Seldinger vs modified Seldinger techniques for ultrasound-guided central venous catheterisation in neonates: a randomised controlled trial.

Edition:

Song et al. BJA 121 (6): 13332-1337 (Dec 2018).

Central venous catheterisation (CVC) in neonates is difficult. This study compares the Seldinger technique (‘wire-through-needle’) to the Modified Seldinger (MS) technique (‘catheter-over-needle-then-wire-through-catheter). It is an RCT of 120 neonates where CVC was placed under GA by experienced paediatric anaesthetists. Participants were allocated to either Seldinger (n = 60) (21g introducer needle) or MS (n = 60) (22g Angiocath PlusTM) techniques.

Further methods explained:

  • Patients were excluded if ASA ³4, central venous anomalies or overlying skin infection.
  • Right internal jugular vein (IJV) was the primary CVC site, unless it measured <2mm, was previously punctured, or contained thrombus. In this case the left IJV was used.
  • Needle insertion was performed using ‘out-of-plane’ ultrasound guidance with patient positioned 30° head down with shoulder roll in place.
  • A 4-F, 2 lumen, Arrow® CVC was used which includes a ‘J’ tip guide wire.

Primary Outcome:

  1. First attempt success was higher in the MS group compared with the Seldinger group (83% vs 65%; relative risk 1.282; 95% CI 1.032-1.594, P = 0.025).

Secondary Outcomes:

  1. Successful guide wire insertion on the first attempt was higher in the MS group (95% vs 75%; relative risk = 1.267; 95% CI 1.082 – 1.482, P= 0.003).
  2. Successful puncture on the first attempt and successful final catheterisation did not differ.
  3. Overall catheterisation time was comparable.

Limitations

  1. Only three anaesthetists partook in the study and their experience with each technique was not defined. Thus, it cannot provide insight into the learning curve for either technique.
  2. A ‘transfixation’ technique was used where the needle pierces both walls of the vein and is slowly withdrawn. In the Seldinger group, continuous negative pressure is applied during withdrawal until blood is aspirated. In the MS group, the inner needle is removed, and the catheter is withdrawn without negative pressure until blood flows freely. This technique may vary from local practice.
  3. The average weight of neonates was 3.5kg (SD 0.9) and 3.6kg (SD 1.2) for the two groups (p = 0.659). Therefore, this study may not translate to low-birth-weight neonates.

Take home message:

The MS technique improved success rates over the Seldinger technique for US-guided IJV CVC. This should be interpreted in the context of a small operator group, small patient group, and the utilisation of a ‘transfixation’ puncture technique which may differ from local practice.

Reviewed by Adam Keys (RCH Fellow)

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