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Transesophageal echocardiography as a guide to central venous catheter placement in pediatric patients undergoing cardiac surgery
T r a n s e s o p h a g e a l E c h o c a r d i o g r a p h y as a G u i d e to Central Venous C a t h e t e r P l a c e m e n t in P e d i a t r i c Patients U n d e r g o i n g C a r d i a c S u r g e r y Dean B. A n d r o p o u l o s , M D
ENTRAL VENOUS CATHETER (CVC) placement for hemodynamic monitoring and access to the central circulation for the infusion of drugs and fluids is an important component of the anesthetic care of infants and children undergoing cardiac surgery. Minimizing complications and maximizing benefits of CVC insertion depend on meticulous attention to proper placement. The tip of a properly placed CVC should be in the superior vena cava (SVC), above the right atrium (RA) and parallel to the SVC wall. 1 This minimizes the risk for great-vessel or cardiac perforation and ensures accurate hemodynamic monitoring and rapid access of important drugs and fluids to the heart. Confirmation of correct placement often awaits the postoperative chest radiograph, potentially allowing malplacement to go unnoticed in the operating room. Transesophageal echocardiography (TEE) has become a regularly used method to assess preoperative and postoperative anatomy, monitor cardiac filling and ventricular function, and assess the presence of intracardiac air, among other uses in pediatric cardiac surgery. 2 This report describes the use of TEE to guide proper positioning of CVCs in the operating room before cardiac surgery in two infants.
C
CASE REPORTS
Case l A 5.0-kg, 12-day-old girl presented to the operating room for the arterial switch operation for transposition of the great vessels with intact ventricular septum and for closure of an atrial septal defect and ligation of a patent ductus arteriosus. After intravenous induction of general anesthesia, nasotracheal intubation, and gastric suctioning, arterial access was established through the left femoral artery. A 3.5/5-MHz biplane pediatric TEE probe (model V705B; Acuson, Mountain View, CA) was passed without difficulty, and a transverse-plane four-chamber view of the heart was obtained. Using sterile Seldinger technique, the fight subclavian vein was entered, and the guidewire was visualized passing into the RA on the TEE. A 4F, 8-cm long, double-lumen polyurethane catheter (CUDLM 401J-AB; Cook Critical Care, Bloomington, IN) was then passed over the guidewire to the hub, and the guidewire was removed. A longitudinal-plane view of the SVC-RA junction was then obtained, and the tip of the catheter was clearly visualized in the upper RA. The catheter was then withdrawn under continuous TEE visualization until it was in the SVC, 0.5 cm above the atrium, and sutured in place at the 6.5-cm mark (Fig 1). Free blood aspiration from both lumens was obtained, and the central venous pressure waveform was appropriate. The surgery proceeded without incident. The postoperative chest radiograph showed the tip of the catheter to be parallel to the SVC wall just above the RA (Fig 2).
From Baylor College of Medicine; and the Division of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Houston, TX. Address reprint requests to Dean B. Andropoulos, MD, Director, Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, 6621 Fannin, Suite 310, Mail Code 2-1495, Houston TX 77030-2399. Copyright © 1999 by W.B. Saunders Company 1053-0770/99/1303-0016510.00/0 Key words: anesthesia, pediatric, cardiac, vascular access, transesophageal echocardiography
320
Case 2
A 5.8-kg, 5-month-old boy with a history of trisomy 21 presented for repair of a complete atrioventricular canal defect and ligation of a patent ductus arteriosus. ARer induction of general anesthesia, the TEE probe was passed, and a transverse-plane four-chamber view of the heart was obtained. A right subclavian CVC was then placed using sterile Seldinger technique, and the guidewire was clearly seen entering the RA on TEE. A 4F, 8-cm, double-lumen catheter was then inserted its full length, and the tip was visualized in the high RA by longitudinal-plane view of the SVC-RA junction. The CVC was withdrawn using TEE visualization until the tip was 0.5 cm above the top of the atrium. It was sutured at the 7-era mark. Postoperative chest radiograph confirmed correct placement in the distal SVC just above the RA.
