Discussions on the complications of central venous catheterization in children typically focus on infectious and the more common mechanical complications of pneumothorax, hemothorax, or thrombosis. Rare complications are often more life-threatening, and inexperience may compound the problem. Central venous catheter complications can be broken down into early or late, depending on when they occur. The more serious complications are typically mechanical and occur early, but delayed presentations of pericardial effusions, cardiac tamponade, and pleural effusions may be of equal severity, and delay in diagnosis can be catastrophic. Careful insertion techniques, as well as continued vigilance in the correct position and function of central venous catheters, are imperative to help prevent serious complications.

Placement of a peripherally inserted central catheter (PICC) is commonplace in infants and children for the infusion of medications, hydration, and nutritional solutions. Vein depletion caused by repeated and prolonged need for vascular access devices has forced practitioners to consider alternate veins for providing care. The external jugular vein has a positive history of use for insertion of the PICC and is becoming increasing popular for this purpose. Pertinent anatomy, patient selection criteria, preparation, and catheter insertion and maintenance processes related to the catheter placed and residing in the external jugular vein are discussed.

OBJECTIVE Ultrasound guidance (USG) for internal jugular cannulation is the best solution in difficult settings where paediatric patients are involved. This is an outcome study on efficacy and complications of the USG for the internal jugular vein (IJV) cannulation in neurosurgical infants as well as an ultrasound study of anatomical findings of the IJVs in infants. DESIGN AND SETTINGS A prospective study conducted in two Academic Neurosurgical hospitals. PARTICIPANTS In 191 babies (body weight <15 kg), anatomical findings were studied. We performed CVC echo guided placement in 135/191 infants (weighting <10 kg). RESULTS After a brief training period, both institutions adopted a common protocol and USG device. We obtained successful cannulation in all patients. Carotid puncture (1.5%) was the only main complication registered and minor complications were poor. Time required for cannulation was 12.5 +/- 5.7 min. Anatomical findings (in 191 patients) were IJV laterality in 34.6% cases, IJV antero-lateral in 59.7% and anterior in 5.7%. A linear relation was found between weight and internal jugular vein diameter even if R(2)= 0.43 and the model cannot be used to predict the exact size of the vein. In 62/135 babies weighting <10 kg, anatomical measurements were done in supine and Trendelemburg position. Trendelemburg position increases significantly (P < 0.001) IJV diameter, but not IJV depth. CONCLUSIONS We considered ultrasound guidance as the first choice in infants because it can enhance IJV cannulation success, safety, and allows one to measure relationships and diameter of the IJV and optimise the central line positioning.

The safe and successful performance of a central venous catheterization (CVC) requires a specific knowledge of anatomy in addition to a working knowledge. Misunderstanding the anatomy may result in failure or complications. This review aims to aid understanding of the anatomical framework, pitfalls, and complications of CVC of the internal jugular veins. CVC is common practice amongst surgeons, anesthesiologists, and emergency room physicians during the preparations for major surgical procedures such as open-heart surgery, as well as for intensive care monitoring and rapid restoration of blood volume. Associated with this technique are certain anatomical pitfalls and complications that can be successfully avoided if one possesses a thorough knowledge of the contraindications, regional anatomy, and rationale of the technique.

A 2-month-old girl with severe pneumonia required a central venous line. Femoral vein catheterisation was attempted but insertion was difficult. Pneumoperitoneum developed, which is a rare complication of femoral vein catheterisation. It is important when undertaking femoral vein catheterisation to use the correct landmarks in the femoral triangle below the inguinal ligament and an appropriate size of catheter.

