British Journal of Anaesthesia, 121 (6): 1332e1337 (2018)

doi: 10.1016/j.bja.2018.08.008
Advance Access Publication Date: 7 September 2018
Paediatric Anaesthesia

Seldinger vs modified Seldinger techniques for

ultrasound-guided central venous catheterisation
in neonates: a randomised controlled trial
I.-K. Song1, E.-H. Kim2, J.-H. Lee2, Y.-E. Jang2, H.-S. Kim2 and J.-T. Kim2,*
1
Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of
Medicine, Seoul, South Korea and 2Department of Anesthesiology and Pain Medicine, Seoul National
University Hospital, Seoul National University College of Medicine, Seoul, South Korea

*Corresponding author. E-mail: jintae73@gmail.com

Abstract
Background: Central venous catheterisation in neonates is difficult. The purpose of this study was to compare
the Seldinger and modified Seldinger techniques for ultrasound-guided internal jugular vein catheterisation in
neonates.
Methods: In this randomised, controlled trial, 120 neonates (
1 month old) requiring central venous catheterisation
under general anaesthesia were allocated into either the Seldinger (n¼60) or the modified Seldinger (n¼60) group. The
primary outcome was the incidence of successful catheterisation on the first attempt. We also assessed the incidences of
successful puncture on the first attempt, successful guide wire insertion on the first attempt, and successful final
catheterisation.
Results: The primary outcome, the incidence of successful catheterisation on the first attempt was higher in the modified
Seldinger group than in the Seldinger group (83% vs 65%; relative risk¼1.282; 95% confidence interval, 1.032e1.594;
P¼0.025). The incidence of successful guide wire insertion on the first attempt was also higher in the modified Seldinger
group (95% vs 75%; relative risk¼1.267; 95% confidence interval, 1.082e1.482; P¼0.003). Other incidences did not differ
significantly between the groups.
Conclusions: For ultrasound-guided internal jugular vein catheterisation in neonates, the modified Seldinger technique
showed superiority over the Seldinger technique in terms of successful catheterisation and guide wire insertion on the
first attempt.
Clinical trial registration: NCT02688595.

