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Classical positioning decreases subclavian vein cross-sectional area in children
Jeff Lukish1, Eric Valladares, Carlos Rodriguez
1Department of Surgery, National Naval Medical Center, Walter Reed Army Medical Center and Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889, USA. jlukish@cnmc.org
Insights
For pediatric subclavian vein catheter placement, avoid turning the head or using a shoulder roll. Maintaining a neutral head position optimizes subclavian vein size, potentially reducing procedure complications.
Area of Science:
- Pediatric critical care medicine
- Vascular access procedures
- Ultrasound imaging
Background:
- Current guidelines for pediatric subclavian vein catheterization are based on adult data.
- Optimizing subclavian vein size is crucial for safe and effective percutaneous catheter placement in children.
Purpose of the Study:
- To identify the optimal body position for maximizing subclavian vein diameter in pediatric patients.
- To inform best practices for subclavian vein cannulation in pediatric populations.
Main Methods:
- Ultrasound assessment of subclavian vein cross-sectional area (CSA) in four supine positions.
- Positions included variations in head turn (neutral vs. 90 degrees away) and shoulder roll (present vs. absent).
- Statistical analysis using Student's t test and Wilcoxon signed rank test compared CSA across positions.
Main Results:
- Nine pediatric patients (mean age 5.3 years) were included.
- Head turned positions significantly reduced subclavian vein CSA by 18-22% (p < 0.05).
- Neutral head position without a shoulder roll yielded the largest CSA.
Conclusions:
- Head turning and shoulder rolls decrease subclavian vein size in children.
- A neutral head position without a shoulder roll is recommended to optimize subclavian vein dimensions.
- This positioning may decrease the risks associated with percutaneous subclavian vein catheterization.
Background:
Recommendations for subclavian vein catheter placement in children are extrapolated from adult experience. The purpose of this study was to determine the ideal body position to optimize the size of the subclavian vein in children for percutaneous catheter placement.
Methods:
Children underwent ultrasound imaging of the subclavian vein in four supine body positions: head in a neutral position with the chin midline (NL) and no shoulder roll (SR); head turned 90 degrees away (TA) and no SR; head NL with an SR; and head TA with an SR. The cross-sectional area (CSA) of the subclavian vein was calculated and statistical significance was determined using the Student's t test and the Wilcoxon signed rank test.
Results:
Nine children participated in the study, with a mean age of 5.3 years. The CSA of the subclavian vein was 0.39 +/- 0.24 cm2 with the head NL and no SR, compared with 0.31 +/- 0.20 cm2 with the head TA or 0.32 +/- 0.23 cm2 with the head TA and SR. This represented a significant reduction in the CSA of the subclavian vein by 22% and 18%, respectively (p < 0.05).
Conclusion:
In children, the recommended maneuvers of turning the head or turning the head and placing a posterior shoulder roll significantly reduce the cross-sectional area of the subclavian vein. Maintaining the head in a normal position with the chin midline without a shoulder roll optimizes subclavian vein size. Positioning children in this manner may serve to reduce the morbidity associated with percutaneous subclavian vein cannulation.