BACKGROUND The primary aim of this study was to compare catheter-associated infections and tip contaminations between percutaneously placed central venous catheters in the internal jugular and subclavian veins in surgical neonates undergoing major noncardiac surgery. METHODS The prospectively computerized protocols of 295 procedures were analyzed retrospectively. RESULTS One hundred twenty-nine internal jugular venous (group I) and 107 subclavian venous catheters (group S) were included. The median postconceptual age was 37 weeks in group I and 38 in group S. The weight ranged from 580 g to 4.5 kg in group I and from 820 g to 4.5 kg in group S at the time of insertion. Significantly more catheter-associated infections were observed in group I (15.5 vs. 4.7%; chi-square analysis: P < 0.01). The internal jugular venous catheters were also associated with a significantly increased probability of an earlier onset of a catheter-associated infection compared with the subclavian venous catheters (log rank test: P < 0.01; Cox model: P < 0.01). This probability was only slightly increased by a lower weight (Cox model: P = 0.075), and it was not increased by a lower age (Cox model: P = 0.93). Significantly more catheter tips were contaminated by pathogens in group I (55.8 vs. 33.6%; chi-square analysis: P < 0.01). CONCLUSION The internal jugular venous catheters were associated with a higher infection rate as well as earlier onset of catheter-associated infection compared with the subclavian venous catheters.

BACKGROUND Placement of central venous catheter is essential in the management of critically ill children. The purpose of the present paper was to evaluate the success rate, mechanical and thrombotic complications and risk factors associated with these complications from different central venous access sites in critically ill children. METHODS A prospective study was undertaken from February 2000 to March 2005 of 369 central venous catheterizations in children in a pediatric intensive care unit. RESULTS The veins most frequently used were femoral vein (45%), subclavian vein (32.2%), and internal jugular vein (22.8%). Mean +/- SD duration of catheterization was 9.5 +/- 6.5 days. The procedure was performed under emergency conditions in 18% of patients with an overall success rate of 92.4%. The success rate was significantly lower in younger patients with subclavian catheterization. Insertion-related complications were noted, including 33 arterial punctures (8.9%), 27 cases of malposition (7.3%), 19 hematomas (5.2%), 12 cases of minor bleeding (3.3%), and three cases of pneumothorax (0.8%), and they were more common in the subclavian vein than in the internal jugular and femoral vein. Multiple attempts and failed attempts significantly correlated with higher incidence of complications. Maintenance-related complications included obstruction (n = 26; 7%), accidental removal (n = 14; 3.8%), central venous thrombosis (n = 8; 2.2%), subcutaneous extravasation (n = 14; 3.8%), dislodgment (n = 1; 0.25%), and extravascular infusion (n = 1; 0.25%). The frequency of catheter maintenance-related complications was significantly higher in femoral catheterizations and increased significantly with an increase in the duration of catheterization. A total of five serious complications were seen (pneumothorax in three, dislodgment in one and extravascular infusion in one) in the present series. CONCLUSIONS Central venous catheterization in critically ill children is a relatively safe procedure, with a 1.3% rate of serious complications and no mortality. It seems safer to choose initially the femoral or internal jugular vein instead of the subclavian vein because of high success rate without serious insertion-related complications.

The safe and successful performance of a central venous catheterization (CVC) requires a specific knowledge of anatomy in addition to a working knowledge. Misunderstanding the anatomy may result in failure or complications. This review aims to aid understanding of the anatomical framework, pitfalls, and complications of CVC of the subclavian (SCV). CVC is common practice amongst surgeons, anesthesiologists, and emergency room physicians during the preparations for major surgical procedures such as open-heart surgery, as well as, for intensive care monitoring and rapid restoration of blood volume. Associated with this technique are certain anatomical pitfalls and complications that can be successfully avoided if one possesses a thorough knowledge of the contraindications, regional anatomy, and rationale of the technique.

