Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures

doi:10.1016/j.jpedsurg.2008.12.004

Journal of Pediatric Surgery

Volume 44, Issue 7, July 2009, Pages 1371-1376

https://doi.org/10.1016/j.jpedsurg.2008.12.004 Get rights and content

Abstract

Aim

The ultrasound-guided percutaneous technique of Hickman line insertion has not been widely adopted in pediatric surgical practice. We wished to review our own experience of using this technique for insertion into the internal jugular vein.

Methods

Our vascular access team consists of a consultant surgeon and 2 consultant anesthetists. All procedures were prospectively recorded on a database and were either performed or directly supervised by our team.

Results

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006. Patients' ages ranged from 14 days to 19 years (median, 44 months). Patients weighed between 600 g to more than 100 kg. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F, with 1-3 lumens), of which 60% were 7F double-lumen lines. Successful cannulation occurred in 99.8%. Perioperative complications (within 30 days) occurred in 12 patients (2.4%) and were all treated conservatively with no need for either blood transfusion or chest drain. Catheter-related sepsis rate was 3.16 per 1000 line days.

Discussion

1.
The technique of ultrasound-guided percutaneous insertion of Hickman line to the internal jugular vein is safe and is applicable to all children regardless of size, age, or diagnosis.
2.
Pediatric surgeons and anesthetists can learn this technique without specific training in interventional radiology.
3.
A learning curve does exist, and we recommend concentrating pediatric vascular access procedures to a specialist team.

Section snippets

Methods

All patients requiring a Hickman line insertion were suitable for the technique of ultrasound-guided percutaneous approach regardless of size, age, weight, and clinical diagnosis and were referred directly to the vascular access service. Our vascular access team consists of a consultant surgeon (GSA) and 2 consultant anesthetists (JB and PB) and aims to provide a range of permanent central venous access devices. Since April 2004, data from all procedures performed by the vascular access team

Technique

The approach we describe is a modification of the standard Seldinger technique. All lines are inserted via the ultrasound-guided percutaneous route using either the internal jugular or innominate veins. Procedures are all done under general anesthetic in the operating theater and involve a separate pediatric anesthetist giving the anesthetic. We use a high-resolution ultrasound probe (CL10-5 compact linear array probe) that is covered with a sterile cover.

With the patient supine and a roll

Results

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006 in 403 patients. Patients had a median age of 44 months (range, 14 days to 19 years); weight ranged from 600 g to more than 100 kg. Indications for line insertion are shown in Table 2. No patient referred to the Vascular Access Service was refused because of size, age, weight, or diagnosis. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F with 1-3 lumens), of which

Discussion

Although permanent central vascular access is essential to the function of any major tertiary-level pediatric hospital, there are few studies comparing the various techniques of insertion. Fatalities and failure to cannulate the vein using the traditional LT without ultrasound visualization are well reported [10], [11], [12], [13], [14], [15], [16], [17], [18], [30], [31], [32], [33], [34], [35]. As a result and although there are no large studies of OSC for direct comparison, many UK pediatric

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Cited by (64)

