title: Optimal site for ultrasound-guided venous catheterisation in paediatric patients: an observational study to investigate predictors for catheterisation success and a randomised controlled study to determine the most successful site.
abstract: BACKGROUND
  Venous catheterisation in paediatric patients can be technically challenging. We examined factors affecting catheterisation of invisible and impalpable peripheral veins in children and evaluated the best site for ultrasound-guided catheterisation.
  
  
  METHODS
  Systolic pressure, age, sex, and American Society of Anaesthesiologists (ASA) physical status were determined in 96 children weighing less than 20 kg. Vein diameter and subcutaneous depth were measured with ultrasound. Logistic regression was used to evaluate the contribution of these factors to cannulation success with (n = 65) or without (n = 31) ultrasound guidance. Thereafter, we randomly assigned 196 patients for venous catheter insertion in the dorsal veins of the hand, the cephalic vein in the forearm, or the great saphenous vein. Success rates and vein diameters were evaluated by using Dunn tests; insertion time was evaluated by using Kaplan-Meier cumulative incidence analysis.
  
  
  RESULTS
  Independent predictors of catheterisation were ultrasound guidance (odds ratio (OR) = 7.3, 95% confidence interval (CI) 2.0 to 26.0, P = 0.002), vein diameter (OR = 1.5 per 0.1 mm increase in diameter, 95% CI 1.1 to 2.0, P = 0.007), and ASA physical status (OR = 0.4 per status 1 increase, 95% CI 0.2 to 0.9, P = 0.03). Cephalic veins were significantly larger (cephalic diameter 1.8 mm, P = 0.001 versus saphenous 1.5 mm, P <0.001 versus dorsal 1.5 mm). Catheterisation success rates were significantly better at the cephalic vein than either the dorsal hand or saphenous vein (cephalic 95%, 95% CI 89% to 100%, P <0.001 versus dorsal 69%, 95% CI 56% to 82%, P = 0.03 versus saphenous 75%, 95% CI 64% to 86%).
  
  
  CONCLUSIONS
  The cephalic vein in the proximal forearm appears to be the most appropriate initial site for ultrasound-guided catheterisation in invisible and impalpable veins of paediatric patients.
  UMIN Clinical Trials Registry as UMIN000010961. Registered on 14 June 2013.
authors.affiliation: Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, 1-1 Fukakusamukaihata-cho Fushimi-ku, Kyoto, 612-8555, Japan. t-k-s-t@koto.kpu-m.ac.jp.
authors.forename: Jun
authors.initials: J
authors.lastname: Takeshita
authors.affiliation: Department of Anaesthesiology and Intensive Care, 465 Kawaramachi Hirokoji Kamigyo-Ku, Kyoto, 602-8566, Japan. na-yoshi@koto.kpu-m.ac.jp.
authors.forename: Yoshinobu
authors.initials: Y
authors.lastname: Nakayama
authors.affiliation: Department of Anaesthesiology and Intensive Care, 465 Kawaramachi Hirokoji Kamigyo-Ku, Kyoto, 602-8566, Japan. nakajima@koto.kpu-m.ac.jp.
authors.forename: Yasufumi
authors.initials: Y
authors.lastname: Nakajima
authors.affiliation: Department of Outcomes Research, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. ds@or.org.
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.affiliation: Department of Anaesthesiology and Intensive Care, 465 Kawaramachi Hirokoji Kamigyo-Ku, Kyoto, 602-8566, Japan. satoru.ogawa78@gmail.com.
authors.forename: Satoru
authors.initials: S
authors.lastname: Ogawa
authors.affiliation: Department of Anaesthesiology and Intensive Care, 465 Kawaramachi Hirokoji Kamigyo-Ku, Kyoto, 602-8566, Japan. teijisw@mac.com.
authors.forename: Teiji
authors.initials: T
authors.lastname: Sawa
authors.affiliation: Department of Anaesthesiology and Intensive Care, 465 Kawaramachi Hirokoji Kamigyo-Ku, Kyoto, 602-8566, Japan. toshim@koto.kpu-m.ac.jp.
authors.forename: Toshiki
authors.initials: T
authors.lastname: Mizobe
mesh_terms: D049628:Body Size; D002406:Catheterization, Peripheral / Q000379:methods*; D002675:Child, Preschool; D005260:Female; D005542:Forearm / Q000098:blood supply*; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D011446:Prospective Studies; D018084:Ultrasonography, Interventional; D014680:Veins / Q000033:anatomy & histology