BACKGROUND:/st> Central venous cannulation in infants remains challenging even for experienced paediatric anaesthesiologists. Ultrasound (US)-guidance techniques are proven to be safer for internal jugular vein catheterization. But the subclavian vein (SCV) is often the preferred site for long-term central venous catheterization in children. We describe a novel US-guided approach for SCV cannulation in infants and children. METHODS:/st> The principle of this technique is to place the US probe at the supraclavicular level to obtain a longitudinal view of the SCV, and to gain access to the vein via the usual infraclavicular route to cannulate it under ultrasonic control. Details and pitfalls of this technique are described. The prospectively collected results of our first 25 punctures are reported. RESULTS:/st> Patients' weight and age range were 2.2-27 kg and 1 day to 9 yr, respectively: 76% of the children weighed less than 10 kg. The success rate at the first attempt was 84% and 100% after two attempts. An asymptomatic thrombus in the SCV could also be detected with this technique. CONCLUSIONS:/st> This US-guided approach of the SCV offers a new possibility for central venous catheterization in children. This technique seems promising for children less than 10 kg and probably also for older children. It provides good quality needle guidance and allows to check the vessel patency before puncture.

To avoid fatal complications of central venous catheterization such as cardiac tamponade, the tip of the central venous catheter (CVC) should be placed outside of the cardiac chamber. To suggest a guideline for a proper depth of CVC in infants, we measured the distance from the skin puncture site to the junction between superior vena cava and right atrium (SVC-RA junction) by using transesophageal echocardiography (TEE). Fifty infants less than 5 kg undergoing surgery for congenital heart disease were enrolled in this prospective study. After the induction of general anesthesia, CVC was inserted via the right subclavian vein. After the tip of the CVC was placed at the SVC-RA junction using TEE guidance, the length of the CVC inserted beneath the skin was measured. The measured distance had a high correlation with the patient's height, weight, and age (r = 0.88, 0.76, and 0.64, respectively). In infants smaller than 5 kg, the following guideline can avoid intraatrial placement of the CVC: a depth between 40 and 45 mm for infants 2.0-3.0 kg in weight, 45-50 mm for those 3.0-3.9 kg, and 50-55 mm for those more than 4.0 kg.

Over the past decade, nonoperative management of most pediatric blunt abdominal trauma has emerged as accepted practice. It is possible that treatment of associated hollow visceral disruption might be missed or delayed because of this nonoperative approach. In a review of all cases of intestinal perforation from blunt trauma seen over the past 6 years, we found 12 cases of intestinal disruption in more than 600 cases of significant blunt trauma. Child abuse caused eight cases and four were motor vehicle related (MVR). Seven of eight battered children had a delay of more than 48 hours from injury to hospital presentation. Three of four MVR patients had an 18-hour delay from injury to operation. Ten of 12 patients survived. The two children who succumbed were both battered and were moribund and unstable when first seen and failed to respond to aggressive stabilization and surgery. Serial physical examinations, contrast radiographic studies, and peritoneal lavage were the most helpful diagnostic modalities. There were no significant complications and no patient required more than one operation (except for ostomy closure). All surviving patients are well at followup and seven of ten have been followed for more than 3 years; two are not yet 1 year from surgery and one is lost to followup. Several principles have emerged from this review: 1) motor vehicle trauma and child abuse are the major etiologic factors in childhood blunt trauma; 2) accurate and rapid diagnosis of intestinal perforation in children is difficult; 3) recovery in the presence of stable vital signs can be expected, even with the long delays; and 4) abused children must be carefully evaluated for abdominal trauma.

The association between pyelonephritis and vesicoureteral reflux (VUR) following pediatric renal transplantation is unclear. To understand the relationship of vesicoureteral reflux with urinary tract infection (UTI) and pyelonephritis, 67 patients were evaluated for reflux and pyelonephritis. Sixty-seven pediatric patients, aged 2 to 18 (39 males and 28 females) underwent renal transplantation. Beginning in 1982, all patients underwent voiding cystourethrography or radionuclide voiding studies 1 to 3 months postoperatively to assess the incidence of VUR. Techniques of ureteroneocystostomy (UNC) included the Leadbetter-Politano (L-p) in 39 cases, and two different modifications of the LICH (herein called LICH-1 and LICH-2) in 30 cases. Urinary cultures were performed routinely. Pyelonephritis was considered present in any patient with UTI and increased serum creatinine or fever greater than 38.5. VUR occurred in 36% of patients; highest in LICH-1 (79%), intermediate in L-P (22%), and lowest in LICH-2 (9%). VUR was not statistically significantly higher in females (43%) v males (31%). UTI occurred in 37% of patients. The difference in incidence between females (54%) and males (26%) was significant (P less than .05). The frequency of UTI in patients with VUR was 46% v 33% in patients without reflux (NS). However, pyelonephritis that occurred in 16% of cases overall was present in 82% of UTIs in patients with reflux v 14% of UTIs in patient without reflux (P less than .01). Pyelonephritis is significantly increased in pediatric renal transplant patients with UTI was have VUR. A nonrefluxing UNC is advocated in all patients. All renal transplant patients should have routine monitoring of urinary cultures and should be evaluated of VUR posttransplant.

