An ultrasound-guided supraclavicular approach for tunneled central venous catheter insertion can be safely performed by junior residents

doi:10.21203/rs.3.rs-4689760/v1

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Research Article

An ultrasound-guided supraclavicular approach for tunneled central venous catheter insertion can be safely performed by junior residents

https://doi.org/10.21203/rs.3.rs-4689760/v1

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Journal Publication

published 23 Jul, 2024

Read the published version in Pediatric Surgery International →

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Purpose

Ultrasound-guided supraclavicular catheterization (UGSC) of the brachiocephalic vein (BCV) for long-term tunneled central venous catheter (tCVC) insertion may be safer than the internal jugular vein approach due to its superior field of view. We examined the clinical outcomes of tCVC insertions performed by junior residents through UGSC of the BCV.

Patients and Methods:

From January 2018 to December 2023, we assessed clinical outcomes and compared the experience levels of surgeons conducting tCVC insertions. Surgeons were categorized into three groups: junior residency (JR), senior residency (SR), and board-certified pediatric surgeons (BCPS).

Results

177 tCVC insertions were done on 146 patients. Intraoperative complications included 6 cases of arterial puncture, 1 case of pneumothorax, 1 case of over insertion of catheter tip, and 1 case of suspected hemothorax. Distribution across groups was as follows: 28 cases (15.8%) in JR group, 92 (52.0%) in SR group, and 57 (32.2%) in BCPS group. Although the JR group exhibited longer operation times than the BCPS group, no significant differences in intraoperative complications were noted.

Conclusion

Junior residents can safely perform UGSC for tCVC insertion. However, careful consideration of complications such as arterial or thoracic puncture is essential, and case selection should be based on experience.

Ultrasound-guided supraclavicular catheterization

long-term tunneled central venous catheter

residency

brachiocephalic vein

patient safety

Tunneled central venous catheters (tCVC) [1, 2] have been widely used for pediatric patients requiring chemotherapy, parenteral nutrition, and other purposes since the 1970s. Ultrasonography (US) has been proposed to reduce the number of CVC-related complications and ensure the safety and efficiency of CVC placement, even in pediatric patients [3]. In the generally performed internal jugular vein puncture, the vein is visualized in a short axis under US guidance, making it difficult to grasp the positional relationship between the vein and the puncture needle. It is challenging for trainees to understand the pitfalls associated with two-dimensional US imaging because a two-dimensional view is not easily translated to the three-dimensional real world of the clinical setting [4].

We previously reported the safety of ultrasound-guided supraclavicular catheterization (UGSC) of the brachiocephalic vein (BCV) for long-term tCVC insertion [5]. We compared a real-time ultrasound-guided supraclavicular in-plane (long-axis) approach to BCV catheterization with an out-of-plane (short-axis) approach to internal jugular vein (IJV) catheterization with a tCVC in pediatric patients. Our findings suggested that the BCV approach might be safer (e.g., low risk of pulmonary puncture) than the IJV approach because the long-axis view of the US provides a superior field of view to grasp the positional relationship between the vein and the puncture needle.

In the present study, we clarified the clinical outcomes of UGSC of the BCV for tCVC insertion performed by junior residents. We evaluated whether junior residents could safely perform tCVC insertion with the BCV approach compared with senior residents or board-certified surgeons.

Study population and participants

We investigated the background characteristics and operative outcomes of tCVC insertion in pediatric patients under 16 years old between January 2018 and December 2023. The Broviac or Hickman catheter kit (Bard Access Systems, Inc., Salt Lake City, UT, USA) was used. The indications for CVC placement included chemotherapy for pediatric hemato-oncologic disorders, intravenous administration, and difficult peripheral venous access.

We reviewed the patients' characteristics, surgical records and intra- and postoperative complications. We excluded data from patients with intestinal failure who underwent CVC placement because different CVC management approaches were applied (e.g., monthly prophylactic ethanol lock therapy) [6]. Patients who weighed <5 kg and those with platelet counts <70,000/mm³ were excluded because CVC insertion was performed using the open surgical cutdown technique in those cases.

We also evaluated the clinical outcomes and compared the experience levels of the surgeons who performed tCVC insertion. The surgeons were divided into three groups: junior residency (JR), senior residency (SR), and board-certified pediatric surgeon (BCPS).

