DR TOMOHIRO YAMAMOTO (Orcid ID : 0000-0001-9968-1325)

Accepted Article
Article type : Research Report

A new way to determine correct depth of central venous catheter

insertion using a real-time ultrasound-guided insertion technique in
pediatric patients

Short Title (Running Header):

Ideal CVC depth for real-time ultrasound-guided insertion

Article category: Original investigation article

Authors’ Information:
1
Tomohiro Yamamoto (yamatomo270@hotmail.com)
1
Ehrenfried Schindler (e.schindler@asklepios.com)
1
Department of Pediatric Anesthesiology and Critical Care Medicine, German Pediatric Heart Center /
Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany

Correspondence:
T. Yamamoto, M.D., Ph.D.
Department of Pediatric Anesthesiology and Critical Care Medicine, German Pediatric Heart Center /
Asklepios Klinik Sankt Augustin,
Arnold-Janssen Street 29, Sankt Augustin, D-53757, Germany
Tel: +49-224-1249641, Fax: +49-224-1294644
E-mail: yamatomo270@hotmail.com (t.yamamoto@asklepios.com)

What is already known about the topic:

Several formulae or methods predicting the ideal depth of central venous catheter (CVC) insertion
are reported. However, they are complicated and often unsuitable in cases requiring rapid

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/pan.13614
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 management. In addition, there is hitherto no report on the ideal CVC insertion depth achieved solely
using the real-time ultrasound-guided technique.
Accepted Article
What new information this study adds:
This study analyzed the ideal depth of CVC inserted using the real-time ultrasound-guided technique
for every 10-cm increase in body height and shows that each body height has its individual ideal
depth of CVC insertion. This article provides a visually simple and practical bar graph to predict the
ideal depth of CVC inserted using only the real-time ultrasound-guided technique for the right internal
jugular vein, left supraclavicular, and right supraclavicular approaches.

Key Words:

- ideal depth of central venous catheter insertion

- internal jugular vein approach

- malposition of the central venous catheter tip

- real-time ultrasound-guided technique

- supraclavicular approach

Abstract

Background: Several formulae or methods are reported to predict the ideal central venous catheter
(CVC) insertion depth. However, they are complicated and often unsuitable in cases requiring rapid
management.

Aim: This study aimed to determine a simple and practical method to predict the ideal CVC insertion
depth after ultrasound-guided right internal jugular, or left or right supraclavicular puncture in pediatric
patients.

Method: Pediatric patients with congenital heart diseases who underwent cardiovascular surgery
between July 2015 and February 2018 in the German Pediatric Heart Center Sankt Augustin were
enrolled. Body height, body weight, patient age (months), and CVC insertion depth were retrieved
from the anesthesia records. Ideal CVC insertion depth was calculated by measuring the distance
between the level of the carina tracheae and the CVC tip on the first postoperative chest radiograph.

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 The relationships of body height, body weight, and patient age (months) to ideal CVC insertion depth
for the right internal jugular, left supraclavicular, and right supraclavicular approaches were
investigated.
Accepted Article
Results: Body height was the best parameter, providing the best coefficients of determination as well
as the simplest relationship. Based on analysis for ideal CVC insertion depth for every 10-cm increase
in body height, there was an ideal CVC insertion depth for each body height, independent of the
anesthesiologist's experience with the approach used. Whereas ideal CVC insertion depths for the
right internal jugular vein approach and the left supraclavicular approach showed no significant
difference, ideal CVC insertion depth for the right supraclavicular approach was significantly shorter
than that of the other two approaches.

Conclusion: This study successfully determined a visually simple and practical bar graph to predict
the ideal CVC depth inserted using only the real-time ultrasound-guided insertion technique for the
right internal jugular vein, left supraclavicular, and right supraclavicular approaches.

