Keiko Imai

Ultrasound detection of guidewires in-plane during pediatric central venous catheterization.

To assess the usefulness of longitudinal ultrasound images of guidewires for pediatric central venous catheter (CVC) placement.

Two case reports of the transverse cervical artery description under and below internal jugular veins in securing pediatric central venous catheters by ultrasound echo images.

in adults but also in children; and not just in the case of an overdose but also when administered within the normal range. Furthermore, the size of the dosage may be an important factor in causing this severe side effect, especially in children and in patients who have a history of convulsions. In addition, we should avoid using tramadol in combination with medicines that may lower the seizure threshold. The primary goal of treatment for severe tramadolcaused seizure should focus on breathing and circulation support. Any ongoing seizure activity should be treated with benzodiazepines. Intensive monitoring and supportive care should also be applied. Conflict of interest

Longitudinal ultrasound images of guidewires placed in the internal jugular veins of children: Correspondence

The symbolsand ± were omitted because of typographic errors. The two affected sentences are listed correctly below: 1. We located the pathways of the right carotid artery and IJV in each patient, using a L10-5 MHz ultrasound probe (TiTAN � , SonoSite Co., Tokyo, Japan), with the neck fully extended and the head turned to the left by 15-30� . 2. The mean ± SD age of the 20 patients was 16.7 ± 22.7 months; height, 74.4 ± 17.3 cm; and weight, 7.5 ± 4.1 kg. The IJV width, length, and depth values were 7.1 ± 2.7, 5.1 ± 1.4, and 7.0 ± 1.3 mm, respectively. We apologize for the errors.

Difficulty Inserting Cuffed Endotracheal Tubes in a Child: A Case Report

We experienced difficulty inserting cuffed inner diameter (ID) 4.5- and 5.0-mm endotracheal tubes (ETTs) in a 5-year-old boy. Postoperative ultrasound investigations showed that the internal transverse width of the cricoid cartilage was 8.0 mm. The maximum outer diameter (OD) of the deflated cuff portion of the cuffed ID 4.5- and 5.0-mm ETTs was 8.5 and 9.6 mm, respectively. The OD of an uncuffed ID 5.5-mm ETT was 7.6 mm; this tube passed the cricoid cartilage. Hence, the transverse width of the cricoid cartilage and ETT diameter including cuff folds should be considered when selecting cuffed ETTs.

In-plane Ultrasound Imaging of the Vertebral Artery for Safe Pediatric Internal Jugular Vein Cannulation

Before cannulation of the internal jugular vein (IJV) in 4 pediatric patients, we obtained in-plane and out-of-plane ultrasound images of the vertebral artery (VA). In 2 of 4 patients, abnormalities were identified and best imaged in the in-plane view. In one patient, the right VA had an anomalous origin and course behind the IJV. In another patient, the in-plane image of both the IJV and the VA clearly showed a narrowed IJV. In some cases, the relationship between the VA and IJV may be more clearly understood with in-plane imaging.

Internal jugular vein duplication with absent carotid sheath detected during ultrasound-guided pediatric central venous catheter placement

To the Editor: Internal jugular vein (IJV) duplication is rare and is often found only incidentally during surgery [1] or imaging [2, 3] or during anatomical studies on cadavers [4]. We encountered an IJV duplication by chance during ultrasound-guided pediatric central venous catheter (CVC) placement. A 4-year-old girl (height, 97 cm; weight, 13.6 kg) presented for repair of tetralogy of Fallot complicated by dextrocardia, polysplenia, right side descending aorta, inferior vena cava defect, partial anomalous pulmonary venous return, and persistent left superior vena cava (SVC). The right SVC led to the coronary sinus and right atrium and the left IJV, confluent with the hemiazygos vein, connected to the left-sided SVC. The patient’s parents provided informed consent for all procedures and for publication of the case report. For CVC placement, the patient was supine with small rolled towels under her shoulders, and her neck extended and rotated approximately 15 to the right. The ultrasound apparatus, equipped with a 6/13 MHz probe (NanoMaxx ; SonoSite, Tokyo, Japan), was kept perpendicular to all planes of the skin. We discovered a 6.3 mm wide 9 4.6 mm thick 9 10.0 mm deep lateral lower left IJV and a 3.4 mm 9 2.7 mm 9 8.2 mm medial upper left IJV (Fig. 1a) at the mid-portion of her neck. The lateral and medial IJV joined caudally near the clavicle (Fig. 1b). The distance between the common carotid artery (CCA) and the duplicate IJVs gradually increased toward the periphery. The lateral lower IJV was successfully punctured (Fig. 1c) with a Jelco Plus 24-G catheter-over-needle device (Smith Medical, Tokyo, Japan). A 0.018-inch guidewire (SafeGuide Microneedle Seldinger Kit; Covidien Japan, Tokyo) was advanced through the outer catheter (Fig. 1d) and the CVC was placed over the guidewire with placement confirmed by chest radiography. There were no complications during placement or after removal of the CVC. IJV duplication has been reported as an incidental finding [1–4]. In this case, we discovered the IJV duplication during ultrasound-guided CVC placement. Our patient was a child with a complex set of congenital anomalies. We speculated that in her case, the IJV duplication was related to polysplenia. Cardiac anomalies in patients with polysplenia are mainly shunting anomalies. In addition, bilateral SVCs have been observed in 6 of 12 previously reported cases, 4 in patients with interruptions of the inferior vena cava. On the other hand, approximately 5–10 % of infants with polysplenia may have no associated anomalies [5]. As noted, in this case the distance between the CCA and the duplicate IJVs gradually increased. The CCA and the IJV usually run parallel and have some overlap in the carotid sheath; in our patient, however, it seemed there was no carotid sheath. In cases of IJV duplication that involve overlap between the lateral or medial IJV and the CCA, which would result in greater risk of mispuncture, ultrasound can enable detailed examination of the anatomical relationships between the IJV and the CCA and promote quality outcomes. K. Kayashima (&) K. Imai K. Murashima Department of Anesthesia, Kyushu Kosei Nenkin Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu-city 806-8501, Fukuoka, Japan e-mail: ken5ji5ka5ya5shi5ma@nifty.com

