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Modification of Seldinger technique for introduction of femoral lines in newborns

Authors:
  • Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences

Abstract

In specializedcardiac set ups, these lines can be used for monitoringcentral venous pressures. Inserting central linesthrough the femoral route in small and sick newbornsis challenging, and has a complication ratesignificantly higher than insertions in older children,owing to the limited caliber of the neonatal femoralvein.
Indian Journal of Pediatrics, Volume 76—September, 2009 965
Scientific Letters to the Editor
Sir,
Central venous catheterization or the placement of long
lines is becoming more common in neonatal set ups.
Indications for central line placement in neonates
include difficult IV access, need for prolonged IV
therapy and total parenteral nutrition.1 In specialized
cardiac set ups, these lines can be used for monitoring
central venous pressures. Inserting central lines
through the femoral route in small and sick newborns
is challenging, and has a complication rate
significantly higher than insertions in older children,
owing to the limited caliber of the neonatal femoral
vein.1 In our Institute, we have been inserting central
lines through a percutaneous femoral route in neonates.
The technique is safe, 1,2 does not need a C-arm, and
has proved not to increase the incidence of infections.2
The lines used included Leaderflex 22 G (Vygon) and
Arrow single lumen 22G catheter.
Although the accepted and time honored technique
for the placement is based on Seldinger’s method, we
found that introduction of the guide wire through the
wide bore needle supplied in the kit was difficult owing
to the small caliber of the neonatal femoral vein, with
minimal movement leading to a counter puncture or the
needle slipping out of the vein. The observation that the
guide wire of the device used would pass equally well
through the sheath of a 22 guage venflon prompted us to
modify the technique with excellent placement results.
After sterile preparation and adequate restraint and
/or sedation, a 22 G veflon is used to make the initial
femoral venipuncture, the sheath and the stilette being
mounted on a 5ml syringe filled with saline. Once
Modification of Seldinger Technique for Introduction of
Femoral Lines in Newborns
venous blood is aspirated, the cannula is introduced
fractionally in, and the stilette is withdrawn. The
syringe is now connected to the venflon sheath and
saline is pushed to make sure that the cannula is in
place. While flushing the cannula, it is gently advanced
into the vein, until the entire sheath has been placed.
Aspiration of blood and free flow confirm that the
venflon is indeed in the vein. Now it is a simple matter
to put the guide wire into the vein through the venflon,
remove the venflon and thread the catheter into the vein
after using a vein dilator. Flushing the catherter,
fixation and dressing complete the procedure.
Using this slight modification, the author has been
able to successfully place 22G femoral lines
percutaneously in babies weighing as little as 800 g. The
author believes this modification enhances the safety of
the procedure and increases the success rate of femoral
placement of central lines.
Dr Anindya Chattopadhyay
Department of Pediatric Surgery
Dr. BC Roy Memorial Hospital for Children
Narkeldanga Main Road, Kolkata, India
E Mail: achattopadhyay@yahoo.com
[DOI--10.1007/s12098--009--0097--y]
REFERENCES
1. Rao S, Alladi A, Das K, Cruz AJ. Medium and long term
venous access in children. Indian Pediatrics 2003; 40:41-44.
2. Stenzel JP, Green TP, Fuhrman BP, Carlson PE,
Marchessault RP. Percutaneous femoral venous
catheterizations: a prospective study of complications. J
Pediatr 1989; 114:411-415.
as ACEI and furosemide should warrant periodic
assessment of renal function, particularly serum
creatinine. In such conditions if renal failure goes
unrecognized, toxicity of drugs excreted through the
kidneys can be more fatal than renal failure itself and
can occur even without elevated levels of the drugs in
the serum.
Sheetal Mehta and M. Vijayakumar1
1Consultant Pediatric Nephrologist
Kanchi Kamakoti CHILDS Trust Hospital
Chennai – 600 034, India
E-mail: docotrmvk@gmail.com
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Scientific Letters to the Editor
Article
Objective: to identify scientific evidence about the Seldinger technique in the insertion of central venous catheters in Neonatology. Method: integrative review in SCOPUS, MEDLINE, Web of Science, Science Direct, Alliance for Vascular Access Teaching and Research databases and citations of interest. Held in December 2020, without time limits. Results: 804 articles were found. Of these, 18 were included. The publications covered the period from 1982 to 2016. International studies predominated, with low levels of evidence, developed by anesthesiologists and surgeons. The Seldinger technique was considered an assertive method that guarantees a minimum incidence of complications and offers patient safety. Furthermore, it is less stressful compared to direct puncture. Conclusion: it is a technology that needs to expand the number of clinical trials to establish strong evidence and incorporate it into qualified and safe care for newborns.
Article
AimFemoral venous catheters (FVCs) provide multi-lumen access in critically ill infants with difficult venous access. This paper reports our experiences of using a modified Seldinger technique to insert FVCs in our neonatal unit.Methods This was a retrospective case series of 34 infants who had FVCs inserted using the modified Seldinger Technique during a four-year period.ResultsThe median (range) postnatal age and weight at the time of insertion was 66 days (1-314), and 3,080 grams (865-8,000). The FVC remained in-situ for a median duration of 21 days (1-63). There were nine infants who died while the FVC remained in-situ. The FVCs were removed from four infants due to complications. In three cases they became dislodged and in one case the line became blocked. In 16 infants, the FVC was removed when it was no longer required and one infant was transferred out of the unit with the FVC in-situ. Transient venous congestion of the distal limb occurred in four infants. In one infant, the FVC was accidently placed in the femoral artery and removed without complications.ConclusionsFVC insertion using a modified Seldinger technique appeared to provide alternate and immediate central venous access in critically ill infants.This article is protected by copyright. All rights reserved.