We have described an infant in whom migration of a transected umbilical artery catheter resulted in sudden vascular ischemia of an extremity. Early operative retrieval was successful, but long-term effects of this complication were encountered. We have outlined an approach to the initial management of the complication. In addition, this case demonstrates the need for careful follow-up for identification and treatment of the long-term sequelae in the involved extremity.

Thymic cysts are considered uncommon lesions in the differential diagnosis of pediatric neck masses. They have been described as asymptomatic and of little clinical consequence. Recent reports have stressed the possibility of respiratory compromise associated with these lesions. We reviewed our experience with cervical thymic cysts with emphasis on respiratory problems. Ten pediatric patients underwent surgery and were found to have cervical thymic cysts. Ages ranged from newborn to 14 years. There were four boys and six girls. Two were found to have the thymic cysts at time of neck exploration for Grave's disease and hyperparathyroidism. Of the remaining eight patients, all had mobile cystic masses, located anterior to but extending beneath the lower third of the sternocleidomastoid muscle. The size of the mass ranged from 3.0 to 8.5 cm. Preoperative diagnosis included cystic hygroma/branchial cleft cyst (five), lymphoma (one), teratoma (one), and thymic cyst (one). All had a history of rapidly developing neck mass. Seven of the eight gave a history of upper respiratory tract infection (URI) prior to the development of the mass. Five had imaging studies that showed tracheal compression. Three of these required airway management in the early postoperative period. All were excised through a neck incision, with two requiring sternal extension. Histology showed cholesterol crystals, Hassall's corpuscles, and giant cell reaction diagnosis of thymic cysts. There has been no recurrence and no permanent respiratory sequela in the ten patients. Cervical thymic cysts are benign lesions that may be more common than literature suggests.(ABSTRACT TRUNCATED AT 250 WORDS)

The ideal wound-support material would reinforce a wound early in the healing process when intrinsic wound strength is the weakest, yet disappear over time, preventing many of the untoward late effects seen with currently utilized nonabsorbable materials. This study was designed to evaluate the effectiveness of a newly designed absorbable material, polyglycolic acid mesh (Dexon), as a buttress for abdominal wounds closed under moderate tension. Young male rats (n = 211) were divided into three experimental groups. Animals in groups 1 (n = 96) and 2 (n = 95) had a 1.2 cm2 midline abdominal wall defect created and closely primarily. Animals in group 2 had a 2 X 5 cm piece of polyglycolic acid mesh sutured to the anterior abdominal wall overlying the closed abdominal defect. Animals in group 3 (n = 20) were unoperated controls. The animals in groups 1 and 2 were killed 1, 2, 3, 4, and 5 weeks after surgery. The entire anterior abdominal wall was removed and placed upon a bursting strength testing device. Bursting strength determinations of the supported and unsupported abdominal closures revealed that the strength of the wounds reinforced with polyglycolic acid mesh was significantly greater than unsupported wounds at 1, 2, and 3 weeks after surgery. Wounds supported with mesh had bursting strengths similar to unoperated abdomens by the first postoperative week. This study demonstrates that abdominal wall defects in rats closed primarily develop increased wound strength when the closure is supported by absorbable polyglycolic acid mesh. The use of an absorbable material may alleviate potential late complications associated with implantation of nonabsorbable materials. The clinical application of such a material remains to be determined.

