During the period between December 2008 and November 2014, we operated on 660 low-birth-weight neonates with venous cut down on the Rt. IJV to insert the CVA. The mean weight of our patients was 1050 g and the mean age was 3.3 days. In terms of sex, there were 370 males and 290 females. There were 550 neonates with surgical neonatal diseases (neonatal intestinal obstruction, tracheoesophageal fistula, congenital diaphragmatic hernia, necrotizing entercolitis) and 110 neonates with medical diseases (respiratory distress, severe prematurity) (Table 1).
A total of 550 neonates underwent the CVA under general anesthesia in the theater and 110 neonates underwent bedside procedures (patients received local analgesics by a subcutaneous injection and sedation). The mean time needed to insert CVA was 11.3 min. The mean duration of CVA was 22.5 days. Accidental dislodgement occurred in 27 cases. Thrombosis of the line occurred in 22 cases. No cases developed pneumothorax. No injury of the Rt. carotid artery or the Rt. vagus occurred. No accidental bleeding or tear of the Rt. IJV occurred. No cases developed hematoma. No pleural or pericardiac complications occurred. Leak from the wound occurred in 27 cases of accidental dislodgement, which was incomplete. Wound infection occurred in 19 cases. In 20 cases, we had to completely ligate the Rt. IJV because of venotomy that extended to more than two-third of the circumference and this occurred during our early experience. Infection of the line occurred in 35 cases and this necessitated extraction of CVA and their tips were sent for culture and sensitivity. We encountered no associated mortality because of the procedure. Except for complicated cases, catheters were removed on elective bases. In cases with accidental dislodgement or thrombosed lines still in need of CVA, this approach enabled us to reinsert on the same side with high success rates in 49 cases (Table 2).
Although CVA is an essential procedure for the functioning of any major tertiary-level pediatric hospitals, there are few studies comparing the various techniques of insertion. Fatalities and failure to cannulate the vein using the traditional landmark technique (LT) without ultrasound guidance are well reported. As a result and although there are no large studies of open surgical cutdown (OSC) for direct comparison, many pediatric surgeons use OSC as a technique of choice; even those interested in using LT often prefer OSC in smaller babies requiring CVA 6–106–106–106–106–10.
Also, in recent years, the development and increasing success of peripherally introduced central catheters have markedly reduced the need for invasive OSC. Also, neonatal care advances and much more smaller and premature babies survive and these babies are small enough to require OSC 11,1211,12.
In our study, we used Rt. IJV as the first and only choice to perform the OSC in our neonatal patients as it is easier and associated with fewer complications compared with the femoral or subclavian veins.
Chait et al. 13 used Rt. IJV for the same reasons and they attempted to place CVA lines through this vein even it had stenosis or partial thrombosis.
During our procedure, we clearly identified the Rt. IJV and venotomy was performed carefully to avoid injury to any other structures.
Alderson and colleagues showed that about 18% of children younger than 6 years of age have anatomical factors that could complicate the classic LT to cannulate the Rt. IJV. They showed that IJV overlaid the common carotid artery in 10% of infants, was unusually small in 4%, ran widely lateral in 2%, and could not be identified in a further 2% 14.
Also, positioning maneuvers such as rotation of the head to the contralateral side can cause the IJV to overlap the common carotid artery, and flatten the IJV even more and decrease the distance between the IJV and the carotid artery 15.
LT for CVA is known to be more difficult in children than adults. The small diameter of IJV in low birth weight neonates to the age and the weight makes its success more difficult than in adults. The smaller dimensions of the IJV in infants increase the number of attempts, favor the changes in puncture points and the depth of needle insertion, and finally increase the risks of complications including carotid artery injury or pneumothorax 16.
In our work, the overall success rate was 100% as there were no multiple trials to puncture the vein and no accidental puncture of adjacent structures.
Verghese et al.17 reported that the overall success rate was 81% for landmark technique (LM) patients compared with 94% with ultra sound (US)-guided insertion, and fewer attempts to achieve successful cannulation and fewer inadvertent carotid punctures.
However, Grebenik et al.18 reported that the overall success rate for LM increased to 89% and there was increased incidence of carotid puncture in the US group, but this was may have been because of limited experience with the US techniques.
The use of LM technique to insert CVA requires multiple trials maneuver can lead to hematoma formation that might induce changes in IJV or might even cause external compression, which makes its access more difficult even when US locations is used as rescue techniques 16.
The rate of venous line occlusion or thrombosis in our series was 3.33%. We adequately visualized the vein before and during venotomy; thus, there was no need for multiple punctures.
Koksoy et al.19 reported 40% venous thrombosis after LT and found that this was significantly associated with the need for multiple needle punctures.
Barnacle and colleagues, showed that the rate of venous thrombosis after OSC may be as high as 33%. They attributed this to the need for multiple punctures and thus adequate visualization before and during cannulation of the vein by US reduced this rate to less than 3% 20.
In our series, we inserted CVA as a bedside technique in 110 neonates, either intubated or by sedation and local analgesia.
This was identical to Hong et al.5, who reported their experience with central venous cut down in neonates as a bedside procedure without general anesthesia.
We encountered no complications such as hematoma, pneumothorax, or pleural effusion, and also avoids inadvertent punctures of the carotid artery or related nerves.
The overall complications rate after LT ranged from 10 to 20% in all cases, but this complication rate decreased to about 3% in neonates subjected to a US-guided approach 21.
We believe that OSC on the Rt. IJV is safe, quite easy, and can be performed either in the operating room or as a bedside procedure; it can also save time and resources in low-birth-weight neonates. In addition, it is associated with lower complication rates. This procedure represents a solution for low-birth-weight neonates subjected to multiple failed trials by LT to cannulate the IJV.
Ethical committee approval was obtained.
Conflicts of interest
There are no conflicts of interest.
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