Ultrasound-guided percutaneous insertion of Broviac lines in infants less than 5kg: Prospective study of 100 consecutive procedures
2022, Journal of Pediatric Surgery
Ultrasound-guided (USG) percutaneous insertion of Broviac lines (cuffed tunnelled silastic central venous catheters, TCVC) has increasingly been adopted throughout the UK. However, vascular access remains a challenge in small babies and in some units is still performed by open cutdown. Our vascular access team, established in 2004, consists of consultant surgeons, anaesthetists and interventional radiologists, who provide all permanent vascular access by the USG technique. We reviewed the outcome in our last 100 patients less than 5 kg.
A prospective database of TCVC insertions in patients <5 kg weight recorded age, gestation, weight, diagnosis, type of catheter and complications within 28 days of insertion. A standardised technique of USG insertion is used by all operators.
One-hundred patients <5 kg had TCVC inserted between 1/1/2018 and 31/3/2020. Median age 46(range0–316)days, gestation 36.5(23–42)weeks, weight 3(0.66 to 5)kg. Indication: parenteral nutrition(75), long term antibiotics(14), cardiac medication(6), chemotherapy(3), other(2). All were tunnelled silicone lines of single 2.7fr(51) and 4.2fr(46) or double lumen 7fr(3). Uncomplicated insertion in 94/100 cases. In 6 patients difficulties were encountered with cannulating the vein. In 4 cases an experienced colleague was called and managed to cannulate the vein; in 1 case a new successful attempt was made on the opposite internal jugular vein, and in 1 the femoral vein was used. No patient required an open cutdown. There were no cases of line sepsis requiring removal but 1 replacement was required for blockage within 28days.
The USG approach in infants<5 kg is safe and can be used exclusively for venous access even in the most tiny babies. It is, however, a technically challenging procedure therefore we would recommend establishing a consultant delivered vascular access team to provide this service. Open venous cutdown in a tertiary children's hospital is no longer necessary for the insertion of TCVC and should be abandoned altogether.
Level I Prognosis Study.
Ultrasound guidance for Port-A-Cath insertion in children; a comparative study
2021, International Journal of Pediatrics and Adolescent Medicine
Citation Excerpt :
These results are consistent with other studies that reported 0.4–2.8% chest tube insertion after central line placement. In a study by Arul and coworkers on 500 pediatric patients, no pneumothoraces were reported [5]. Our results showed a higher insertion complication rate with the landmark technique (P = .052).
Gaining vascular access in children is challenging. Ultrasound-guided central line insertion in adults became the standard of care; however, its role in children is not clear. Our objective was to evaluate the ultrasound-guided Port-A-Cath or totally implanted long-term venous access device insertion in pediatric patients compared to the traditional approach.
This single-institution retrospective cohort study included 169 children who had port-A-catheters between May 2016 and Oct 2019. The patients were divided into two groups; group A included patients who had Port-A-Cath insertion using the landmark method (n = 117), and Group B included patients who had ultrasound-guided Port-A-Cath insertion (n = 52). Preoperative, operative, and postoperative data were collected and compared between the two groups. The study outcomes were operative time and catheter insertion-related complications.
There was no significant difference in age or gender between both groups (P = .33 and .71, respectively). Eleven cases in group A and two cases in group B were converted to cut down technique because of difficulty in inserting the guidewire. There was no difference in the indication of the need for the port-A-Cath between both groups. The mean operative time for group A was 47 min and for group B was 41.7 min (P < .042). Two patients had intraoperative bleeding and hemothorax and required blood transfusion and chest tube insertion in group A. No statistically significant difference was found in the reported complications between the groups. However, the insertion-related complications were higher in group A (P = .053). No procedure-related mortality was reported.
Ultrasound-guided insertion of Port-A-Cath is an effective and safe technique with a reduction of failure rate. It should be considered the standard technique for Port-A-Cath insertion in the pediatric population.
Open Versus Ultrasound Guided Tunneled Central Venous Access in children: A Randomized Controlled Study
2021, Journal of Surgical Research
Citation Excerpt :
This study demonstrated ultrasound guided percutaneous insertion was safe, resulted in shorter operating times, no increased risk of complication rates, and preservation of vessel size. While ultrasound guided percutaneous access has been compared and proven to be safer than blind punctures,2 it has not been compared with open surgical access. Ours is the first randomized trial comparing open versus ultrasound guided percutaneous catheter insertion in children.
The purpose of this study was to compare open insertion to ultrasound guided percutaneous insertion of central access catheters performed in a tertiary pediatric hospital in terms of its safety and complication rates.
This was an ethics approved prospective randomized trial of children under 16 y of age. Procedure was performed by surgeons with varying experience with percutaneous and open insertion. Primary outcome studied was complications-immediate and late. Secondary outcomes were time taken to complete procedure, conversion rates, duration of line use.
A total of 108 patients were analyzed. Sixty-four were male. Right internal jugular vein was accessed in 97. Eighty-one lines were double lumen, 23 implantable access devices, and the rest were single lumen catheters. More than one needle puncture was needed in 22% of the cases but there were no conversions in the ultrasound group. Twelve patients needed more than one insertion to achieve optimal position of the tip. Eleven patients had immediate and late complications. Percutaneous lines lasted 45 d longer though this was not statistically significant. Operating time was 20.6% shorter with percutaneous access. Post-removal measurement of vein size by ultrasound demonstrated significant decrease in size in the open group.
Ultrasound guided percutaneous insertion was safe. The study also demonstrated a decrease in operating times, preservation of vein size, and no increase in complication rates in the US group when performed by operators of varying expertise.
Hickman Central Venous Catheters in Children: Open Versus Percutaneous Technique
2020, Annals of Vascular Surgery
The ideal technique for insertion of tunneled central venous catheters (CVCs) in children is still debatable. This study aimed to compare the outcomes of open versus percutaneous technique for the insertion of tunneled CVCs.
The study included 279 patients who had CVCs insertions from 2010 to 2020. Patients were divided into two groups according to the technique of insertion: group 1 (n = 90) included patients who had the open cutdown method and group 2 (n = 189) included patients who had the percutaneous technique.
There was no difference in age and gender distribution between groups (P = 0.152 and 0.102, respectively). Chemotherapy was the most common indication of insertion (77 [85.56%] vs. 165 [87.30%]); in group 1 vs. 2, P = 0.688). The left external jugular was the most common site of insertion in group 1 (n = 66; 73.33%), and the left subclavian was the most common site in group 2 (n = 77; 40.74%). Complications of insertion were nonsignificantly higher in group 2 (P = 0.170). Nine patients in group 2 required conversion to cutdown technique (4.76%). Complications during removal were nonsignificantly higher in group 2 (P = 0.182), and the most common was bleeding (n = 4; 2.12%). The most common indication for catheter removal was the completion of the treatment (36 [40%] vs. 85 [44.97%] in groups 1 and 2, respectively).
Percutaneous and open tunneled central venous catheter insertion are safe in pediatric patients who require long-term venous access. Both techniques have a low complication rate. The choice of each method should be tailored to the condition of each patient.
Ultrasound guidance improves safety and efficiency of central line placements
2019, Journal of Pediatric Surgery
Use of ultrasound-guidance for central venous access in adults is the standard of care. There is, however, less clarity in the role of routine ultrasound use in obtaining venous access in children. We sought to evaluate safety and efficiency of the placement of central lines utilizing an ultrasound-guided approach compared to the traditional, landmark approach in pediatric patients.
A single-institution retrospective chart review, using CPT codes, was performed for all tunneled central venous catheters in children between 2005 and 2017 by the same pediatric surgery group. During the study period, a practice change occurred from exclusively landmark-based line placement to ultrasound-guided line placement. Groups were divided into three phases: a traditional/landmark era (Phase 1), transitional period (Phase 2), and the ultrasound era (Phase 3). The primary outcomes analyzed were postoperative chest tube insertions and operative time.
A total of 2010 tunneled central lines were included for analysis: Phase 1 (N = 930), Phase 2 (N = 313) and Phase 3 (N = 767). Venous access for chemotherapy was the most common indication (29%). Phase 1 had a chest tube placement rate of 9.7/1000 procedures, while Phase 2 had a rate of 6.4/1000 procedures, and Phase 3 had no chest tube insertions (p = 0.009). Phase 1 had longer OR times compared to Phase 2 (57 vs. 49, p = 0.0026) and Phase 3 (57 vs. 46 min, p < 0.001).
This study represents the largest analysis of ultrasound-guided access for children. A complete practice transition to the ultrasound-guided approach was feasible within a two-year period. The ultrasound-guided approach had a shorter operative time and less chest tube insertions than the traditional, landmark technique in children.
Level III evidence.
Open tunneled central line insertion in children — External or internal jugular vein?
2018, Journal of Pediatric Surgery
Tunneled central venous catheters (TCVCs) are commonly used to manage pediatric patients with chronic disease. The aim of this study is to compare the outcomes of external jugular vein (EJV) and internal jugular vein (IJV) tunneled catheters inserted using the open technique.
This is a single institution retrospective analysis of patients requiring an IJV or EJV TCVC in the period between 2009 and 2014. Data collected included the following: patient demographics, site/side of insertion, catheter size, number of lumens, duration of catheter in situ, and complications.
A total of 942 TCVCs (690 IJV; 252 EJV) were inserted in 761 patients. No statistical difference was seen between the two groups for procedure indications, age, gender, duration of line in situ, side of insertion, catheter size, number of lumens, and rate of premature catheter removals owing to complications. Rates of infection, blockage, and breakage were similar, but dislodgement was higher in the IJV group. EJV access was successful in 91% of attempts.
Open EJV TCVC insertion is a safe, quick, and feasible alternative to IJV insertion. EJV access offers comparable outcomes, reduced surgical morbidity, and improved hemostasis especially in children with coagulopathy and/or reduced platelet counts.
Retrospective comparative study.
Level 3.

