month)] (Adjusted R-squared 0.7275, 0.7140).
Conclusions: We recommended the appropriate CVC
length via RIJV approach should be between these two calculated lengths
and the CVC length in each age according to the BSA.
Keywords: Central venous catheter, Children, Right
internal jugular vein.
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Central venous catheters (CVC) are commonly
indicated in patients in pediatric intensive care units for medications,
volume replacement, parenteral nutrition, obtaining blood sampling,
hemodialysis vascular access, or central venous pressure (CVP)
monitoring. Regardless of the indications, the position of the CVC tip
is important to avoid potential serious complications, including
pneumothorax, hemothorax, pericardial effusion leading to cardiac
tamponade, cardiac perforation, or arrhythmias due to irritation to the
endocardium [1,2]. Some guidelines recommended that the CVC tip should
be positioned in the superior vena cava (SVC) above the level of the
pericardial reflection to be certain that it is outside the pericardium
[3-6]. Studies proposed that the carina was a reliable and simple
radiographic marker for the position of the CVC tip, based on the
examination of either embalmed or fresh cadavers [4-8]. Some recommended
that the CVC tip should be placed just above the superior vena cava and
right atrium (SVC-RA) junction to avoid malposition and CVC tip
perforation [9-11]. The length of CVC insertion from skin to SVC at the
level of the carina or to SVC at SVC-RA junction, using right internal
jugular vein (RIJV) approach may be varied according to age, bodyweight,
and height, especially in children. The aims of this study were to
evaluate the length from the skin at the puncture site of RIJV to the
SVC at the level of the carina and the length from the skin at the
puncture site of RIJV to the SVC at the level of SVC-RA junction. We
also devised a formula for ideal catheter insertion length from RIJV
approach in children.
Methods
Contrast enhancement computerized tomography imagings
of the thorax (CT-thorax) performed in patients aged 6 days to 19 years
between July 2008 and July 2011 were retrospectively reviewed. Patients
with congenital heart diseases, cardiovascular abnormalities, neck or
mediastinal masses, SVC obstruction, abnormality of cervical spine, and
gross deformity of chest wall were excluded. In addition, those studies
with inadequate quality, including poor contrast opacification of the
RIJV, and studies which did not cover the lower border of the 6th
cervical spine level representing cricoid
cartilage, the same level of skin using for landmark of RIJV approach
were also excluded.
Demographic data including age, sex, weight, height,
and BSA were obtained. All CT-thorax cases were loaded into the Picture
Archiving and Communications System (PACS), using a DICOM Conformance
(Synapse version 3.2.0, FUJIFILM Medical Systems USA’s Synapse PACS
System, USA). This study was approved by the Institute Ethics Committee.
Measurements
Measurement of three lengths in CT-thorax included
length A, measured in axial plane at the level of the lower border of
the 6 th C-spine from the
skin to RIJV at its mid lumenl ength B, measured in sagittal plane from
RIJV at the level of the lower border of the 6th
C-spine to SVC at the level of carina; and length C, measured in the
sagittal plane from SVC at the level of carina to SVC at the level of
SVC-RA junction. Lengths A plus B represented the length of the CVC
insertion when expected the CVC tip in SVC at the level of carina (CVCcarina).
Lengths A plus B and C represented the length of the CVC insertion when
expected the CVC tip in SVC at the level of SVC-RA junction (CVCSVC-RA).
All measurements were performed in mediastinal window with the window
level ranges 40-80 HU, window width ranges 300-400 HU and magnified to
250-300%. Inter-observer agreement for first 10% of cases was measured
by experienced cardiovascular radiologist, radiology resident, and
pediatric resident. The remaining cases were reviewed for inter-observer
agreement by radiology and pediatric residents. Twenty cases (12%) were
repeatedly measured by the pediatric residents blinded to the first
measurement for intra-observer agreement.
Statistical analysis: Continuous variables
including age, height, weight, body surface area (BSA), and distances
were described as mean and standard deviation (SD). Categorical
variables were described as percentage. All statistical analyses were
performed using retrospective descriptive study and linear regression
analysis. STATA version 10 (STATA Corp, College Drive, Texas, USA)
statistical software was used to analyze data. Paired T-test and
Bland-Altman method were used for assessing agreement between
inter-observer and intra-observer measurements. A P value <0.05
was considered to be statistically significant.
Using sample size estimation for correlation
coefficients, if we expected to have power (1-beta) of 0.99, probability
of type I error (alpha) of 0.05, and correlation coefficient rho of 0.5,
we needed the sample size of 55 in the validation study.
Results
Of 250 cases, 85 cases were excluded whereas 165
cases with mean age of 8.1 ± 4.70 years, height of 121.4 ± 29.0 cm,
weight of 26.7 ± 16.0, and BSA of 0.9±0.4 m 2
were included in this study.