DISCUSSION
The use of TEE in adults to assist in the placement of pulmonary artery catheters, 3 right atrial air aspiration catheters for sitting craniotomy, 4 and for proper positioning of ventriculoatrial shunts 5 has been described. The use of ultrasound devices to locate the internal jugular vein in the neck in children has also been described. 6 However, the use of TEE to assist in CVC placement in children undergoing cardiac surgery has not been described. Because TEE is used in the majority of pediatric cardiac surgical patients in this institution, it is a simple matter to place the probe before CVC placement. The guidewire and catheter were easily visualized by the TEE in these cases. The TEE probe can be manipulated through the sterile drapes by the operator with one hand, while the other hand is used to adjust the position of the guidewire or the CVC. This does not interfere with the procedure. Correct positioning was confirmed radiographically. Preoperative confirmation of correct CVC placement is especially important when the subclavian vein is used, because the incidence of malplacement is greater than with the internal jugular vein. As many as 20% of subclavian catheters are placed in the ipsilateral internal jugular vein or the innominate vein when a blind positioning technique is used. 7-9 In contrast, the internal jugular approach appears to lead to placement outside the SVC or RA 0% to 2% of the time. 1°-13 Although intraoperative perforation of the heart or great vessels from CVC placement is rare, the high incidence of severe morbidity or mortality when it occurs suggests that preoperative confirmation of correct positioning would be useful. TM The time and expense of a preoperative chest radiograph are obstacles to the use of this method. Standard clinical methods, such as observing the electrocardiogram for premature atrial contractions to confirm atrial placement and measuring externally for depth of CVC insertion, may be inaccurate. Low positioning of the CVC just above the RA-SVC junction is chosen for several reasons. First, the catheter tip is often not visible by TEE when more than 2 cm above the RA. Second, the total length of the SVC in small infants may only be 4 to 5 cm, and higher placement may result in the proximal port (1 to 1.5 cm from the tip) of a multilumen catheter being outside the vascular space. The tip may also migrate proximally with sternal retraction or with inspiration, as observed by TEE in
Journal of Cardiothoracic and Vascular Anesthesia, Vo113, No 3 (June), 1999: pp 320-321
TEE IN CVC PLACEMENT
321
Fig 1. Longitudinal-planetransesophageal echocardiographic view of the SVC-RA junction in patient 1. The catheter tip is seen in the SVC above the atrium. Abbreviations: LA, left atrium; SVC, superior vena cava; RA, right atrium.
Fig 2. Postoperative chest radiograph in patient I showing subclavian catheter tip in the SVC, above the RA.
several other patients not described in this case report. In the author's practice, the low position in the SVC has not interfered with SVC cannulation or the placement of pursestring sutures or snares by the surgeon. In summary, two cases are described in which small infants
undergoing cardiac surgery had a CVC placed using TEE to confirm both initial placement of the guidewire in the RA and final placement of the tip of the catheter in the SVC. It appears that TEE-guided CVC placement may be a rapid method of early confirmation of correct position.
REFERENCES
1. CoIlier PE, Goodman GB: Cardiac tamponade caused by central venous catheter perforation of the heart: A preventable complication. J Am Coll Surg 181:459-463, 1996 2. Muhiudeen IA, Cahalan MK, Silverman NH: Intraoperative transesophageal echocardiography in patients with congenital heart disease, in Greeley WJ (ed): Perioperative Management of the Patient With Congenital Heart Disease. Baltimore, MD, Williams & Wilkins, 1996, pp 43-65 3. Turnage WS, Fontanet H: Transesophageal echocardiographyguided pulmonary artery catheter placement. Anesth Analg 77:858-859, 1993 4. Roth S, Aronson S: Placement of a right atrial air aspiration catheter guided by transesophageal echocardiography. Anesthesiology 83:1359-1361, 1995 5. McGrail KM, Muaai DA, Losasso TJ, Meyer FB: Ventricnloatrial shunt distal catheter placement using transesophageal echocardiography: Technical note. Nemosurgery 30:747-749, 1992 6. Randolph AG, Cook DJ, Gonzales CA, et al: Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Meal 24:2053-2058, 1996 7. Pybus DA, Poole JL, Crawford MC: Subclavian venous catheterization in small children using the Seldinger technique. Anaesthesia 37:451-453, 1982
8. Venkataraman ST, Orr RA, Thompson AE: Percutaneous infraclavicular subclavian vein catheterization in critically ill infants and children. J Pediatr 113:480-485, 1988 9. Sanchez R, Halck S, Walther-Larsen S, et al: Misplacement of subclavian venous catheters: Importance of head position and choice of puncture site. Br J Anaesth 64:632-633, 1990 10. Nicholson SC, Sweeney MF, Moore RA, Jobes DR: Comparison of internal and external jugular cannulation of the central circulation in the pediatric patient. Crit Care Med 13:747-749, 1985 11. Hayashi Y, Uchida O, Takaki O, et al: Internal jugular vein catheterization in infants undergoing cardiovascular surgery: An analysis of factors influencing successful catheterization. Anesth Analg 74:688-693, 1992 12. Prince SR, Sullivan RL, Hackel A: Percntaneous catheterization of the internal jugular vein in infants and children. Anesthesiology 44:170-174, 1976 13. Cote' CJ, Jobes DR, Schwartz AJ, et al: Two approaches to cannulation of a child's internal jugular vein. Anesthesiology 50:371373, 1979 14. Milo S, Sawaed S, Adler Z, et al: Misplaced arterial catheter in an infant causes intraoperative death. J Cardiothorac Vasc Anesth 6:101104, 1992
ENTRAL VENOUS CATHETER (CVC) placement for hemodynamic monitoring and access to the central circulation for the infusion of drugs and fluids is an important component of the anesthetic care of infants and children undergoing cardiac surgery. Minimizing complications and maximizing benefits of CVC insertion depend on meticulous attention to proper placement. The tip of a properly placed CVC should be in the superior vena cava (SVC), above the right atrium (RA) and parallel to the SVC wall. 1 This minimizes the risk for great-vessel or cardiac perforation and ensures accurate hemodynamic monitoring and rapid access of important drugs and fluids to the heart. Confirmation of correct placement often awaits the postoperative chest radiograph, potentially allowing malplacement to go unnoticed in the operating room. Transesophageal echocardiography (TEE) has become a regularly used method to assess preoperative and postoperative anatomy, monitor cardiac filling and ventricular function, and assess the presence of intracardiac air, among other uses in pediatric cardiac surgery. 2 This report describes the use of TEE to guide proper positioning of CVCs in the operating room before cardiac surgery in two infants.
