A Retrospective Analysis of the Clinical Effectiveness of Supraclavicular, Ultrasound-guided Brachiocephalic Vein Cannulations in Preterm Infants
The authors present a single-centre, retrospective analysis of brachiocephalic vein (BCV) cannulation in babies under 2.5kg. The primary aims of the study were to determine the effectiveness and safety of the technique. Secondary aims included a comparison of right versus left BCV cannulation and success of internal jugular vein (IJV) cannulation if the BCV approach was unsuccessful. A detailed description of ultrasound-guided, supraclavicular approach to the BCV was provided with step-by-step comments on this intricate technique. A 22g or 24g cannula was inserted followed by a Seldinger technique to place a 2F single lumen catheter into the BCV. The protocol for number of attempts, use of left or right BCV and use of IJV were discussed.
Over a seven-year study period the BCV was cannulated 142 times in babies between 590g and 2500g. Left and right BCVs were evenly used (47% v 53%). Overall success with BCV cannulation was 94% with up to three insertion attempts. Left BCV approach was more successful than right BCV on first attempt (78% v 64%). Lower weight babies required more cannulation attempts. Failure of right BCV cannulation led to 4 babies receiving an IJV line. The only arterial puncture (subclavian artery) occurred during a right-sided cannulation with no sequelae reported. One operator performed 92% of cannulations. 94% of babies were successfully cannulated with very few complications. The advantages of cannulating the BCV versus IJV included the non-compressible nature of the vein while being cannulated and the ability to sonographically visualise the length of vein at all times. The left BCV was easier to cannulate than the right BCV with less complications and failures reported.
Take home messages:
This is a well written paper which sheds light on the challenging area of central access in very small babies- few large studies exist in this specialised area leading to limited quality outcome data. The findings of this study are largely based on the efforts of a single anaesthetist who performed 92% of cannulations. An important consideration given the significant ‘learning curve’ for such a specialised technique. In the event of iatrogenic bleeding, the incompressible nature of the BCV would be of concern to anaesthetists as would the risk of haemothorax or pneumothorax. No such complications were reported in this study.
Reviewed by: Dr Nicholas Hogan