BACKGROUND/PURPOSE: Children who require a liver transplant at an early age risk chronic allograft rejection (CAR) and other causes of allograft loss. Multiple retransplants may be required for long-term patient survival. The authors evaluate this approach based on our results and technical difficulties. METHODS: Charts of 7 children who received 3 or more liver transplants from 1989 to the present were reviewed retrospectively. RESULTS: A total of 151 children required liver transplantation at our institution since 1989. Of these, 4 boys and 3 girls (mean age, 6.2 years; range, 3 to 14 years) have received 3 or more allografts. The etiology of liver failure for the penultimate allograft was CAR (n = 6) and hepatic artery thrombosis (HAT; n = 1). Five cases required modification of portal vein or hepatic artery anastomoses. Two patients with vena caval strictures required supradiaphragmatic vena caval reconstruction. The original Roux-en-Y limb was adequate for biliary reconstruction in all cases. Five children currently are alive (survival rate, 71%) with good graft function having had a mean follow-up of 23 months (range, 2 to 48 mos.). CONCLUSIONS: The operative procedure for the multiple hepatic transplant child is challenging. The transplant team must be prepared for intraoperative issues such as extended organ ischemia time during hepatectomy, extensive blood loss, and potential need for creative organ revascularization techniques. Overall, multiple retransplant results are good and justify the use of multiple allografts.

PURPOSE: The aim of this review was to determine the incidence of gastrointestinal perforation after pediatric liver transplantation and to identify risk factors and clinical indicators that may lead to an earlier diagnosis. METHODS: A retrospective chart review of all children who presented with gastrointestinal perforation after liver transplantation at our institution between January 1, 1987 and August 1, 1996 was performed. RESULTS: One hundred fifty-seven orthotopic liver transplants were performed in 128 children. Fifty-eight reexplorations, excluding those for retransplantation, were performed in 38 children. Ten perforations occurred in six children (incidence, 6.4%). Two children required multiple reexplorations because of several episodes of perforation. The sites of perforation were duodenum (n=1), jejunum (n=8), and ileum (n=1). A single-layer closure was used to repair five perforations, two-layer closures in four, and resection with primary anastomosis in another. The type of repair did not affect the occurrence of subsequent perforations. All the children were less than 18 months old. Four children had undergone prior laparotomy. All children had choledochoenteric anastomoses, but only one had a perforation associated with it. One child sustained bowel injury during the dissection for the liver transplant, but none of the perforations occurred at this site. Bowel function had returned before perforation in five children. Five children were receiving systemic antibiotics at the time of their perforation, and none had been dosed with pulse steroids for rejection. All of the children had significant changes in their temperature. Acute leukopenia developed in one child. A leukocytosis developed in the rest of the children. Abdominal radiographs demonstrated pneumoperitoneum in only one child. All children had positive culture findings from their abdominal drains. Cytomegalovirus developed in one child. Although the diagnosis of gastrointestinal perforation after pediatric liver transplant remains difficult, positive drain culture findings and significant alterations in temperature and leukocyte counts suggest its presence. Pneumoperitoneum is rarely present. CONCLUSION: A high index of suspicion and timely laparotomy, especially in children less than 2 years of age, may be the only way to rapidly diagnose and treat this potentially devastating complication of liver transplant.