C
CASE REPORTS
Case l A 5.0-kg, 12-day-old girl presented to the operating room for the arterial switch operation for transposition of the great vessels with intact ventricular septum and for closure of an atrial septal defect and ligation of a patent ductus arteriosus. After intravenous induction of general anesthesia, nasotracheal intubation, and gastric suctioning, arterial access was established through the left femoral artery. A 3.5/5-MHz biplane pediatric TEE probe (model V705B; Acuson, Mountain View, CA) was passed without difficulty, and a transverse-plane four-chamber view of the heart was obtained. Using sterile Seldinger technique, the fight subclavian vein was entered, and the guidewire was visualized passing into the RA on the TEE. A 4F, 8-cm long, double-lumen polyurethane catheter (CUDLM 401J-AB; Cook Critical Care, Bloomington, IN) was then passed over the guidewire to the hub, and the guidewire was removed. A longitudinal-plane view of the SVC-RA junction was then obtained, and the tip of the catheter was clearly visualized in the upper RA. The catheter was then withdrawn under continuous TEE visualization until it was in the SVC, 0.5 cm above the atrium, and sutured in place at the 6.5-cm mark (Fig 1). Free blood aspiration from both lumens was obtained, and the central venous pressure waveform was appropriate. The surgery proceeded without incident. The postoperative chest radiograph showed the tip of the catheter to be parallel to the SVC wall just above the RA (Fig 2).
From Baylor College of Medicine; and the Division of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Houston, TX. Address reprint requests to Dean B. Andropoulos, MD, Director, Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, 6621 Fannin, Suite 310, Mail Code 2-1495, Houston TX 77030-2399. Copyright © 1999 by W.B. Saunders Company 1053-0770/99/1303-0016510.00/0 Key words: anesthesia, pediatric, cardiac, vascular access, transesophageal echocardiography
320
Case 2
A 5.8-kg, 5-month-old boy with a history of trisomy 21 presented for repair of a complete atrioventricular canal defect and ligation of a patent ductus arteriosus. ARer induction of general anesthesia, the TEE probe was passed, and a transverse-plane four-chamber view of the heart was obtained. A right subclavian CVC was then placed using sterile Seldinger technique, and the guidewire was clearly seen entering the RA on TEE. A 4F, 8-cm, double-lumen catheter was then inserted its full length, and the tip was visualized in the high RA by longitudinal-plane view of the SVC-RA junction. The CVC was withdrawn using TEE visualization until the tip was 0.5 cm above the top of the atrium. It was sutured at the 7-era mark. Postoperative chest radiograph confirmed correct placement in the distal SVC just above the RA.
