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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 79-85

Comparison of external jugular venous access with internal jugular venous access in pediatric shock: An observational, prospective study


Department of Pediatrics, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India

Date of Submission02-Nov-2020
Date of Decision30-Dec-2020
Date of Acceptance15-Jan-2021
Date of Web Publication10-Mar-2021

Correspondence Address:
Dr. Krutika Tandon
Department of Pediatrics, Pramukhswami Medical College, Bhaikaka University, Anand, Karamsad - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_176_20

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  Abstract 


Background: Central venous access is usually preferred over the peripheral venous route when circulatory failure needs inotropes and vasopressors. However, in resource-limited settings with underskilled personnel, it is not feasible always and so patients are being treated with the peripheral venous route with variable results. We aimed to compare external jugular venous (EJV) access with internal jugular venous (IJV) access for effectiveness, ease of procedure, complications, and treatment cost in pediatric shock.
Subjects and Methods: This was a prospective, nonrandomized, observational study from January 2014 to June 2015 in 66 pediatric patients with shock at a 7-bedded pediatric intensive care unit. Parents were explained about both routes. Depending on their affordability and consent, one route was chosen. Pertinent data were obtained, and analysis was done as per objectives.
Results: EJV and IJV had 50 and 16 patients, respectively. Baseline characteristics were comparable. Death and discharge against medical advice rates are high in both the groups. No procedure-related life-threatening complications in any group and local site problems were similar in both the groups. Overall attempts and duration of procedure were similar in both the groups, and although the initial cost of the procedure of the IJV group was higher, overall final hospital bill had no significant difference. The median (Q1, Q3) hours of achieving shock-free status were 48 (24, 96) and 46 (12, 108) (P = 0.412). The median (Q1, Q3) improvement in base deficit at the end of 24 h was −4.5 (−8.1, 0.27) and −1.9 (−4.2, −0.6) (P = 0.259) in the EJV and IJV groups, respectively.
Conclusion: For pediatric shock management, EJV access is an effective, easy, and cost economic procedure without significant complications as compared to IJV access.

Keywords: External jugular venous access, internal jugular venous access, pediatric shock


How to cite this article:
Kumar A, Tandon K, Shah KM, Tandon R, Patel MR. Comparison of external jugular venous access with internal jugular venous access in pediatric shock: An observational, prospective study. J Pediatr Crit Care 2021;8:79-85

How to cite this URL:
Kumar A, Tandon K, Shah KM, Tandon R, Patel MR. Comparison of external jugular venous access with internal jugular venous access in pediatric shock: An observational, prospective study. J Pediatr Crit Care [serial online] 2021 [cited 2021 Apr 20];8:79-85. Available from: http://www.jpcc.org.in/text.asp?2021/8/2/79/311058




  Introduction Top


Vascular access is one of the most common invasive procedures performed in sick patients. Intravenous (IV) lines are essential for any sick child. Peripheral lines are used for reasons such as the infusion of IV fluids and the administration of medications. Central lines have the added advantage of real-time venous pressure monitoring and are preferred in circulatory shock. However, recent international septic shock guideline/national update recommends peripheral access also an acceptable route to administer vasoactive therapy during the management of shock as the time matters in life and death situations.[1],[2]

Central venous catheter (CVC) is inserted in great venous vessels whereas the external jugular vein is one of the easily detectable and palpable veins close to the central vein among the superficial peripheral thick veins. Central venous catheterization may cause complications such as hemorrhage, pneumothorax, thrombosis, and infections.[3],[4],[5] However, in adults who could be managed either with a peripheral venous catheter (PVC) or a CVC, a strategy based on the systematic insertion of CVCs is associated with fewer complications.[6] The external jugular vein has become much more prevalent than cut-downs or open surgical techniques, because the procedure is simpler to perform, relatively rapid, less expensive, and requires only mild sedation or pain relief with lesser complications.[7],[8] Central line-associated blood infections are more common than peripheral cannula, and it creates a high financial burden.[7],[8] Furthermore, a recent study of pediatric intensive care unit (PICU) concluded that peripherally inserted CVCs had a lower occurrence of central line-associated bloodstream infection than CVCs and similar catheter survival probabilities.[9]

It was our common observation that children admitted in PICU with septic shock recovered even without insertion of the central line which is usually recommended when patients need inotropes and vasopressors. In these children, external jugular venous (EJV) access was the main venous access. Hence, based on this observation, we decided to conduct a prospective study of comparison of two diverse routes of venous access. We hypothesized that if EJV access achieves shock-free status not longer than 6 h as compared to internal jugular venous (IJV) access, then it is effective and if taking longer than 24 h then to consider noneffective.


