Coskun Demet, Mahli Ahmet, Oncul Sema, Ilvan Gizem, Dalgic Aydin
Department of Anesthesia and Reanimation, Gazi University Medical Faculty, Ankara, Turkey.
Cases J. 2009 Jun 3;2:7998. doi: 10.1186/1757-1626-2-7998.
Clinicians use either direct or indirect (Seldinger) techniques for internal juguler or subclavian vein catheterization. This report aims to point out that the success rate of the direct technique where the catheter is inserted directly through the cannula may be higher particularly in catheterization of pediatric cases.
A 7.5-month-old female infant weighing 7200 gm was operated on for liver transplantation. The patient suffered jaundice at one month of age and was diagnosed with neonatal colestatic hepatitis. After routine monitoring, via indirect technique, central catheterization was attempted through internal jugular vein. However, the attempt failed. Therefore, again via indirect technique, catheterization was achieved through the right subclavian vein and fixed at 8 cm. After the operation started, fluid replacement and central venous pressure monitoring were performed with this catheter. Immediately after the operation, a control postero-anterior chest radiograph of the patient was obtained. This graph revealed that the tip of the catheter was fixed in the right internal jugular vein. Since the vital symptoms of the patient were not stable, the catheter was not removed and fluid replacement was performed via this technique. The catheter was removed on the postoperative 2(nd) day.
The J wire advanced via the indirect technique advances anatomically following the upper wall of subclavian vein. Because of the smaller vessel dimensions and sharper, more angulated routes the subclavian and internal jugular veins make in infants, the rigid J wire may advance in the cephalic direction. However, in the technique where the catheter (Cavafix ((R)) catheter) is inserted directly through the cannula, this probability is less since J wire is not used and the catheter employed is flexible. We concluded that especially in pediatric cases, employment of the technique where the catheter is inserted directly through the cannula would be more convenient in order to decrease the catheter malpositioning probability.
临床医生在进行颈内静脉或锁骨下静脉置管时，会使用直接法或间接法（塞丁格技术）。本报告旨在指出，直接将导管通过套管插入的直接法成功率可能更高，尤其是在儿科病例的置管中。
一名7.5个月大、体重7200克的女婴接受了肝移植手术。该患者在1个月大时出现黄疸，被诊断为新生儿胆汁淤积性肝炎。经过常规监测，尝试通过间接法经颈内静脉进行中心静脉置管。然而，尝试失败。因此，再次通过间接法经右锁骨下静脉成功置管，并固定在8厘米处。手术开始后，使用该导管进行补液和中心静脉压监测。术后立即为患者拍摄了后前位胸部X线片。该片显示导管尖端固定在右颈内静脉。由于患者生命体征不稳定，未拔除导管，而是通过该技术进行补液。术后第2天拔除导管。
通过间接法推进的J形导丝在解剖学上沿着锁骨下静脉的上壁前进。由于婴儿的锁骨下静脉和颈内静脉血管尺寸较小，走行更尖锐、角度更大，刚性的J形导丝可能会向头侧方向推进。然而，在直接将导管（Cavafix（R）导管）通过套管插入的技术中，由于未使用J形导丝且所用导管较柔软，这种可能性较小。我们得出结论，特别是在儿科病例中，为了降低导管错位的概率，采用直接将导管通过套管插入的技术会更方便。