The length of CVCSVC-RA varied in each age group. This length significantly
correlated with patients’ height (r = 0.87, P<0.001), weight (r =
0.74, P<0.001), and BSA (r = 0.83, P <0.001). Using
multiple regression analysis, after adjusting for other variables,
patients’ age and BSA were significantly correlated with length of CVC.
The formula that predicted this length of the CVC insertion was
calculated as the following.
Length of CVCSVC-RA (cm) = 6.4 + 2.8[BSA (m 2)]
+ 0.022[age (month)]; (Adjusted R2=0.7275)
The length of CVC Carina
varied in each age group. This length significantly correlated with
patients’ height(r = 0.85, P<0.001), weight (r = 0.76,
<0.001), and BSA (r = 0.83, P<0.001). Using multiple regression
analysis, after adjusting for other variables, patients’ age and BSA
were significantly correlated with length of CVC. The formula that
predicted this length of the CVC insertion was calculated as the
following:
Length of CVCcarina (cm) = 4.9 + 2.7[BSA (m 2)]
+ 0.013[age (month)]; (Adjusted R2
= 0.7140)
There were no statistical significant differences of
inter-observer agreement for first 10% of cases (n=15) in
measuring these lengths and for the remaining cases (n = 150).
There were no statistical significant differences of intra-observer for
the lengths of CVCcarina and
CVC SVC-RA. Bland-Altman plot
demonstrated acceptable agreement in measurement of the lengths of CVCcarina
and CVCSVC-RA by two
observers with bias (mean difference) and precision (±1SD) of these two
lengths by two independent observers equal to 0.02 ± 1.21 and -0.05 ±
1.59, respectively. Most of the differences between two observers’
measurements were in the limit of agreement lines (±1.96 SD).
TABLE I Length (in cm) of Central Venous Catheter Insertion in the Superior Vena Cava (SVC)
at various Sites and Length of SVC at the Level of Carina to SVC and Right Atrium Junction (N=165).
Age (y) |
No. (%) |
CVCcarina |
CVCSVC-RA |
Length |
|
|
|
|
carina-junction |
6 d-1 |
8 (4.8) |
5.6 ± 1.2 |
6.9 ± 1.0 |
1.3 ± 0.4 |
>1-3 |
23 (14.0) |
6.8 ± 0.9 |
8.7 ± 1.5 |
1.9 ± 0.7 |
>3 -6 |
31 (18.8) |
7.4 ± 0.8 |
9.6 ± 1.1 |
2.1 ± 0.7 |
>6-9 |
29 (17.6) |
8.1 ± 1.5 |
10.5 ± 1.6 |
2.4 ± 0.6 |
>9-11 |
21 (12. 7) |
8.9 ± 0.7 |
11.8 ± 0.9 |
2.9 ± 0.7 |
>11-13 |
22 (13.3) |
9.8 ± 1.2 |
12.9 ± 1.9 |
3.2 ± 1.0 |
³13 |
31 (18.8) |
11.4 ± 1.3 |
14.6 ± 1.8 |
3.2 ± 0.9 |
CVCSVC-RA = Length of the
central venous catheter (CVC) insertion when expected the tip of
the CVC in the superior vena cava (SVC) at the level of SVC and
right atrium junction; CVCcarina=
Length of the central venous catheter (CVC) insertion when
expected the tip of the CVC in the superior vena cava (SVC) at
the level of carina; Lengthcarina-junction = Length from
superior vena cava (SVC) at the level of carina to SVC at the
level of SVC and right atrium junction. |
Discussion
In this study, length of CVCcarina
and length of CVCSVC-RA were
accurately measured by CT-thorax imaging. These two lengths could be
calculated from our recommended formula. Although the superior part of
the pericardial reflection which transverses SVC could not be
identified, neither on plain chest X-ray nor CT-thorax imaging,
but it is approximately 0.8 cm below the SVC at the level of the carina
in adult population [4]. Study from pediatric populations demonstrated
that the carina was 0.5 ± 0.04 cm above the pericardial reflection as it
transverses the SVC [5]. However, study from neonates demonstrated that
the pericardial reflection may transverse the SVC at a distance of 5 mm
below the carina or even 4 mm above the carina [12]. Nevertheless, the
carina is still an easily sighted and clear radiological landmark in
children similar to that in adults to confirm that the CVC tip is
outside the pericardial reflection [4, 5]. Some authors recommended the
CVC tip to be in the lower SVC regardless of the concern that the CVC
tip might be below the pericardial reflection to make the CVC tip be
more parallel to the vessel wall [13]. If the CVC tip was positioned
more in the proximal SVC, it had a higher rate of malposition or
migration to other vessels consisting of azygos, internal mammary, left
innominate, subclavian, and internal jugular veins. This position could
not represent a proper central vein and carried risks of thrombus,
infection, and extravasation [14]. Positioning the CVC tip in the distal
SVC at the level below the carina, but above the SVC-RA junction could
reduce these risks and also extend the time use of the CVC [14-16]. Our
data demonstrated that the length between SVC at the level of the carina
and SVC at the SVC-RA junction also increased according to increased BSA
and age. Therefore, we recommended that the CVC tip to be positioned
more toward the SVC at the level of carina in younger age and more
toward the SVC-RA junction in older age.