  Subjects and Methods Top


This study was conducted between January 2014 and June 2015 at a 7-bedded PICU of a tertiary care teaching hospital located in a semi-rural area. During the study period, patients with shock admitted to PICU were screened for the study.

Inclusion criteria

  1. Age between 3 months and 18 years
  2. Low mean arterial pressure (<5th percentile for that age/sex) or systolic blood pressure 2 standard deviation below normal for age/sex/height despite administration of an isotonic IV fluid bolus ≥40 mL/kg or prolonged capillary refill time >5 s, cold extremities, and low-volume peripheral pulses despite administration of isotonic IV fluid bolus ≥40 mL/kg or need for vasoactive drug to maintain age/sex appropriate BP (dopamine >5 μg/kg/min or dobutamine, adrenaline, and noradrenaline in any dose)
  3. Base deficit >10.0 mEq/L documented by arterial blood gas.


Exclusion criteria

  1. Deranged coagulation profile and/or evidence of bleeding
  2. Suspected cervical cord injury
  3. Local site infection.


Primary objective

The primary objective of this study was to compare EJV to IJV for the time for the procedure and attempts required to get the access, complication rate, procedure cost, and overall hospital cost.

Secondary objective

The secondary objective of this study was to compare EJV access (peripheral) to IJV access (central) for the time required to achieve shock-free status (clinical warm extremities, well-palpable peripheral pulses, capillary refill time 3 s or less, and age-appropriate normal BP along with laboratory criteria of base deficit <5.0 mEq/L documented by arterial blood gas analysis).

The study was approved by the Institutional Human Ethics Research Committee (HMPCMCE: HREC/UGPG/23/session1/18 (17/02/2014). After fulfillment of inclusion and exclusion criteria, the parents or caregivers of patients were explained about both routes of venous accesses with benefits, cost, and possible complications. They had chosen one of the venous accesses as per their affordability and feasibility. Those who had chosen EJV access assigned as Group 1 and those who had chosen IJV assigned as Group 2 [Figure 1].
Figure 1: Flowchart of study

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Appropriate size CVC for IJV access and intracath no. 22, 20, and 18 for EJV access were inserted with all sterile precautions. IJV access gained by modified Seldinger technique and secured by stitches and transparent dressing. The EJV line was taken as per standard procedure by intracath, but utmost care was taken in positioning the child to visualize the external jugular vein properly. EJV access was secured by the Elastoplast dressing. Procedures were performed by duty resident doctors who had taken these IV accesses successfully previously. The duration of the procedure was determined from the point when the person washed, ready with personal protected equipment till the time of fixation and dressing. The number of attempts of insertion was also recorded in both the groups. Continuous monitoring of the patients was done throughout the procedure. Radiographs were taken after the central venous catheterization to look for tip position and to see any complications. Care of venous lines was taken as per standard measures. Removal of the central line or intracath was performed when clinically not indicated or any local site complication or catheter-related problem was there. In none of the patients, internal jugular access followed EJV access and vice versa. Pertinent details were filled in pro forma after the procedure over as well as at the time of removal of the IV line. The baseline PRISM III score was calculated in both the groups. Patients were followed up regularly till the discharge or death or discharge against medical advice (DAMA). The clinical assessment was done every hour by on-duty doctors as per our standard monitoring chart in PICU starting from successful venous access for up to 72 h. Arterial blood gas was done every 6 h till clinically shock-free status or till 72 h. When Base deficit by arterial blood was achieved <5.0 mEq/L, then that hour was considered as an exit point for the calculation of hours required for shock-free status. Final diagnoses, the overall cost of treatment, stay, and outcome were also noted.