PURPOSE Fibrosing colonopathy is a newly described entity seen in children with cystic fibrosis. The radiological hallmarks are foreshortening of the right colon with varying degrees of stricture formation. High-dose enzyme therapy has been implicated as the cause of this process. The purpose of this study is to review the author's experience with evaluation and treatment of these patients. METHODS There are currently 380 patients being treated at our CF center. Fifty-five of these patients have been treated with high-dose enzyme therapy (> 5,000 units of lipase/kg). The medical records of these patients, who are at risk for developing fibrosing colonopathy, were reviewed for the presence of recurrent abdominal complaints, and the work-up and treatment of these symptoms. RESULTS Chronic complaints of abdominal pain, distension, change in bowel habits, or failure to thrive were present in 24 of the 55 patients treated with high-dose enzymes. So far, 18 of these 24 patients have been evaluated by contrast enema. Thirteen of eighteen have been found to have fibrosing colonopathy characterized by foreshortening and strictures of the colon. Additional findings included focal strictures of the right colon (7 of 13), long segment strictures (5 of 13), and total colonic involvement (1 of 13). Nine patients with the most severe symptoms have undergone colon resection, including five segmental right colectomies, three extended colectomies (ileo-sigmoid anastomosis), and one subtotal colectomy with end-ileostomy. Pathological evaluation has shown submucosal fibrosis, destruction of the muscularis mucosa, and eosinophilia. No postoperative complications or deaths occurred. All nine postoperative patients have noted marked symptomatic improvement. Contrast enema follow-up results are available for six patients, and have documented no recurrent strictures to date. Three of four nonoperative patients have less severe symptoms and are currently being treated conservatively. The other family has refused surgery and the patient is being treated symptomatically. CONCLUSION High-dose lipase replacement has been implicated as the etiology for FC and was present in all of our patients. Our cystic fibrosis center now routinely limits lipase to 2,500 U/kg per dose. We recommend the use of the contrast enemas to evaluate at-risk patients who have chronic abdominal complaints or who present with recurrent bowel obstruction. Colon resection should be performed in those with clinically and radiographically significant strictures with the expectation of a good outcome.

A simple technique for determining the correct catheter length in percutaneous tunnelled catheters in infants and young children has been devised that virtually guarantees accurate catheter tip placement. Sixty-six patients, aged newborn to 5 years (mean, 1.6 years) have successfully undergone this technique. It is safe, simple, precise, quick, and cost effective. It requires only a hemostat, a suture, and the supplies provided in the prepackaged catheter kit. This technique should be used whenever a percutaneous technique for accessing the vein is used and fluoroscopy is available.

Hemodialyzed patients are at risk of multiple catheterizations. Nephrologists performing such procedures need to be familiar with congenital and acquired vascular abnormalities. We describe a successful insertion and use of a cuffed-tunneled catheter in a patient with unusual anatomy of the central venous system. Computed tomography angiography revealed thrombosis of the right subclavian vein and bilateral occlusion of innominate veins. The left internal jugular and subclavian veins joined to form a large vessel that drained through the accessory hemiazygos and azygos veins into the superior vena cava. The catheter was implanted through the left internal jugular vein into the accessory hemiazygos vein. The presented case demonstrates that the catheter can be implanted into distended collateral, especially when no other location is possible.

Central venous catheterization is widely used in neonatology. Although ultrasonic guidance for central venous catheter placement is available, complications occur significantly more frequently in infants, especially neonates, than in adults. This study seeks to determine the characteristics, topographical conditions, regional relationships, and diameters of the venous structures of the upper extremity and the thoracic central venous system in extremely small preterm neonates (mean: 900 g). Nine formaldehyde-fixed preterm stillborns were prepared (mean 27 2/7 weeks' gestational age). The anatomical preparation involved the complete thoracic wall, neck and shoulder region, and preparation of the upper extremities. It was shown that the course of the internal jugular vein can be influenced by rotation of the head. Maximum head rotation (80°) to the contralateral side leads the internal jugular vein to overlap the common carotid artery and sharpens the confluence angle of the internal jugular into the brachiocephalic vein. We propose that this has the potential to result in dislocation of the catheter. Less rotation of the head (<30°) is favorable as the internal jugular vein and common carotid artery run in parallel. Commonly used central venous catheters (2F-4F) may not occlude the vascular lumen completely. Small central venous cannulation using a single-orifice catheter through arm veins (1F) may also not occlude peripheral vessels of the upper extremity (cephalic and basilic veins). The right internal jugular vein has a straight course, appears suitable for central venous access and less hazardous, especially when using stiff catheters. The use of small straight wire guides is recommended.