DISCUSSION
The use of TEE in adults to assist in the placement of pulmonary artery catheters, 3 right atrial air aspiration catheters for sitting craniotomy, 4 and for proper positioning of ventriculoatrial shunts 5 has been described. The use of ultrasound devices to locate the internal jugular vein in the neck in children has also been described. 6 However, the use of TEE to assist in CVC placement in children undergoing cardiac surgery has not been described. Because TEE is used in the majority of pediatric cardiac surgical patients in this institution, it is a simple matter to place the probe before CVC placement. The guidewire and catheter were easily visualized by the TEE in these cases. The TEE probe can be manipulated through the sterile drapes by the operator with one hand, while the other hand is used to adjust the position of the guidewire or the CVC. This does not interfere with the procedure. Correct positioning was confirmed radiographically. Preoperative confirmation of correct CVC placement is especially important when the subclavian vein is used, because the incidence of malplacement is greater than with the internal jugular vein. As many as 20% of subclavian catheters are placed in the ipsilateral internal jugular vein or the innominate vein when a blind positioning technique is used. 7-9 In contrast, the internal jugular approach appears to lead to placement outside the SVC or RA 0% to 2% of the time. 1°-13 Although intraoperative perforation of the heart or great vessels from CVC placement is rare, the high incidence of severe morbidity or mortality when it occurs suggests that preoperative confirmation of correct positioning would be useful. TM The time and expense of a preoperative chest radiograph are obstacles to the use of this method. Standard clinical methods, such as observing the electrocardiogram for premature atrial contractions to confirm atrial placement and measuring externally for depth of CVC insertion, may be inaccurate. Low positioning of the CVC just above the RA-SVC junction is chosen for several reasons. First, the catheter tip is often not visible by TEE when more than 2 cm above the RA. Second, the total length of the SVC in small infants may only be 4 to 5 cm, and higher placement may result in the proximal port (1 to 1.5 cm from the tip) of a multilumen catheter being outside the vascular space. The tip may also migrate proximally with sternal retraction or with inspiration, as observed by TEE in
Journal of Cardiothoracic and Vascular Anesthesia, Vo113, No 3 (June), 1999: pp 320-321
TEE IN CVC PLACEMENT
321
Fig 1. Longitudinal-planetransesophageal echocardiographic view of the SVC-RA junction in patient 1. The catheter tip is seen in the SVC above the atrium. Abbreviations: LA, left atrium; SVC, superior vena cava; RA, right atrium.
Fig 2. Postoperative chest radiograph in patient I showing subclavian catheter tip in the SVC, above the RA.
several other patients not described in this case report. In the author's practice, the low position in the SVC has not interfered with SVC cannulation or the placement of pursestring sutures or snares by the surgeon. In summary, two cases are described in which small infants
undergoing cardiac surgery had a CVC placed using TEE to confirm both initial placement of the guidewire in the RA and final placement of the tip of the catheter in the SVC. It appears that TEE-guided CVC placement may be a rapid method of early confirmation of correct position.
REFERENCES
1. CoIlier PE, Goodman GB: Cardiac tamponade caused by central venous catheter perforation of the heart: A preventable complication. J Am Coll Surg 181:459-463, 1996 2. Muhiudeen IA, Cahalan MK, Silverman NH: Intraoperative transesophageal echocardiography in patients with congenital heart disease, in Greeley WJ (ed): Perioperative Management of the Patient With Congenital Heart Disease. Baltimore, MD, Williams & Wilkins, 1996, pp 43-65 3. Turnage WS, Fontanet H: Transesophageal echocardiographyguided pulmonary artery catheter placement. Anesth Analg 77:858-859, 1993 4. Roth S, Aronson S: Placement of a right atrial air aspiration catheter guided by transesophageal echocardiography. Anesthesiology 83:1359-1361, 1995 5. McGrail KM, Muaai DA, Losasso TJ, Meyer FB: Ventricnloatrial shunt distal catheter placement using transesophageal echocardiography: Technical note. Nemosurgery 30:747-749, 1992 6. Randolph AG, Cook DJ, Gonzales CA, et al: Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Meal 24:2053-2058, 1996 7. Pybus DA, Poole JL, Crawford MC: Subclavian venous catheterization in small children using the Seldinger technique. Anaesthesia 37:451-453, 1982
8. Venkataraman ST, Orr RA, Thompson AE: Percutaneous infraclavicular subclavian vein catheterization in critically ill infants and children. J Pediatr 113:480-485, 1988 9. Sanchez R, Halck S, Walther-Larsen S, et al: Misplacement of subclavian venous catheters: Importance of head position and choice of puncture site. Br J Anaesth 64:632-633, 1990 10. Nicholson SC, Sweeney MF, Moore RA, Jobes DR: Comparison of internal and external jugular cannulation of the central circulation in the pediatric patient. Crit Care Med 13:747-749, 1985 11. Hayashi Y, Uchida O, Takaki O, et al: Internal jugular vein catheterization in infants undergoing cardiovascular surgery: An analysis of factors influencing successful catheterization. Anesth Analg 74:688-693, 1992 12. Prince SR, Sullivan RL, Hackel A: Percntaneous catheterization of the internal jugular vein in infants and children. Anesthesiology 44:170-174, 1976 13. Cote' CJ, Jobes DR, Schwartz AJ, et al: Two approaches to cannulation of a child's internal jugular vein. Anesthesiology 50:371373, 1979 14. Milo S, Sawaed S, Adler Z, et al: Misplaced arterial catheter in an infant causes intraoperative death. J Cardiothorac Vasc Anesth 6:101104, 1992