Keywords: central venous catheterisation; jugular vein; ultrasonography

Editorial decision: 9 August 2018; Accepted: 9 August 2018

© 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

1332
 Central venous catheterisation techniques in neonates - 1333

National University Hospital, Korea, between March 2016 and

Editor’s key points May 2017. The study protocol was approved by the Seoul Na-
tional University Hospital Institutional Review Board
 With a classical Seldinger technique, a hollow needle is
(February 11, 2016/No.1601-108-736). The reporting of the re-
inserted into a blood vessel (or body cavity), a round-
sults followed the CONSORT(Consolidated Standards of
tipped guide wire is inserted through the needle, and
Reporting of Trials) guidelines for randomised trials.8 The
the needle is subsequently withdrawn. A catheter can
study team evaluated the eligibility of patients, obtained
then be safely advanced over the guide wire into the
written informed consent from parents, and enrolled partici-
vessel.
pants prior to surgery. The inclusion criteria were neonates
 A modified Seldinger technique entails advancing a fine
aged
1 month with an ASA physical status 1e3 who were
catheter over a needle into the vessel and withdrawing
scheduled for cardiothoracic, general, or neurosurgery under
the needle. The fine catheter rather than the needle can
general anaesthesia requiring central venous catheterisation.
then be used as a conduit for inserting the guide wire.
The exclusion criteria were central venous anomalies or
 In this randomised study, researchers investigated
thrombosis, and signs of infection on the skin of the neck.
whether ultrasound-guided central venous catheter-
isation was more successful in neonates with a modi-
fied Seldinger technique compared with a classical Randomisation
Seldinger technique.
The patients were allocated by simple randomisation to either
 The modified Seldinger technique resulted in more
the Seldinger group or the modified Seldinger group with an
frequent guide wire and central venous catheter
allocation ratio of 1:1 using computer-generated random-
insertion on the first attempt, suggesting the superior-
isation software (http://www.randomization.com). Group al-
ity of the modified Selfinger technique.
locations were concealed in sequentially numbered, opaque,
sealed envelopes opened by a trained study member after in-
duction of general anaesthesia. Each envelope contained the
Central venous catheterisation in neonates is technically
group allocation with instructions for the attending anaes-
demanding, even for experienced physicians. Nevertheless,
thetist. The modified intention-to-treat analysis was applied
central venous catheterisation is often necessary in neonates
in this study. Operators started the procedure with the tech-
undergoing major surgery or in critically ill patients in
nique determined by randomisation; however, if the rando-
neonatal and paediatric intensive care units. The adoption of
mised technique was unsuccessful (maximum attempts of
ultrasound-guided techniques for central venous catheter-
three), operators were allowed to cross over to the other
isation has led to increased success rates, decreased cathe-
technique. Data analysis of the crossed-over patient is
terisation time, and reduced complications in paediatric
described in the “Outcome variables and statistics” section.
patients; therefore, ultrasound-guided techniques are recom-
mended by most guidelines.1e5
Considering small vessel sizes in neonates, accurate Ultrasound-guided central venous catheterisation
puncture of the centre of the vein using ultrasound and deli-
After conventional general anaesthesia, the patient was
cate insertion of the guide wire are two critical steps in
positioned in a 30 Trendelenburg position with a shoulder
ultrasound-guided central venous catheterisation. Even with
roll to extend the neck, which was rotated to expose the
successful puncture of the vein, inserting the guide wire
puncture site. After sterile skin preparation, ultrasound-
through a needle can be difficult in neonates because of easy
guided central venous catheterisation was performed by
displacement of the needle from the vein and the use of a J-
one of three paediatric anaesthetists, who all had success-
shaped guide wire.6
fully performed more than 100 ultrasound-guided central
Two techniques are commonly used for central venous
venous catheterisations in paediatric patients with each
catheterisation: the wire-through-thin-wall-needle technique
technique before this study.
(i.e., Seldinger technique) and the catheter-over-the-needle-
The primary catheterisation site was the right IJV. The left
then-wire-through-the-catheter technique (i.e., modified Sel-
IJV was selected in patients with a very small right IJV (diam-
dinger technique). In adults, the Seldinger technique has a
eter <2 mm), thrombus, previous puncture history, or a pre-
superior success rate for needle and guide wire insertion on
existing catheter in the right IJV. A 4-F radiopaque poly-
the first attempt compared with the modified Seldinger tech-
urethane indwelling catheter (Pediatric Two-Lumen Central
nique during ultrasound-guided internal jugular vein (IJV)
Venous Catheterisation Set with Blue FlexTip® ARROWgþard
catheterisation.7 However, there are currently no studies
Blue® Catheter; Arrow International Inc., Reading, PA, USA)
comparing the two techniques for ultrasound-guided IJV
was used in all patients. The 4e10 MHz hockey stick trans-
catheterisation in paediatric patients.
ducer (i12L-RS; GE Healthcare, Wauwatosa, WI, USA) of the
We therefore hypothesised in the current study that the
ultrasound (LOGIQ® e; GE Healthcare) was protected with a
modified Seldinger technique would be associated with
long sterile cover and placed over the puncture site perpen-
increased success rates on the first attempt compared with the
dicular to the vein, lateral to the trachea, and above the clav-
Seldinger technique for ultrasound-guided IJV catheterisation
icle so as to see the vein in the short-axis view. Once the IJV
in neonates.
and carotid artery were identified, the probe was manipulated
to find the spot where the vein’s diameter was largest. Liver
Methods compression was applied to expand the vein. A cross-sectional
image of the vein was saved to measure the diameter and
Study design and participants
depth of the vein.
This study was designed as a randomised, controlled, single- Catheterisation was performed using an ‘out-of-plane’
blind superiority trial and was performed at the Seoul approach with a bevel-up orientation at approximately 45e60
 1334 - Song et al.
to the skin and perpendicular to the transducer, adhering
closely to the centre of the transducer’s long axis.
In the Seldinger group, a 21-G introducer needle was used