Insertion technique

Catheter insertion in the brachiocephalic vein was performed using a previously reported method [7]. The procedure was performed under sterile conditions and general anesthesia in pediatric patients. A US system with a 5 to 10 MHz linear-type probe was used. The US probe was first placed at the side of the neck in the transverse position to identify the IJV and carotid artery. It was then slowly moved toward the clavicle, which was visualized in the terminal part where it met the IJV and subclavian vein. The US probe was then placed in the supraclavicular fossa to obtain an in-plane (long-axis) view of the BCV (Fig.1a). The puncture and placement of the

needle for BCV catheterization were performed in the in-plane (long-axis) view (Fig.1b). A tunnel was created from the anterior chest wall through the previous stab incision. The vessel dilator and sheath introducer unit from the Broviac or Hickman catheter kit were cautiously advanced over the guidewire under fluoroscopic guidance. The vessel dilator and guidewire were then withdrawn, and the catheter was inserted through the sheath, at which point the sheath was removed.

Junior residents were certified to perform UGSC in clinical cases after they underwent a job training program using a phantom simulator. Senior residents were trained surgeons who had finished their JR.

Statistical analyses

The Kruskal-Wallis test with Bonferroni post-hoc analysis was used to analyze the patient's clinical data, and the χ² test or Fisher's exact test was used to analyze the frequency of postoperative complications. Data are shown as mean ± standard deviation or median with interquartile range. A p-value less than 0.05 was considered statistically significant. All statistical analyses were performed using EZR[8] (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria).

Ethical approval

This clinical study was performed in accordance with the ethical guidelines of clinical research of the Japanese Ministry of Health, Labor, and Welfare. This study was approved by the Research Ethics Committee of Kagoshima University Hospital (registration number: 200055).

Patients' background characteristics

Table 1 shows patients' background characteristics. A total of 177 tCVC insertion procedures were performed in 146 patients with a mean age of 6.27 ± 4.53 years old. Patients who required tCVC insertion had hematologic diseases (n=86, 48.6%: e.g., leukemia, lymphoma), solid tumors (n=75, 42.4%: e.g., neuroblastoma, hepatoblastoma), and other diseases (n=16, 9.0%: e.g., immunological disease, metabolic disease). Their height was 112.59 ± 32.29 cm, and their weight was 22.85 ± 14.36 kg. By weight, 100 cases (56.5%) were < 20 kg, 54 cases (30.5%) were 20-40 kg, and 23 cases (13.0%) were > 40 kg.

Clinical outcomes according to underlying disease

Table 2 shows clinical outcomes according to underlying disease. Based on the underlying disease, there were 86 cases (48.6%) in the hematologic disease group, 75 cases (42.4%) in the solid tumor group, and 16 cases (9.0%) in the others group. There were no significant differences in age, body height, body weight and operating time among the groups.

Intraoperative complications were recognized 4 cases (4.6%) in the hematologic disease group, 2 cases (2.7%) in the solid tumor group, and 3 cases (18.8%) in the others group, respectively. The intraoperative complication rate in the others group was significantly higher than the other two groups (p=0.049).

Clinical outcomes according to physicians' experience levels

Table 3 shows clinical outcomes according to physicians' experience levels. Based on the physicians' experience levels, there were 28 cases (15.8%) in the JR group, 92 (52.0%) in the SR group, and 57 (32.2%) in the BCPS group. The patients in the JR group were significantly older than the patients in the BCPS group (JR group: 8.0 years old [4.0-12.0], SR group: 5.00 years old [3.0-10.0], BCPS group: 4.0 years old [2.0-9.0]). There were no significant differences in body height or body weight among the groups. However, the JR group tended to be bigger than the BCPS group. The operation time of the BCPS group had a significantly shorter operation time than those of the other two groups (JR group: 43.5 minutes [34.0-50.5], SR group: 34.0 minutes [28.0-44.5], BCPS group: 30.0 minutes [22.0-36.0]). Intraoperative complication were recognized 1 case (3.6%) in the JR group, 6 cases (6.5%) in the SR group, and 2 cases (3.6%) in the BCPS group, respectively. But there were no significant differences in intraoperative complications among the groups (p =0.663)