On comparing the length of CVC insertion recommended
by Andropoulos, et al. [10] and our recommendation according to
BSA and age, our recommendation was less than the previous study,
especially younger age. This was because they measured the length when
the CVC tip was in the SVC at the level of SVC-RA junction [10]. For
simplification and recall purposes, we recommended CVC length starting
at the age of 1 year to be equal to 6.5 cm, then, increasing by 0.5 cm
every 1 year of age up to the age of 12 years (12.0 cm) (Table
II). Importantly, the recommended lengths of CVC in each age group
are based on the assumption that the weight and height are normal (50 th
percentile). Therefore, it is not recommended for use if a child is
malnourished or obese.
TABLE II Suggested Length for Central Venous Catheter Insertion by Right Internal Jugular Vein Approach in Each Age (y)
Age |
Wt |
Ht |
CVC |
CVC |
Recommended
|
Andro- |
(y) |
P50th |
P50th |
carina |
SVC-RA |
length |
poulos’s
|
|
|
|
(cm) |
(cm) |
(cm) |
Formula(cm) |
1 |
10 |
75 |
6.3 |
8.0 |
6.5 |
6.5 |
2 |
12 |
89 |
6.7 |
8.4 |
7.0 |
7.9 |
3 |
14 |
95 |
7.0 |
8.9 |
7.5 |
8.5 |
4 |
16 |
100 |
7.3 |
9.3 |
8.0 |
9.0 |
5 |
18 |
107 |
7.6 |
9.7 |
8.5 |
8.7 |
6 |
20 |
115 |
7.9 |
10.1 |
9.0 |
9.5 |
7 |
23 |
122 |
8.3 |
10.6 |
9.5 |
10.2 |
8 |
26 |
128 |
8.6 |
11.1 |
10.0 |
10.8 |
9 |
29 |
133 |
8.9 |
11.5 |
10.5 |
11.3 |
10 |
33 |
138 |
9.2 |
11.9 |
11.0 |
11.8 |
11 |
37 |
144 |
9.9 |
12.7 |
11.5 |
12.4 |
12 |
42 |
151 |
10.4 |
13.3 |
12.0 |
13.1 |
13 |
46 |
157 |
10.8 |
13.8 |
13.0 |
13.7 |
14 |
49 |
160 |
11.1 |
14.3 |
14.0 |
14.0 |
15 |
52 |
162 |
11.4 |
14.7 |
14.0 |
14.2 |
16 |
54 |
163 |
11.6 |
15.0 |
14.0 |
14.3 |
17 |
55 |
163 |
11.8 |
15.3 |
14.0 |
14.3 |
CVCSVC-RA = Length of the central venous catheter
(CVC) insertion when expected the tip of the CVC in the superior
vena cava (SVC) at the level of SVC and right atrium junction; #CVCcarina=
Length of the central venous catheter (CVC) insertion when
expected the tip of the CVC in the superior vena cava (SVC) at
the level of carina; Ht = height, Wt = weight, P50th= fifty
percentile; Andropoulos’s formula (cm): (Height/10) –1 (Ht
≤100 cm), (Height/10) –2 (Ht >100
cm) [10]. |
This study had some limitations. Firstly, we assumed
the puncture site at the level of the lower body of the 6th
C-spine to be the surface anatomical landmark. This may not hold true in
all cases, since the puncture site may be varied. The angle of measure
of this length was perpendicular, whereas in the real situation,
approximately 15-30 degrees are to be expected. As a result, this
assumption may cause shorter length from this measurement when compared
to the real situation. However, this length (length A) was quite short
when compared to the others (lengths B and C), thereby limiting the
degree of error in itself. Secondly, the number of patients in each age
group was not high and may not represent all variables of weight,
height, and BSA. Thirdly, none of these had the CVC in the imaging.
However, this might not be so important, since we just wanted to know
the length if we expected the CVC tip to be in the SVC at the level of
carina and SVC-RA junction. The strength of this study was that all
lengths were accurately measured in CT-thorax which satisfactorily
demonstrated the SVC at the level of the carina and SVC-RA junction.
In conclusion, the length of CVC insertion by RIJV
approach in pediatric populations could be calculated from BSA and age.
This study has put forward the length for each age group in year.
Nevertheless, validation in clinical practice is warranted to confirm
our suggestion.
Acknowledgements: Udomsubpayakul U and
Yongcharoen S for their contribution in statistical analyses and Dr.
Chinnapha (Johnny) M for his contribution in copyediting the language of
this manuscript.
What is Already Known?
• In children, the ideal position and
recommended length of central venous catheter via the right
internal jugular vein remains controversial.
What This Study Adds?
• We suggest the appropriate length of the central venous
catheter via the right internal jugular vein in each age group
from 1 year to 17 years.
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