A Prospective Randomized Trial of Ultrasound- vs

Landmark Guided Central Venous Access in the

Pediatric Population
SIR-RFS Journal Primer

Quick Summary
BOTTOM LINE

Ultrasound (US) reduced the number of cannulation attempts necessary for venous access
performed by pediatric surgeons, thereby decreasing risk of complications.

MAJOR POINTS

Success at first attempt was achieved in 65% of patients in the US group vs 45% in the landmark
(LM) group.

Success within 3 attempts was achieved in 95% of the ultrasound group and 74% of the landmark
group.

Complications rates in the ultrasound group were 4.5% and 4.7% in the landmark group.

Times to successful cannulation were 33 seconds (range 2 to 220s) in the US group and 42 seconds
(range 4 to 410s) in the LM group

CRITICISM

Study was not powered to compare the complication rates between the two groups.

Sample size of n = 150 at two institutions

Variation in experience of the practitioner Any attending pediatric surgeon or pediatric surgery
fellow who completed the American College of Surgeons online course on surgical ultrasound and
were proctored for at least 20 procedures with ultrasound-guided technique could participate.

Variation in the use of micropuncture kit versus 18 gauge needle based on surgeon preference.

Study design

TWO CENTER PROSPECTIVE

REVIEW

150 patients enrolled

between April 2008 and
September 2011.

INCLUSION CRITERIA

All patients between the ages

of 0 and 18 years undergoing
tunneled central venous line
placement under general
anesthesia.

EXCLUSION CRITERIA

Children known
preoperatively to have
nonpatency of veins or
coagulopathy.

Purpose

COMPARE LANDMARK- TO ULTRASOUND-GUIDED CENTRAL VENOUS

ACCESS WHEN PERFORMED BY PEDIATRIC SURGEONS

Technique
SUCCESSFUL ATTEMPT
Defined as positive venous flash during advancement or withdrawal of the needle.
LANDMARK TECHNIQUE
Internal jugular (anterior approach) or subclavian vein (infraclavicular approach) on either side chosen for access, depending
on operator preference.
If unsuccessful after 3 attempts, the study was terminated, and the operator was free to use either US or landmark at another
site.
A single pass of the needle was defined as a single episode of needle advancement and withdrawal; a second pass occurred if
needle was readvanced or removed and reinserted.
A failed attempt was recorded if aspiration resulted in no venous flash, arterial puncture, or air.
ULTRASOUND-GUIDED TECHNIQUE
Internal jugular vein accessed on either side, depending on operator preference (though the right vein was typically used).
11-Hz linear probe was used with sterile technique.
Patient placed in Trendelenburg, and both sides of the neck and anterior chest were prepped and draped in the usual fashion,
with patient head positioned away from insertion side.
US probe placed at apex of the triangle formed by the 2 heads of the sternocleidomastoid muscle and the clavicle; the IJ and
common carotid artery were visualized, and after flashback of venous blood, Seldinger technique was followed for catheter
insertion.
After 3 failed attempts using US, operator was free to use landmark or US-guided approach at any other site.
BOTH GROUPS
Depending on operator preference, a micropuncture 21-gauge (0.018-inch wire) or an 18-gauge (0.035-inch wire) needle on a
3-5-mL syringe was used to access the vein; if the micropuncture set was used, the wire was upsized for catheter placement.
Fluoroscopy used in all cases to confirm guide wire placement, determine appropriate catheter length, and confirm final tip
position.
Post-procedural chest radiograph also routinely performed.

Outcome

Credits

SUMMARY BY:
Alexander Covington, MD PGY2
Emily Ochmanek, DO PGY2
Department of Radiology

FULL CITATION:
Bruzoni M, Slater BJ, Wall J, St Peter SD, Dutta S. A prospective randomized trial of ultrasound- vs landmark-guided central venous access
in the pediatric population. J Am Coll Surg. 2013 May; 216(5):939-43.

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