Head position for facilitating the superior vena caval placement of catheters during right subclavian approach in children

Objective: To evaluate the effect of head position as a method to facilitate the superior vena caval placement of catheters during right subclavian catheterization in children. Design: Prospective, randomized, clinical trial. Setting: Department of anesthesiology, university hospital. Patients: One hundred sixty-eight pediatric patients, aged <8 yrs, undergoing simple cardiac surgery or pediatric general surgery. Interventions: At operation, the patients were assigned by the stratified randomization for age to one of the four groups (n = 42 each): when the patients turned their heads away from the puncture side, this was away-turning group; when turned toward the puncture side, toward-turning group; when lateral-flexed (tilted) away from the puncture side, away-lateral-flexion group; and when lateral-flexed toward the puncture side, toward-lateral-flexion group. Each group was divided into two subgroups depending on the age: infant (n = 24 each) and young children (>12 months; n = 18 each). Measurements and Main Results: Right infraclavicular subclavian catheterization, using the Seldinger technique, was attempted. After catheterization, a simple chest radiograph was used to identify the location of catheter tip. There was no difference in age and body weight between the groups. Only in infants was the successful placement rate of toward-lateral-flexion group (92%) higher than that of the other three groups (54% [away-lateral-flexion], 63% [away-turning], or 54% [toward-turning]), and there was no difference among the others. Conclusion: In infants, tilting the head toward the catheterization side can reduce the incidence of catheter malposition during the right subclavian approach.