to puncture the vein. After advancing the introducer needle
through the vein, it was slowly withdrawn with negative
pressure until blood was aspirated.
In the modified Seldinger group, a 22-G Angiocath Plus™
catheter (Becton Dickinson Infusion Therapy Systems Inc.,
Sandy, UT, USA) was used to puncture the vein. After punc-
turing the vein, a needle inside the angiocath was removed,
and the angiocath was slowly withdrawn without negative
pressure until flashback of blood occurred. The angiocath was
then advanced fully into the vein until the hub of the angio-
cath reached the skin. If flashback of blood occurred when the
needle was removed, the angiocath was advanced into the
vein until the hub reached the skin.
In both groups, after venous blood flashback, a ‘J’ tip guide
wire (Spring-wire guide with Arrow Advancer™; Arrow Inter-
national Inc.), tissue dilator, and indwelling catheter were
introduced consecutively. Both the tissue dilator and
indwelling catheter were inserted only after confirming suc-
cessful guide wire insertion in the vein using the ultrasound.
Outcome variables and statistics
The following data were collected for each patient: age,
height, weight, sex, and catheterisation site. The primary
outcome was the incidence of successful catheterisation on
the first attempt. In addition, we assessed the diameter and
depth of the vein, other incidences (successful puncture on
the first attempt, successful guide wire insertion on the first
attempt, and successful final catheterisation), frequency
variables (number of puncture attempts and number of guide
wire insertion attempts), time variables, and complications
(arterial puncture and haematoma). Puncture time was
defined as the period between skin penetration of the needle
or angiocath and the first flashback of blood. Angiocath
insertion time was defined as the period between skin
penetration of the angiocath and skin contact of the hub.
Guide wire insertion time was defined as the period between
skin penetration and removal of the needle or angiocath after
guide wire insertion. Total catheterisation time was defined
as the period between skin penetration of the needle or
angiocath and insertion of the indwelling catheter. Intervals
between the time points were also measured. In the Sel-
dinger group, the puncture time, interval between vessel
puncture and guide wire insertion, guide wire insertion time
(puncture time þ interval between vessel puncture and guide
wire insertion), interval between guide wire insertion and
catheterisation, and total catheterisation time were deter-
mined. In the modified Seldinger group, the puncture time,
interval between vessel puncture and angiocath insertion,
angiocath insertion time, interval between angiocath inser-
tion and guide wire insertion, guide wire insertion time
(angiocath insertion time þ interval between angiocath
insertion and guide wire insertion), interval between guide
wire insertion and catheterisation, and total catheterisation
time were determined.
Regarding the modified intention-to-treat analysis, the
crossed-over patients were categorised in the group to which
they were allocated, and their data were included in this
group. However, among the outcome variables, the time var-
iables of the crossed-over patients were excluded from the
final analysis because the time data were collected
continuously from the initial starting point where the opera-
tors started with the randomised technique until the final
ending point where the catheterisation was succeeded with
the crossed-over technique, which might lead to biased re-
sults. Other variables (baseline characteristics, diameter and
depth of the vein, incidences, frequency variables, and com-
plications) were analysed as recorded.
The required sample size was calculated on the basis of our
previous data obtained from infants.6 When the Seldinger
technique was used in infants, the incidence of successful
catheterisation on the first attempt was 51%. To observe 25%
absolute increase in the incidence of successful catheter-
isation on the first attempt by applying the modified Seldinger
technique, the required sample size was 60 for each group,
with a set alpha error of 0.05, a power of 80%, and a dropout
rate of 10%. Sample size was calculated using an electronic
source (Sealed Envelope Ltd. 2012; https://www.
sealedenvelope.com/power/binary-superiority/).
All data are expressed as mean (SD) or median [inter-
quartile range, (range)], unless otherwise specified. The
KolmogoroveSmirnov test was used to determine the
normality of the distribution. The baseline characteristics of
the study population were compared using Student’s t-test
and c2 test. The primary outcome was evaluated using the c2
test. Comparisons between groups in diameter and depth of
the vein were made using Student’s t-test. The
ManneWhitney U test was used for comparing the time and
frequency variables. The c2 test was used for comparing the
catheterisation site and incidences. P<0.05 was considered
statistically significant. Statistical analysis was performed
using IBM® SPSS® Statistics 23 (SPSS Inc., IBM Corporation,
Armonk, NY, USA).
Results
From March 18, 2016 to May 23, 2017, 120 children were
enrolled and randomised into the Seldinger (n¼60) and modi-
fied Seldinger (n¼60) groups (Fig. 1). The baseline characteris-
tics of the study population are summarised in Table 1. There
were no statistically significant differences in baseline char-
acteristics between the groups.
Procedural data are summarised in Table 2. The primary
outcome, the incidence of successful catheterisation on the
first attempt, was higher in the modified Seldinger group than
in the Seldinger group [83% vs 65%; relative risk (RR)¼1.282;
95% confidence interval (CI), 1.032e1.594; P¼0.025]. The inci-
dence of successful guide wire insertion on the first attempt
was also higher in the modified Seldinger group than in the
Seldinger group (95% vs 75%; RR¼1.267; 95% CI, 1.082e1.482;
P¼0.003). In addition, the number {median [inter-quartile
range (range)]} of guide wire insertion attempts was lower in
the modified Seldinger group than in the Seldinger group {1
[1e1 (1e2)] vs 1 [1e1 (1e3)]; P¼0.021}.
Although the guide wire insertion time in seconds was
longer in the modified Seldinger group than in the Seldinger
group {62 [46e81 (23e277)] vs 45 [33e68 (21e217)]; P¼0.003}, the
total central venous catheterisation time was similar in the
two groups {121 [85e144 (57e420)] vs 122 [101e153 (74e294)];
P¼0.642}.
Crossover to the other group occurred in two patients in the
Seldinger group, and central venous catheterisation was then
successful with the modified Seldinger technique. Venous
haematomas were detected in three patients in the Seldinger
group, and these resolved by the end of surgery.
 Central venous catheterisation techniques in neonates - 1335