In the statistical analysis, continuous variables were presented as mean (SD)/median (interquartile range). The Student's t-test was applied for the calculation of statistical significance whenever the data followed a normal distribution. Mann–Whitney U-test was applied whenever data followed nonnormal distribution. Categorical variables were expressed as frequencies and percentages. Nominal categorical data between the groups were compared using the Chi-squared test/Fisher's exact test. P < 0.05 was taken to indicate a statistically significant difference. Stata 14.2 StataCorp 4905 Lakeway Drive College Station, Texas 77845 USA was used for the computation of statistics.


  Results Top


Out of 78 screened patients, 66 were finally enrolled. The EJV group had 50 and the IJV group had 16 patients. Baseline characteristics such as sex, age, PRISM III score within 12 h and at 24 h, clinical diagnosis, and duration of hospital stay of both the groups are shown [Table 1]. Both the groups were comparable, and the difference was not statistically significant.
Table 1: Baseline characteristics, Pediatric Risk of Mortality III score#, and outcome in both the groups

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A procedure-related comparison like the mean duration of the procedure and total number of attempts by resident doctors (seniority wise) were shown in [Table 2]. Common problems observed in the EJV group were bleeding from the local site in 3, hematoma in 6, failure to insert in the first attempt in 6, and line-related suspected sepsis in 2 cases. Complications observed in the IJV group were the occurrence of an arterial puncture in 4 cases with a local hematoma in 2 and catheter-related suspected sepsis in 1. There was no occurrence of pneumothorax in any group. [Table 2] also mentions the mean duration of the device in situ and the major causes of its removal. The average initial cost for inserting EJV and IJV was 450 and 4200 Indian rupees, respectively, whereas the overall average hospital bill in the EJV group was Rs. 64,724 and Rs. 68,385 in the IJV group.
Table 2: Primary outcomes

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The secondary outcome of the duration of achieving shock-free status was 48 (24, 96) in Group 1 and 46 (12, 108) in Group 2 (median [Q1, Q3]) (P = 0.412) [Graph 1]. The serial base deficit (arterial blood) was documented at 0, 6, 12, and 24 h in both the groups, as shown in [Graph 2].



The median (Q1, Q3) improvement in base deficit at the end of 24 h was −4.5 (−8.1, 0.27) and −1.9 (−4.2, −0.6) (P = 0.259) in the EJV and IJV groups, respectively, as per [Table 3].
Table 3: Secondary outcome

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  Discussion Top


In our study, baseline characteristics such as sex, age, PRISM III score within 12 h and at 24 h, clinical diagnosis, and duration of hospital stay of both the groups, as shown in [Table 1], were comparable, and the difference was not statistically significant. However, there was a male preponderance in both the groups. This type of scenario is common in India.[10],[11] This shows serious gender discrimination issues in India and reflects preferential health preponderance for the male child.[10],[11] The median age (in years) was 2 (0.8, 4.2) and 4 (2, 9.5) in Groups 1 and 2, respectively. This indicates that we had relatively younger patients in both the groups. This indirectly explains a higher vulnerability of infants and young children to disease as well as more referrals to tertiary care centers from smaller nursing homes or private hospitals. They tend to refer more critical cases more so with younger age having difficulty in IV access and need for ventilator support. Similar results were seen in other studies.[10],[11] Hence, there is a need for special consideration for these groups in health-care provision planning.[12],[13]

In our unit, the majority of the patients were admitted for medical reasons the same as other Indian studies.[14],[15] This is quite different from developed countries where the majority of the patients were admitted due to surgical causes or from oncology.[16] The spectrum of the diseases accounting for PICU admission was infective etiology such as sepsis, pneumonia, meningitis, encephalitis, and acute respiratory distress syndrome mainly. In our study, we used the PRISM III score for comparing the severity of the patients' condition and the chances of mortality. A patient who has a high PRISM III score on admission has more chances of mortality.[10],[11] In our study, baseline PRISM III score was also comparable in both the groups. As per [Table 1] combine percentage of death and DAMA were 60 and 75 in the EJV and IJV groups, respectively, but the study is underpowered to establish relationship between PRISM III score with outcome of patients. The study population itself was sickest among all PICU admission, and we know that sepsis and multi-organ dysfunction are major contributors to death in general. The median duration of hospital stay was 6 (2, 11) and 5 (3, 26) days in the EJV and IJV groups, respectively, with P = 0.531 and had higher death and DAMA rates in both the groups.

