Defining the surface anatomy of the central venous system in children

Abstract

Pediatric emergency physicians, pediatric critical care specialists, and pediatric surgeons perform central venous catheterization in many clinical settings. Complications of the procedure are not uncommon and can be fatal. Despite the frequency of application, the evidence-base describing the surface landmarks involved is missing. The aim of the current study was to critically investigate the surface markings of the central venous system in children. The superior vena cava/right atrial (SVC/RA) junction, superior vena cava (SVC) formation, and brachiocephalic vein (BCV) formation were examined independently by two investigators. Three hundred computed tomography (CT) scans collected across multiple centers were categorized by age group into: 0-3 years, 4-7 years, and 8-11 years. Scans with pathology that distorted or obscured the regional anatomy were excluded. The BCV formation was commonly found behind the ipsilateral medial clavicular head throughout childhood. This contrasts with the variable levels of SVC formation, SVC length, and SVC/RA junction. In the youngest group, SVC formation was most commonly at the second costal cartilage (CC), but moved to the first CC/first intercostal space (ICS) as the child grew. The SVC/RA junction was at the fourth CC in the youngest group and moved to the third CC/third ICS as the child grew. This study demonstrates the variable anatomy of SVC formation and the SVC/RA junction with respect to rib level. This variability underscores the unreliability of surface anatomical landmarks of the SVC/RA junction as a guide to catheter tip position.

Apprasial of the surface anatomy of the Thorax in an adolescent population

“…This approach has many limitations because cadaveric studies do not take into account the changes incurred during the embalming process, or the effects of air in the thoracic cavity, which would have an effect on the position of thoracic structures (Hale et al ). Recently, several international studies have been published that have focused on population specific surface anatomy in living subjects by utilizing modern imaging techniques such as X‐ray, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound scanning (Emamian et al ; Chukwuemeka et al ; Kim et al , ; Soleiman et al , ; Glodny et al, ; Mirjalili et al ; Mirjalili et al ; Mirjalili et al ; Keough et al ; Subramaniam et al ; Tarr et al ). These studies reported both similarities and differences between our current anatomical knowledge and the findings of their studies.…”

A reappraisal of pediatric thoracic surface anatomy

“…Recently, Subramaniam et al () provided comprehensive evidence of abdominal surface anatomy in children. Meanwhile, Tarr et al () provided an evidence‐base for the surface anatomy of the central venous system in this population.…”

A Comparison of the external anatomical landmark and the radiological landmark for obtaining the optimal depth of a right internal jugular venous catheter in pediatric cardiac patients

“…In this study, no specific relationship of the CVC depth of the EL and RL to patients' age was illustrated. Although the length and the position of the SVC‐RAJ were associated with age, our EL and RL were comparable to the TEE in all age‐groups. The measurement of specific patient anatomical distance as surrogated to their SVC‐RAJ distance regardless of their age may explain the satisfactory results.…”

“…In children, a clinical study found that the right third ICS had a significant correlation with the SVC‐RAJ level . An anatomical study reported that the SVC‐RAJ was usually positioned around the right third to fourth CC . Therefore, using the EL for positioning, the CVC tip at point C had a high probability of locating its tip at the lower SVC or the SVC‐RAJ level.…”

“…The pericardial reflection is located above the carina by 31% . Placement of the CVC tip in the extrapericardial SVC remained difficult . In the present study, we followed the guidelines of the Association of Anesthetists of Great Britain and Ireland which recommended that the CVC tip should be positioned in the lower third of the SVC or at the SVC‐RAJ .…”