Fig 1. CONSORT (Consolidated Standards of Reporting of Trials) flow diagram. * The crossed-over patients were categorized in the allocated
group and their data (excluding the time variables) were analysed in the Seldinger group.

Discussion neonates. Contrary to the results obtained in adults advo-

cating the Seldinger technique for ultrasound-guided IJV
In this study, we compared the Seldinger and modified Sel-
catheterisation,7 our results support the modified Seldinger
dinger techniques for ultrasound-guided IJV catheterisation in
technique based on three outcomes: higher incidences of
successful catheterisation and guide wire insertion on the first
attempt, fewer guide wire insertion attempts, and comparable
Table 1 Baseline characteristics of patients included in the catheterisation time despite one more step (advancing the
study. Values are mean (SD) or number (%)
angiocath fully into the vein until the hub of the angiocath
reaches the skin) during the procedure. To the best of our
Seldinger Modified Seldinger P-value
knowledge, this is the first randomised controlled trial exam-
group group (n¼60)
(n¼60) ining the Seldinger and modified Seldinger techniques for
central venous catheterisation in paediatric patients.
Age, day (range) 18 (1e31) 18 (1e31) 0.930 Because neonates have relatively small vessels, any failure
Male 24 (40) 29 (48) 0.462 in puncture or guide wire insertion attempt can be serious or
Height, cm 50.3 (4.4) 51.0 (5.5) 0.474 lead directly to complications such as hematoma, which may
Weight, kg 3.5 (0.9) 3.6 (1.2) 0.659
hinder the next attempt. Furthermore, central venous
catheter-related mechanical complications are closely related
 1336 - Song et al.

Table 2 Procedural data of the study. Values are mean (SD), median [IQR (range)], or number (%) as appropriate. CI, confidence interval;
IJV, right internal jugular vein; RR, relative risk. *Two crossed-over patients were categorised in the Seldinger group as randomised and
their data were analysed in the Seldinger group, except the time variables which were excluded from the final analysis

Seldinger (n¼60) Modified seldinger P-value RR 95% CI

(n¼60)

Catheterisation site (right IJV) 54 (90) 52 (87) 0.571 1.333 0.492e3.611

IJV diameter (mm) 5.5 (1.0) 5.1 (1.4) 0.145 e0.129 to 0.866
IJV depth (mm) 5.1 (1.0) 5.3 (1.1) 0.303 e0.689 to 0.216
Incidences (n)
Successful puncture on the first attempt 44 (73) 52 (87) 0.072 1.182 0.985e1.418
Successful guide wire insertion 45 (75) 57 (95) 0.003 1.267 1.082e1.482
on the first attempt
Successful catheterisation on 39 (65) 50 (83) 0.025 1.282 1.032e1.594
the first attempt
Successful final catheterisation 60 (100) 60 (100)
Frequency variables (n)
Puncture attempts 1 [1e2 (1e3)] 1 [1e1 (1e3)] 0.061 e0.002 to 0.369
Guide wire insertion attempts 1 [1e1 (1e3]] 1 [1e1 (1e2]] 0.021 0.038e0.362
Time variables (s)
Puncture time 21 [16e27 (7e169)] 16 [12e26 (4e62)] 0.026 e0.957 to 12.25
Angiocath insertion time 42 [30e60 (18e250]]
Interval between puncture/angiocath 19 [13e35 (8e203)] 15 [10e21 (3e73)] 0.017 4.369e25.64
insertion and guide wire insertion
Guide wire insertion time 45 [33e68 (21e217]] 62 [46e81 (23e277)] 0.003 e36.49 to 0.466
Interval between guide wire 44 [32e67 (20e216)] 58 [43e79 (11e155)] 0.085 e13.95 to e12.10
insertion and catheterisation
Total catheterisation time 122 [101e153 (74e294)] 121 [96e144 (57e420]] 0.642 e30.55 to 14.28
Complication (n) 3 (5) 0 0.195 0.143 0.008e2.707
Cross-over (n) 2 (3)* 0 0.296 0.200 0.010e4.080