In both the groups, venous access was achieved at the first attempt in half of the cases, as shown in [Table 2]. Second- and 3rd-year residents were more involved in taking venous access than 1st years, but in the EJV group, the 1st year had taken venous access in 12% of cases as compared to 0% (no chance) in the IJV group. In the EJV and IJV groups, the mean (SD) times (in minutes) to take IV access were 27.7 (25) and 15.6 (13.7) (P = 0.07), respectively, whereas medians (Q1, Q3) were 20 (10, 40) and 10 (10, 13), respectively. This was an important finding that insertion of internal jugular vein needs specialized training sessions and hand-on experience before the adoption of routine IJV insertion, but once inserted by a trained person, the usual overall time was less. In contrast to IJV, although the EJV insertion was a simpler procedure but performed by 1st-year residents, it might have taken longer meantime with wide variation. Furthermore, the EJV group had a comparatively younger age group posing more difficulty in putting EJV due to short neck area, and some cases might have taken exceptionally longer duration. IJV route was a rather planned procedure as compared to EJV. Hence, IJV access was better in many parameters but in situations where immediate venous access was needed EJV served as a good alternative to IJV even in hands of juniors or relatively less experienced persons. Furthermore, this was a better alternative when parents could not afford the central line in an emergency setting in a short span. None of the groups encountered any of the life-threatening complications. Hence, both are safe in hands of resident doctors with reasonable experience though some studies have shown that the central line was associated with major complications.[6],[8] A retrospective observational study from Hyderabad[8] suggested that the EJV route seems to be underutilized by pediatricians for IV fluid resuscitation and inotropic infusion. In their pilot study, it was shown that vasoactive agents were successfully and safely infused through the EJV in most children. Complications associated with EJV cannulation were comparable with any other routine peripheral venous access and were significantly less compared to the central venous route. EJV access was easier and much less expensive as compared to conventional central venous access methods. Central venous catheterization may cause complications such as hemorrhage, pneumothorax, thrombosis, and infections.[3],[4],[5],[7] In one of the adult studies which managed patients either with a PVC or a CVC, a strategy based on the systematic insertion of CVCs was associated with fewer complications.[6]

It is usual practice to take peripheral lines in in shock patients as the first choice when a patient who came to the emergency center. Most of the patients who were enrolled for the study were from the lower socioeconomic class. For them, it was not possible to spend initial cost of CVC. The average initial cost for inserting EJV and IJV was 450 and 4200 Indian rupees, respectively. This was significantly low for the EJV group. However, once the patients shifted to PICU and financial matter sorted out, IJV was inserted replacing other peripheral routes. Hence, on-duty doctors found out EJV as a good alternative when the financial condition was poor and central line insertion was not possible. There was no significant difference in clinical outcome in both the groups. Previous study from our center has shown that unplanned admission, lack of insurance cover, significant medical cost as well as no earning by staying away from work push parents into more financial and psychological distress.[17]

In our study, we encountered the greatest number of cases with septic shock with multi-organ dysfunction followed by septic shock along with respiratory causes which were similar to that of our one of the previous studies from the same center.[18] Mortality was higher among the patients with septic shock secondary to respiratory causes. This might be due to more critical patients admitted with respiratory disease or may be fact that primary respiratory disease requires long-term ventilator support as compared to other pathologies which lead to higher chances of ventilator-associated pneumonia and secondary infections which have higher chances of mortality.

The secondary outcome of the duration of achieving shock-free status was 48 (24, 96) in Group 1 and 46 (12, 108) in Group 2, and the median (Q1, Q3) improvement in base deficit at the end of 24 h was − 4.5 (−8.1, 0.27) and − 1.9 (−4.2, −0.6) (P = 0.259) in the EJV and IJV groups, respectively, suggesting that the trend was little better in the IJV group though the difference was no statistically significant between the groups. However, the external jugular and the IJV access are diverse routes and merely comparing them with the shock-free state can overestimate the results.