Article
In a prospective, 45-month study, we compared the complication rates of percutaneously placed femoral and nonfemoral central venous catheters in critically ill pediatric patients. Forty-one percent of the 395 central venous catheters placed during this interval were femoral. Noninfectious complications were recognized for 2.5% of femoral catheters and 2.1% of nonfemoral catheters. Only three complications occurred with catheter insertion, all during nonfemoral attempts. Systemic infections that were possibly attributable to the central venous catheter were found in 3.7% of patients with femoral catheters and 7.3% of those with nonfemoral catheters. Femoral venous catheterization offers several practical advantages for central access over other sites. The low incidence of complications documented in this study suggests that the femoral vein is the preferred site in most critically ill children when central venous catheterization is indicated.
Article
In a prospective, 45-month study, we compared the complication rates of percutaneously placed femoral and nonfemoral central venous catheters in critically ill pediatric patients. Forty-one percent of the 395 central venous catheters placed during this interval were femoral. Noninfectious complications were recognized for 2.5% of femoral catheters and 2.1% of nonfemoral catheters. Only three complications occurred with catheter insertion, all during nonfemoral attempts. Systemic infections that were possibly attributable to the central venous catheter were found in 3.7% of patients with femoral catheters and 7.3% of those with nonfemoral catheters. Femoral venous catheterization offers several practical advantages for central access over other sites. The low incidence of complications documented in this study suggests that the femoral vein is the preferred site in most critically ill children when central venous catheterization is indicated.
Article
The angiotensin converting enzyme inhibitors constitute a major treatment modality for cardiovascular diseases, including congestive heart failure and hypertension. In addition to their beneficial hemodynamic effects, they offer other advantages, such as a relative lack of adverse effects on other cardiovascular risk factors. When used judiciously, the angiotensin converting enzyme inhibitors may also contribute to improved renal function. These agents induce vasodilation of both efferent and afferent renal vessels, which may facilitate improved renal blood flow and glomerular filtration rate in individuals whose renal insufficiency results from hyperadrenergic activity. Improvements in renal function may also be observed when angiotensin converting enzyme inhibitors are employed in other clinical conditions, such as diabetic nephropathy or proteinuric renal disease. Although the renal protective effects of the angiotensin converting enzyme inhibitors are well recognized, their use in certain circumstances may actually contribute to renal dysfunction. The factors which may predispose an individual to angiotensin converting enzyme inhibitor-induced renal dysfunction must be recognized by the clinician and appropriate interventions taken to prevent this potentially deleterious effect. This article reviews those factors which increase risk for angiotensin converting enzyme inhibitor-induced renal dysfunction and provides recommendations for prevention.
Article
The goals of therapy for congestive heart failure (CHF) are to improve quality of life and to prolong it. Improvement in patients with CHF can only be realized, however, if a multidisciplinary healthcare team can provide effective management in both the inpatient and outpatient settings. Inhibition of compensatory mechanisms that perpetuate CHF is the first step in achieving treatment goals. Combination therapy with diuretics, digoxin (Lanoxicaps, Lanoxin), and vasodilators is used for patients with symptomatic heart failure and volume overload. Because angiotensin-converting enzyme inhibitors improve survival rates more than other vasodilators, they are preferred in patients with systolic dysfunction.
Article
The use of ACE inhibitors in patients with CHF, hypertension, and chronic nephropathies is often a double-edged sword. As long as renal perfusion pressure is adequate and volume depletion is not severe, ACE inhibitors can improve renal hemodynamics so that an improvement in renal salt excretion can be achieved. However, because Ang II is necessary for maintenance of GFR during states of significant volume depletion, these agents also can cause GFR to decrease rapidly, with consequent oliguric or anuric renal failure. ACE inhibitors can generally be safely restarted after resolution of an ARF episode, particularly if the underlying conditions having predisposed to the episode can be rectified. The principles of ACE inhibitor therapy are summarized in Table 3.
Article
From September 2000 to August 2001, 104 central venous access devices (CVAD) were inserted in 91 children, governed by a uniform protocol. Thirty catheters were inserted in neonates, 29 in infants, 37 in children and 8 in adolescents. Fifty-one were planned insertions in the operating suite and 53 were emergencies - often by the bedside. There were 12 insertion related complications-all of which were minor. Neonatal age and bedside introduction had a higher risk of insertion related problems. The incidence of non-infectious complications was 20% (rate of 13.7/1000 line days) and was influenced by the child's age and insertion site. Femoral route was the safest. Incidence of catheter associated infections (CAI) was 15.4% (rate of 11/1000 line days). Only 2 children had catheter associated bloodstream infection. Neonates were at higher risk of catheter related infections. Age, insertion site and occurence of insertion complications influenced duration of catheterization (median 7.5 days, range 2-243 days) There was no major complication, though more than 50% insertions were in neonates and infants. In our practice, use of CVAD is feasible and safe, especially in neonates and infants.
AHA Scientific Statement Renal Consideration in Angiotensin-Converting Enzyme Inhibitor Therapy
  • Sica Schoolwerth Ac
  • Da
  • Bj Ballermann
  • Wilcox
Schoolwerth AC, Sica Da, Ballermann BJ, Wilcox CS. AHA Scientific Statement Renal Consideration in Angiotensin-Converting Enzyme Inhibitor Therapy. Circulation 2001; 104: 1985-1991. Scientific Letters to the Editor