Evaluation of Mechanical Complications During Pediatric Central Venous Catheter Placement from 1994 to 2013

Pediatric central venous catheter placement could be associated with mechanical complications. Knowledge of detailed information described in case reports on such mechanical complications can help improve patient safety. Through an extensive literature search for case reports in PubMed and other databases from 1994 to 2013, 86 cases (from 63 articles) of mechanical complications related to pediatric central venous catheter placement were identified. Of the 86 patients, 22 died: 16 had tamponade; 3 had malposition, including migration, extravasation, and dislodgement; 1 had arterial puncture; 1 had hemothorax; and 1 had cardiac perforation. Cardiac tamponade was reported more frequently when umbilical catheters were used (23 cases) compared to cases where catheters were inserted at 13 other sites. Most of the cases of cardiac tamponade appeared to be related to the location of the catheter tip in the right atrium. Mechanical complications may lead to life-threatening outcomes. Therefore, the location of the tip of the central venous catheter should be assessed immediately after insertion, particularly in neonates, and any signs of abnormality should be identified as soon as possible to ensure appropriate management. Thus, we believe that awareness of the details of case reports on mechanical complications related to central venous catheter placement in children could help reduce the unfavorable outcomes.

Longitudinal ultrasound images of guidewires placed in the internal jugular veins of children

The symbols and ± were omitted because of typographic errors. The two affected sentences are listed correctly below: 1. We located the pathways of the right carotid artery and IJV in each patient, using a L10-5 MHz ultrasound probe (TiTAN , SonoSite Co., Tokyo, Japan), with the neck fully extended and the head turned to the left by 15–30 . 2. The mean ± SD age of the 20 patients was 16.7 ± 22.7 months; height, 74.4 ± 17.3 cm; and weight, 7.5 ± 4.1 kg. The IJV width, length, and depth values were 7.1 ± 2.7, 5.1 ± 1.4, and 7.0 ± 1.3 mm, respectively.

Mispositioning the end of a cuff inflating line in long-axis ultrasound imaging of the pediatric larynx and trachea

1. Polaner DM, Taenzer AH, Walker BJ, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115:1353-1364. 2. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621-627. 3. Mu~ noz F, Cubillos J, Bonilla AJ, Chin KJ. Erector spinae plane block for postoperative analgesia in pediatric oncological thoracic surgery. Can J Anaesth. 2017;64:880-882. 4. B€ uttner W, Finke W. Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies. Paediatr Anaesth. 2000;10:303-318.

Images in Anesthesiology: Ultrasonographic Images of Internal Jugular Vein Duplication.

<zdoi;10.1097/ALN.0000000000000869> Anesthesiology, V 124 • No 4 958 April 2016 U ltrasonography was performed in a 79-yr-old man to determine the spatial relationship between his common carotid artery (CCa) and internal jugular vein (IJV) to guide central venous catheter placement before surgery. This figure revealed IJV duplication (A), with two unusually small IJVs. one (5 mm wide) was on the lateral side of the neck along the CCa; the other (10 mm wide) was on the medial side along the CCa (B), midway between the clavicle head and mandible angle (C). The medial IJV had a curved course and crossed the CCa. The lateral IJV was straight and joined the medial branch approximately 45 mm from the clavicle, forming a single IJV measuring 13 mm wide, 6.6 mm thick, and 8.0 mm deep at a point 30 mm from the clavicle (D). The embryologic development of the IJV is determined by genetics, hemodynamics, growth factors, neural factors, and mechanical constraints. Jugular venous duplication occurs when these factors combine to prevent vascular pruning (selective removal of vascular branches) from occurring when it normally would, resulting in medial and lateral IJVs1; its incidence is approximately 4 cases per 1,000 cervical dissections.2 The two IJVs may join to a form a single vessel, as in our case, or they may enter the subclavian vein separately.1 The duplication is usually discovered during surgery2 and occasionally on computed tomography scan but seldom during ultrasonography.3 Jugular venous duplication is a clinically significant finding that can increase the difficulty of puncture point selection for the successful central venous catheter placement, necessitating particular care.