Gross anatomical observations of bovine thoracic duct pathways and the lymph-venous junctions revealed that 37% of these ducts connected to the left venous angle at one location, whereas the other terminal connected to other areas, such as the left internal jugular vein, the left subclavian vein and the right venous angle, at more than one location. The thoracic duct pathways were classified according to Adachi's classification as types III, VI and IX. The frequencies of types VI, IX and III were 76%, 15%, and 9%, respectively and 48% of cattle had more than one ring formation in the thoracic duct pathway. These findings demonstrate many anatomical variations in bovine thoracic duct pathways and lymph-venous junctions.

Internal jugular veins (IJV) are commonly used to obtain central venous access. However percutaneous cannulation of the IJVis difficult in infants and young children because of its diminutive size. The aim of this study was to evaluate the effect of skin traction on the cross-sectional area of the IJV in anaesthetised infants (younger than one year) and young children (one to six years) using ultrasound. Sixty-seven subjects undergoing general anaesthesia were studied. The cross-sectional area of the IJV was measured at the junction of the two heads of the sternocleidomastoid using ultrasound. Skin traction was performed by stretching the skin over the puncture point with pieces of surgical tape in both cephalad and caudad directions. The measurements were made after the induction of anaesthesia with patients in the supine position and with positive pressure ventilation. Skin traction increased the maximum cross-sectional area of the IJV by 39.9 +/- 29.6% in infants and by 33.8 +/- 21.9% in children (P < 0.01). This increase might facilitate easier and safer IJV cannulation in infants and children.

Chronic jugular vein or central venous cannulation is routinely performed in human and animal patients for access to blood circulation. In mature swine, chronic catheter placement techniques have typically involved venous isolation via extensive cut-down, blunt dissection and manipulation of ventral neck tissues prior to catheter placement. More recently, guide-wire-assisted percutaneous techniques have become standard practice in human and veterinary medicine due to the minimization of soft tissue and vessel damages. Laboratory animal piglets are becoming more popular research models because of their immature immunological system, ease of handling and costs. However, external jugular veins are very difficult to catheterize in paediatric animals including freshly weaned piglets. The objective of this study was to develop a simple, safe and efficient method for external jugular vein cannulation in young piglets. In total, 20 piglets were anaesthetized and percutaneously catheterized with a guide-wire technique using palpable anatomical landmarks and triangulation. With this minimally invasive catheterization, it has allowed our veterinarians and veterinary technicians to quickly and easily obtain central venous access in piglets undergoing operative procedures.

There is an ongoing debate on the technique for central venous catheterization associated with the lowest complication rate and the highest success rate. In an attempt to better define the easiest and safest venous approach, we have reviewed our 7-year experience with 5479 central venous percutaneous punctures (by Seldinger's technique) for the insertion of short-term (n=2109), medium/long-term (n=2627) catheters, as well as double-lumen, large-bore catheters for hemodialysis and/or hemapheresis (n=743). We have analyzed the incidence of the most frequent in-sertion-related complications by comparing seven different venous approaches: jugular vein, low lateral approach; jugular vein, high lateral approach; jugular vein, low axial approach; subclavian vein, infraclavicular approach; subclavian vein, supraclavicular approach; external jugular vein; femoral vein. The results of our retrospective study suggest that the 'low lateral' approach to the internal jugular vein, as described by Jernigan and modified according to our protocol, appears to be the easiest and safest technique for percutaneous insertion of central venous access, being characterized by the lowest incidence of accidental arte-rial puncture (1.2%) and malposition (0.8%), no pneumothorax, and an extremely low rate of repeated attempts (i.e. more than two punctures before successful cannulation)(3.3%). We advocate the 'low lateral' approach to the internal jugular vein as first-choice technique for venipuncture in both adults and children, for both short-term and long-term central venous percutaneous cannulation.

