Insertion of central venous catheter (CVC) can be difficult and challenging in children and can have several procedure-related as well as long-term complications.[1]
[2] The use of the ultrasound facilitates the procedure by delineating the vascular anatomy and minimizing the risk of serious complications. However, certain problems related to the small and fragile guidewire of the pediatric central venous cannulation set are frequently encountered in clinical practice. We report one such problem and method to overcome it.
In our case, catheterization of the right internal jugular vein (IJV) was attempted with a 5F CVC under ultrasound guidance in a 2-year-old boy scheduled to undergo surgery for posterior fossa tumor. We encountered difficulty in inserting the guidewire into IJV thrice in spite of getting free flow of blood after puncture of the central vein with the introducer needle. In fourth attempt, we could manage to insert the guidewire, but we encountered difficulty in advancing the CVC over the guidewire even after dilating the skin tract. Therefore, we removed the CVC and railroaded the entire sheath of the 22G intravenous (IV) cannula over the guidewire and removed the guidewire, keeping the sheath inside. The removed guidewire was found to be kinked ([Fig. 1A]). We confirmed the IV position of the sheath after observing free flow of blood on aspiration. Insertion of a new guidewire was attempted through the IV cannula sheath, and adequate length of the guidewire could be easily inserted. The rest of the procedure was uneventful, and the CVC could be inserted easily. The child did not have any CVC insertion–related complication in the postoperative period. In our case, probably owing to the pressure applied while railroading the CVC over the guidewire, the soft and fragile guidewire got kinked preventing the advancement of the CVC further. In that situation, current practice advocates removal of the guidewire and reattempting CVC. However, we tried CVC insertion using a 22G IV cannula ([Fig. 1B]), because we were not able to insert the guidewire into IJV. It was probably due to displacement of introducer needle (after localization of vein), either before or during insertion of J-tip guidewire. This can happen during pediatric CVC insertion.[3] Finally, when we inserted the guidewire into the IJV, it got kinked while railroading the CVC. Hence, reattempting CVC insertion might not have solved the problem and would have led to another puncture, thereby increasing the risk of further CVC insertion–related complications. Use of IV cannula for ease of CVC insertion in pediatric patients has been reported previously.[3]
[4] In our case, being soft and flexible, the IV cannula sheath could be easily threaded over the kinked portion of the guidewire into the central vein. Later, the sheath acted as a conduit for insertion of a new guidewire.
Fig. 1 (A) Kinked guidewire. (B) Guidewire inside a 22G intravenous catheter.
With this report, we suggest use of IV cannula for exchanging kinked guidewire during difficult CVC insertion in pediatric patients.