to needle and guide wire insertion.7 The number of attempts is
a known risk factor for mechanical complications during
central venous catheterisation.9,10 Mechanical complications
reportedly occur with each additional attempt during central
venous catheterisation in paediatric patients.9 Therefore, it is
important to succeed at every step of central venous cathe-
terisation on the first attempt. Although overall incidence of
successful catheterisation is an important end point, we
considered the incidence of successful catheterisation on the
first attempt to be a more meaningful parameter in neonates.
The modified Seldinger technique was better than the Sel-
dinger technique in terms of reducing attempts, thereby
increasing the incidence of successful catheterisation on the
first attempt for central venous catheterisation in neonates.
In this study, failure of catheterisation on the first attempt
occurred because of failure of venous puncture (16 of 21, 76%)
or guide wire insertion (five of 21, 24%) in the Seldinger group
and failure of venous puncture (eight of 10, 80%) or guide wire
insertion (two of 10, 20%) in the modified Seldinger group. In
contrast, in a study conducted in adults, failure of venous
puncture was the cause of failed catheterisation on the first
attempt in 53% of patients in the Seldinger group and 47% of
patients in the modified Seldinger group.7 This implies that
venous puncture is more challenging in neonates and that
securing the needle or angiocath firmly inside the vessel lumen
is essential. When the Seldinger technique is used, only the
needle tip is located inside the vessel lumen when blood is
aspirated. Nevertheless, considering the needle bevel length,
there is a possibility of the needle tip spanning the vessel wall
and lumen, which may block guide wire insertion despite blood
aspiration. In contrast, when the modified Seldinger technique
is used, the angiocath is fully inserted into the vessel lumen. As
the inserted angiocath is flexible and stable, insertion of the
guide wire is facilitated once the angiocath resides within the
vessel. In other words, the modified Seldinger technique
demonstrated a higher incidence of successful catheterisation
on the first attempt for two reasons: more accurate venous
puncture and greater ease of guide wire insertion.
Regarding the time variables, sliding the angiocath fully
into the vein in the modified Seldinger technique was time
intensive, resulting in a longer guide wire insertion time than
that with the Seldinger technique. Nonetheless, because the
puncture time and interval between angiocath insertion and
guide wire insertion were shorter in the modified Seldinger
technique, the total catheterisation time was similar with the
two techniques.
In adults, almost 80% of blood aspiration was recorded as
aspiration-on-advance, which was defined as free flowing of
blood into the syringe during advancing.7 However, in neo-
nates, aspiration-on-advance is rarely achievable owing to the
easy collapsibility of the vessels. Therefore, blood aspiration
was performed mostly by withdrawing the needle or angio-
cath, and sometimes, the posterior wall of the IJV was punc-
tured using the transfixation technique.11,12 Although
puncturing the posterior wall of the IJV carries the risk of
accidental puncture of the artery, there were no cases of
arterial puncture in either group.
Contrary to a previous finding that subcutaneous tissue
dilation was more difficult in the modified Seldinger tech-
nique,7 in our study, the tissue dilator was inserted more
easily in the modified Seldinger technique than in the Sel-
dinger technique. This could be attributable to the pre-dilating
effect of the angiocath considering the soft skin and subcu-
taneous tissue of neonates.
Commonly reported mechanical complications associated
with IJV catheterisation in paediatric patients include arterial
 Central venous catheterisation techniques in neonates
puncture, catheter malposition, arrhythmias, and hema-
toma.9,13 The only complication that occurred in this study
was venous haematoma, which was observed in three pa-
tients in the Seldinger group (5%). Even though we only
enrolled neonates, the incidence of mechanical complications
associated with central venous catheterisation was lower than
that in previous reports.2,9,13e15 Ultrasound guidance and the