Intraoperative complications

Details of cases with intraoperative complications are shown in Table 3. Intraoperative complications were observed in 6 cases (3.4%) of arterial puncture, 1 case (0.6%) of pneumothorax (pulmonary puncture suspected), 1 case (0.6%) of suspected hemothorax, and 1 case (0.6%) of over insertion of the tip (without no clinical symptom). Hemothorax was suspected because of postoperative pleural effusion. All complications, including hemothorax, improved conservatively without invasive treatment (Clavien-Dindo Classification grade I). The median age, body height, and body weight of the patients with intraoperative complications were 3 years old [0-7], 90cm [74-115], and 12.8 kg [5.6-19.7], respectively. The median operation time was 38 minutes [15-77]. The patients with intraoperative complications tended to be younger and smaller than other patients. Three cases of the others group were two insertion procedures for one patient with inflammatory bowel disease (IBD) and (case 1, 6) one patient with carnitine palmitoyl transferase II deficiency (case 7). The patient with IBD had a history of multiple temporary CV catheter insertions. Therefore, the patient had difficulty inserting the CV catheter.

This article is the first report to evaluate the safety of ultrasound-guided supraclavicular BCV cannulation by comparing three different physician experience levels. This study showed that even resident surgeons can safely insert the tCVC without complications using the US-guided supraclavicular BCV cannulation technique. The major findings of this study were as follows: (1) the operating time of the JR group was significantly longer than that of the other groups, (2) arterial puncture is the most common intraoperative complication of tCVC, and (3) intraoperative complications are more common in infant and young children than elder children.

In our institution, according to the recommendations concerning the use of the US for CVC, we implemented a real-time US-guided approach for cannulation of the IJV using a short-axis procedure [9]. However, since we experienced severe complications, including penetration of the innominate vein leading to severe hemothorax, which requires vein repair, we decided to change the practice of CVC and adopt an open surgical venous cutdown approach, which has the advantage of needle visualization of the vessel and improved patient safety. However, in 2018, we introduced the UGSC of the BCV for long-term tCVC insertion because of its safety and lack of need to sacrifice the vein by the cutdown approach.

The most challenging point is making trainees understand the pitfalls of two-dimensional imaging, as a two-dimensional view is not easily translated to a three-dimensional real-world clinical setting [4,10]. In the approach to IJV cannulation with a short-axis view, it is not easy to visualize and identify the needle tip of the CVC and IJV during the cannulation process. The BCV approach, by contrast, is performed with in-plane imaging (long-axis), which typically permits real-time observation of needle penetration into the vein, thereby minimizing the risk of pleural or arterial puncture [11].

Visualization of veins in the long-axis view allows for safe catheter insertions. Lin et al. [12] analyzed the outcomes of 113 cases of totally implantable venous access devices (TIVADs) placed by junior residents using US-guided percutaneous axillary vein catheterization. In this study, the success rate of TIVAD placement using the US-assisted percutaneous axillary vein approach was 100%, with only 1 case of mild pneumothorax. Visualization of the axillary vein in the long-axis view, similar to our BCV approach, helps reduce intraoperative complications. Oligomerize et al. reported that ultrasound-guided supraclavicular in-plane (long-axis) BCV cannulation improved first-attempt CVC cannulation success rates and reduced puncture attempts and cannulation time compared with US-guided out-of-plane (short-axis) IJV in critically ill children [13]. Our group also reported that US-guided placement of tCVC through the BCV results in a low rate of postoperative complications despite longer CVC indwelling times compared to IJV insertion.

In this study, there was no significant difference in the incidence of intraoperative complications between the junior residents and experienced surgeons. However, intraoperative complications tended to occur more frequently in younger patients than in older ones. Our research revealed that junior residents can perform tCVC insertion in patients who are at least school-age; intraoperative complications can thus be reduced by assigning older patients to residents despite longer operation time.

Several limitations associated with the present study warrant mention. This article was a single-center retrospective study, and the procedures were performed using several different US systems. Differences in age and number of cases among the groups could be a selection bias. The observation period was not sufficient to evaluate long-term outcomes. A prospective randomized controlled study is needed to clarify the differences between the three experienced surgeons, including evaluating long-term complications.

Our results suggest that UGSC for tCVC insertion can be safely performed even by junior residents, although it takes longer operation time. However, complications such as arterial or thoracic puncture should be carefully considered, and cases should be selected based on physicians' experiences.

Author contributions

Study conception and design: Yumiko Iwamoto, Shun Onishi, Koshiro Sugita, Kazuhiko Nakame

Data acquisition: Yumiko Iwamoto, Kazuhiko Nakame, Masato Ogata, Lynne Takada, Ayaka　Nagano, Koji Yamada, Waka Yamada, Takafumi Kawano, Mitsuru Muto

Analysis and data interpretation: Yumiko Iwamoto, Masakazu Murakami, Toshio Harumatsu, Ryuta Masuya,

Drafting of the manuscript: Yumiko Iwamoto, Shun Onishi

Critical revision: Tatsuru Kaji, Satoshi Ieiri

Conflict of Interest:

The authors declare no conflict of interest associated with this study.