Limitations

In our study, smaller sample size, nonrandomization, and unequal groups were the major limitations. Achieving a therapeutic endpoint of shock based on many interventions such as timely recognition, administration of oxygen, fluid and antibiotics, and other supportive care can be confounding factors.


  Conclusion Top


For pediatric shock management, EJV access is an effective, easy, and cost economic procedure without significant complications as compared to IJV access.

Acknowledgment

We would like to thank participants, nursing staff of PICU, and residents of pediatrics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weiss SL, Peters MJ, Alhazzani W, Agus MS, Flori HR, Inwald DP, et al. Executive summary: Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020;46:1-9.  Back to cited text no. 1
    
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Sahoo T, Aradhya AS, Gulla KM. International guidelines 2020 for the management of septic shock in children. Indian Pediatr 2020;57:671-5.  Back to cited text no. 2
    
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Haas NA. Clinical review: Vascular access for fluid infusion in children. Crit Care 2004;8:478-84.  Back to cited text no. 3
    
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Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med 2007;35:1390-6.  Back to cited text no. 4
    
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Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32.  Back to cited text no. 5
    
6.
Ricard JD, Salomon L, Boyer A, Thiery G, Meybeck A, Roy C, et al. Central or peripheral catheters for initial venous access of ICU patients: A randomized controlled trial. Crit Care Med 2013;41:2108-15.  Back to cited text no. 6
    
7.
Pérez ER. Catheter related bloodstream infections in critical care. Luciano Azevedo (Editor). Sepsis. An Ongoing and Significant Challenge. Croatia. In Tech; 2012. p. 261-72.  Back to cited text no. 7
    
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Prasad VS, Daharwal S, Bahe A. External jugular venous access in children: A low cost and feasible route for emergency fluid resuscitation and inotropic therapy in resource-poor clinical settings. J Pediatr Crit Care 2016;3:16-21.  Back to cited text no. 8
    
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Shimizu Y, Hatachi T, Takeshita J, Inata Y, Kyogoku M, Aoki Y, et al. Occurrence and risk factors for unplanned catheter removal in a PICU: Central venous catheters versus peripherally inserted central venous catheters. Pediatr Crit Care Med 2020;21:e635-42.  Back to cited text no. 9
    
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Singhi S, Singhi S, Gupta G. Comparison of pediatric emergency patients in a tertiary care hospital vs a community hospital. Indian Pediatr 2004;41:67-72.  Back to cited text no. 10
    
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Khilnani P, Sarma D, Singh R, Uttam R, Rajdev S, Makkar A, et al. Demographic profile and outcome analysis of a tertiary level pediatric intensive care unit. Indian J Pediatr 2004;71:587-91.  Back to cited text no. 11
    
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Nancy Scheper-Hughes (Editor). Child Survival. Anthropological Perspectives on the Treatment and Maltreatment of children. Holland. Reidel Publishing Company; 1987.  Back to cited text no. 12
    
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PICANet National Report 2005-2007. Available from: https://www.picanet.org.uk/wp-content/uploads/sites/25/2018/05/PICANet_National_Report_2008.pdf. [Last accessed on 2021 Feb 12].  Back to cited text no. 13
    
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Garg P. Pediatric hospitalizations at two different setting community hospitals in north India: Implications for regionalization of care. Indian J Pediatr 2009;76:711-6.  Back to cited text no. 14
    
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Bhadoria P, Bhagwat AG. Severity scoring systems in pediatric intensive care units. Indian J Anaesth 2008;52 Suppl 5:663-75.  Back to cited text no. 15
    
16.
American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, et al. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists task force on central venous access. Anesthesiology 2012;116:539-73.  Back to cited text no. 16
    
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Shah K, Varma JR, Patel MV, Tandon KR, Phatak AG, Nimbalkar SM. Financial burden, depression, and coping strategies among parents of children admitted to paediatric intensive care unit (PICU). J Clin Diagn Res 2018;12:VC10-3.  Back to cited text no. 17
    
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Dave H, Kumar VH, Tandon KR, Tandon RK. Mechanical ventilation practices in a pediatric intensive care unit located at a rural tertiary care teaching hospital of Gujarat – A retrospective descriptive study. Journal of Pediatric Critical Care 2017;4:27-33.  Back to cited text no. 18
    


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