operators’ skill could have contributed to the low number of
complications in this study.
There are several limitations in this study. First, the study
could not be performed in a double-blind manner. Second,
because ultrasound-guided central venous catheterisation
was performed by experienced paediatric anaesthetists, our
results cannot be generalised to physicians unfamiliar with
ultrasound-guided central venous catheterisation in paediat-
ric patients using the Seldinger and modified Seldinger
techniques.
Conclusions
In conclusion, the modified Seldinger technique showed su-
periority over the Seldinger technique for ultrasound-guided
IJV catheterisation in neonates in terms of successful cathe-
terisation and guide wire insertion on the first attempt and
number of attempts for guide wire insertion.
Authors’ contributions
Study concept/design: IeK.S., HeS.K., J-T.K.
Study conduct: IeK.S., E-H.K., J-H.L., Y-E.J., J-T.K.
Data analysis: IeK.S., J-T.K.
Writing of the manuscript: IeK.S., J-T.K.
Revision of the manuscript: all authors.
Acknowledgements
The authors thank J.B. Lee (Department of Clinical Epidemi-
ology and Biostatistics, Asan Medical Center, University of
Ulsan College of Medicine, Seoul, Republic of Korea), for
contribution as a statistic advisor.
Declaration of interests
The authors declare that they have no conflicts of interest.
References
1. Lamperti M, Bodenham AR, Pittiruti M, et al. International
evidence-based recommendations on ultrasound-guided
vascular access. Intensive Care Med 2012; 38: 1105e17
2. Oulego-Erroz I, Gonzalez-Cortes R, Garcia-Soler P, et al.
Ultrasound-guided or landmark techniques for central
venous catheter placement in critically ill children. Inten-
sive Care Med 2018; 44: 61e72
- 1337
3. Lau CS, Chamberlain RS. Ultrasound-guided central
venous catheter placement increases success rates in
pediatric patients: a meta-analysis. Pediatr Res 2016; 80:
178e84
4. Troianos CA, Hartman GS, Glas KE, et al. Special articles:
guidelines for performing ultrasound guided vascular
cannulation: recommendations of the American society
of echocardiography and the society of cardiovascular
anesthesiologists. Anesth Analg 2012; 114: 46e72
5. Shime N, Hosokawa K, MacLaren G. Ultrasound imaging
reduces failure rates of percutaneous central venous
catheterization in children. Pediatr Crit Care Med 2015; 16:
718e25
6. Song IK, Lee JH, Kang JE, et al. Comparison of central
venous catheterization techniques in pediatric patients:
needle vs angiocath. Paediatr Anaesth 2015; 25: 1120e6
7. Lee YH, Kim TK, Jung YS, et al. Comparison of needle
insertion and guidewire placement techniques during
internal jugular vein catheterization: the thin-wall intro-
ducer needle technique versus the cannula-over-needle
technique. Crit Care Med 2015; 43: 2112e6
8. Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010
statement: updated guidelines for reporting parallel group
randomised trials. BMJ 2010; 340: c332
9. Rey C, Alvarez F, De La Rua V, et al. Mechanical compli-
cations during central venous cannulations in pediatric
patients. Intensive Care Med 2009; 35: 1438e43
10. Calvache JA, Rodriguez MV, Trochez A, Klimek M,
Stolker RJ, Lesaffre E. Incidence of mechanical complica-
tions of central venous catheterization using landmark
technique: do not try more than 3 times. J Intensive Care
Med 2016; 31: 397e402
11. Di Nardo M, Tomasello C, Pittiruti M, et al. Ultrasound-
guided central venous cannulation in infants weighing
less than 5 kilograms. J Vasc Access 2011; 12: 321e4
12. Breschan C, Platzer M, Likar R. Central venous catheter for
newborns, infants and children. Anaesthesist 2009; 58:
897e900. 2e4 (in German)
13. Firat AC, Zeyneloglu P, Ozkan M, Pirat A. A randomized
controlled comparison of the internal jugular vein and the
subclavian vein as access sites for central venous cathe-
terization in pediatric cardiac surgery. Pediatr Crit Care Med
2016; 17: E413e9
14. Hayashi Y, Uchida O, Takaki O, et al. Internal jugular vein
catheterization in infants undergoing cardiovascular sur-
gery: an analysis of the factors influencing successful
catheterization. Anesth Analg 1992; 74: 688e93
15. Costello JM, Clapper TC, Wypij D. Minimizing complica-
tions associated with percutaneous central venous cath-
eter placement in children: recent advances. Pediatr Crit
Care Med 2013; 14: 273e83
Handling editor: M. Avidan