Acknowledgments

We thank Mr. Brian Quinn for his comments on this manuscript. This work was supported by JSPS KAKENHI (grant number JP22K15925) and The Uehara Memorial Foundation.

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Table 1. Patients' background characteristics

Number of insertion procedure	177
Underlying disease Hematologic disease Solid tumor Others	86 (48.6%) 75 (42.4%) 16 (9.0%)
Sex male: female	103 (58.2%) : 74 (41.8%)
Age (years)	5 [2-10]
Body height (cm)	109 [90-139]
Body weight (kg)	18.4 [12.9-30.3]
< 20 kg	100 (56.5%)
20-40 kg	54 (30.5%)
> 40 kg	23 (13.0%)

Table 2. Clinical outcomes according to underlying disease

	Hematologic disease 86 (48.6%)	Solid tumor 75 (42.4%)	Others 16 (9.0%)
Sex (male)	47 (54.7%)	45 (60.0%)	11 (68.8%)	0.528
Age at procedure (years)	5.00 [3.00-9.00]	5.00 [2.00-11.00]	8.00 [1.75-14.00]	0.863
Body height at the procedure (cm)	108.25 [95.25-131.32]\|	106.70 [87.00-148.10]	119.70 [73.12-144.18]	0.835
Body weight at the procedure (cm)	18.35 [14.00-26.17]	17.40 [12.25-36.05]	19.10 [8.65-34.10]	0.748
Operating time (minutes)	34.50 [29.00-44.00]	35.00 [30.50-41.50]	35.00 [30.50-41.50]	0.201
Intraoperative complications	4 (4.6%)	2 (2.7%)	3 (18.8%)	0.049

Table 3. Outcomes according to physicians' experience levels

	JR (n=28, 15.8%)	SR (n=92, 52.0%)	BCPS (n=57, 32.2%)	p-value
Sex (male)	21 (75.0%)	46 (50.0%)	36 (63.2%)	0.111
Age at procedure (years)	8.0 [4.0-12.0]	5.00 [3.0-10.0]	4.0^* [2.0-9.0]	0.046
Body height at the procedure (cm)	121.9 [102.7-145.4]	107.35 [90.7-135.7]	101.40 [84.1-128.0]	0.056
Body weight at the procedure (cm)	22.75 [15.65-35.31]	18.15 [12.8-27.3]	16.5 [10.9-26.8]	0.161
Operating time (minutes)	43.5 [34.0-50.5]	34.0 [28.0-44.5]	30.0^,* [22.0-36.0]	< 0.001
Intraoperative complications	1 (3.6%)	6 (6.5%)	2 (3.6%)	0.663

Table 4. Intraoperative complications

Case	Operator	Sex	Underlying disease	Age (years)	Body Height (cm)	Body Weight (kg)	Operating time (minutes)	Intraoperative complications
1	JR	Male	Others	2	74	8.7	46	Arterial puncture
2	SR	Male	Hematologic disease	2	87	12.8	15	Arterial puncture
3	SR	Male	Hematologic disease	3	82	12.1	48	Arterial puncture
4	SR	Female	Solid tumor	0	57	5.6	77	Arterial puncture
5	SR	Male	Solid tumor	5	110	17.4	41	Over insertion of the tip
6	SR	Female	Others	3	92	13.6	26	Arterial puncture
7	SR	Female	Others	7	115	19.7	37	Pneumothorax
8	BCPS	Male	Hematologic disease	1	90	12.7	38	Hemothorax
9	BCPS	Female	Hematologic disease	4	96	15.4	34	Arterial puncture
Median	-	-	-	3	90	12.8	38	-

No competing interests reported.

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Journal Publication

published 23 Jul, 2024

Read the published version in Pediatric Surgery International →

Editorial decision: Accepted
06 Jul, 2024
Reviews received at journal
06 Jul, 2024
Reviewers agreed at journal
06 Jul, 2024
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Submission checks completed at journal
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You are reading this latest preprint version

An ultrasound-guided supraclavicular approach for tunneled central venous catheter insertion can be safely performed by junior residents

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