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^☆: Interest declared: Our Hickman lines are all (except 2.7F) supplied by Bard Access Systems, Salt Lake City, UT, which financially supports vascular access educational events in which the authors participate. Our 2.7F lines are supplied by Vygon Ltd, Ecouen, France. Other manufacturers make similar products. Neither of our suppliers has in any way influenced the content of this paper, nor have the authors received any incentive to endorse a particular product or technique.

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Original articleUltrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures☆

Abstract

Aim

Methods

Results

Discussion

Section snippets

Methods

Technique

Results

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Br J Anaesth

Br J Anaesth

Surgeon

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

A silicone rubber atrial catheter for prolonged parenteral alimentation

Surg Gynecol Obstet

A modified right atrial catheter for access to the venous system in marrow transplant recipients

Surg Gynecol Obstet

Technique for placement of a permanent home hyperalimentation catheter

Surg Gynecol Obstet

Internal jugular vein patency rates following tunnelled central venous access by open surgical and ultrasound guided percutaneous techniques

Significant association with location of central venous line placement and risk of venous thrombosis in children

Thromb Haemost

Percutaneous placement of central venous catheters: comparing the anatomical landmark method with the radiologically guided technique for central venous catheterization through the internal jugular vein in emergent hemodialysis patients

Acta Radiologica

Original article
Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures☆