The right internal jugular vein is widely accepted as the vessel of choice for placement of long-term central venous catheters for hemodialysis. As vascular access sites become progressively depleted, alternate anatomic locations for access must be sought. We describe a non-surgical (fluoroscopy assisted, percutaneous) technique for placement of external jugular, tunneled, cuffed hemodialysis catheters, and provide long-term blood flow and dialysis adequacy data for EJV catheters.

BACKGROUND A specifically designed ultrasound scanner may be helpful in percutaneous cannulation of the internal jugular vein in pediatric patients. We report a new two-dimensional (2D) ultrasound prelocation (UL) technique using a transesophageal echocardiography (TEE) intraoperative probe instead of the portable scanner, and have compared the new technique with conventional anatomical landmark method (AL) for central venous catheterization in infants and children. METHODS Sixty-two infants (body weight <12 kg) undergoing elective surgery for congenital heart disease were randomized into two groups. In the AL group, the landmark for cannulation was the palpation of the common carotid pulsation or the sternocleidomastoid triangle. In the UL group, the central vein was located by 2D ultrasonic imaging using a TEE intraoperative probe for HP SONOS 4500. The number of cannulation attempts, success rate, and complication rate were recorded. RESULTS For the UL and AL groups, the cannulation success rate was 100% and 80%(P < 0.05), the incidence of arterial puncture was 3.1% and 26.7%(P < 0.025), and the number of attempts was 1.57 +/- 1.04 and 2.55 +/- 1.76 (P < 0.001), respectively. CONCLUSIONS Two-dimensional ultrasound prelocated central venous catheterization in infants and children is convenient and can markedly increase cannulation success rate and reduce the incidence of complications.

BACKGROUND Cephalic vein (CV) cut down for totally implantable venous access device (TIVAD) placement has been accepted as an alternative to the percutaneous subclavian vein approach. The aim of this retrospective study was to validate the external jugular vein (EJV) cut-down approach when the CV is not feasible. METHODS Patients receiving a TIVAD from January 1995 to December 2003 were included in this study. Age, sex, surgical technique, disease, device used, length of the procedure, and morbidity were considered. RESULTS A total of 427 TIVADs were placed in 425 patients: 253 men (59.5%) and 172 women (40.5%) aged 31 to 79 years. Of 425 patients, 5 were excluded; 420 underwent a CV cut down on the first attempt, and 391 (93.1%) procedures were successful. Among the final 29 patients, 20 (68.96%) underwent a TIVAD placement through the ipsilateral EJV cut-down approach. In the remaining nine patients (31.04%), TIVAD placement was performed through the ipsilateral internal jugular vein in four cases, via the ipsilateral axillary vein in three cases, and through the ipsilateral coracobrachial vein in the other cases. No immediate postoperative complications were detected in any of the patients. CONCLUSIONS TIVAD placement by the CV cut-down approach is safe and fast, and its success rate is very high. By avoiding the immediate complications associated with the percutaneous approach, the EJV cut down has to be considered a valid, safe, and suitable alternative when the CV is not feasible.

Central venous access is an important aspect of medical treatment in intensive care units. We frequently require central venous catheterization (CVC) for total parenteral nutrition (TPN), intravenous antibiotics, multiple transfusions, and chemotherapy. The primary aim of this study is to demonstrate that percutaneous central venous catheterization in patients with body weight (BW) less than 10 kg can be conducted by the subclavian vein rather than the traditional femoral vein. Between January 1998 and December 2003, we performed 70 subclavian vein catheterizations (SVCs) in 46 patients with BW less than 10 kg in the pediatric intensive care unit (PICU) of a tertiary medical center. We divided patients according to their body weight into two groups, BW less than 5 kg and BW between 5 and 10 kg. We found SVC had a high total success rate, 92.9%(65/70), for the whole group. Success rate was 83.3%(15/18) for the BW less than 5 kg group and 96.2%(50/52) for the BW 5-10 kg group. In this study we found percutaneous subclavian venous catheterization in children with BW below 10 kg to be a relatively safe procedure with low risk of complication and no risk of mortality.