Introduction

A central venous catheter (CVC) is an essential step in the treatment for numerous conditions.
Appropriate location of the CVC tip is important, because a CVC placed too deep in the right atrium
can interrupt the operative manipulation in heart surgery with cardiopulmonary bypass (CPB), can be
unusable during CPB, and can lead to life-threatening complications such as arrhythmia, thromboses,
cardiac perforation, or pericardial tamponade (1, 2). Numerous reports have suggested formulae to
calculate the ideal CVC insertion depth based on body characteristics (height, weight, or age) in adult
(3) and pediatric patients (4-6), defining the level of the carina tracheae as the ideal location of the
CVC tip, as it corresponds to the level of connection between the superior vena cava and right atrium
(7, 8). However, these formulae are complex. Methods employing transesophageal echocardiography
(TEE) (5, 9), an intracavitary electrocardiography (ECG)-guided system (3, 10, 11), and computed
tomography (CT) (4) have been reported. However, TEE, the intracavitary ECG-guided system, or CT
are not always available. Other reports have introduced measurement methods using external
landmarks to determine the ideal CVC insertion depth for the internal jugular vein approach in
pediatric patients (4, 5) and subclavian vein approaches in pediatric patients (4) and adults (4, 12).
However, these procedures are complicated and often unsuitable in cases requiring rapid
management. Using a real-time ultrasound-guided technique has become the current standard for
vascular access (13, 14). In addition, the real-time ultrasound-guided supraclavicular approach is
reported to be a promising alternative for central venous access (15-18). Therefore, the primary aim
of this study was to determine a simple and practical method for clinical practice to predict the ideal
CVC depth of insertion using an ultrasound-guided insertion technique. This study considered the
right internal jugular vein approach as the most popular approach for anesthesia management and
emergencies, the left supraclavicular approach as an easy-to-learn alternative approach (15, 17, 19),
and the right supraclavicular approach as a promising alternative (15, 16). While preceding reports

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 used the landmark-guided puncture method (3-6), we investigated a new approach in determining the
ideal depth for CVC insertion after an ultrasound-guided insertion technique; thus, skin puncture
points may differ between these two methods. The secondary aim of this study was to evaluate the
Accepted Article
hypothesis that there could be a difference in ideal CVC insertion depth between patients undergoing
the Glenn/Fontan operation and those undergoing other operations; this is because the positional
relation of the carina tracheae and right superior vena cava (SVC) can be changed by the operation
per se. This study also examined the hypothesis that ideal CVC insertion depth could be influenced
by the experience of the inserting anesthesiologists, who likely exhibit different habits based on the
approach used.

Methods

Study protocol and patients

This study was conducted retrospectively in the German Pediatric Heart Center Sankt Augustin.
Pediatric patients with congenital heart diseases who underwent cardiovascular surgery between July
2015 and February 2018 were enrolled. Written informed consent for insertion of CVC was obtained
from the parents or persons having parental authority for all patients undergoing cardiovascular
surgery. Body height, body weight, patient age (months), and CVC insertion depth were retrieved
from anesthetic records. Ideal CVC insertion depth was calculated by measuring the distance
between the level of the carina tracheae and the CVC tip on the first postoperative chest radiograph
performed directly after the operation on the picture-archiving communication system (“measured
ideal CVC insertion depth”: Figure 1). Relationships of ideal CVC insertion depth to body height, body
weight, and patient age (months) were investigated.

CVC insertion methods using the real-time ultrasound-guided technique

CVC insertion methods using the real-time ultrasound-guided technique during the right internal
jugular vein approach (14), left supraclavicular approach (15-18), and right supraclavicular approach
(15-18) have been described previously. An object such as a towel roll or cushion was placed under
the patient’s back, depending on the preference of the operator (15). The skin was punctured at the
level of the thyroid cartilage during the right internal jugular vein approach (14). During the
supraclavicular approach, the patient’s position was similar to that of internal jugular vein access. The
puncture needle was inserted as close to the probe as possible using the long-axis view, keeping the
confluence of internal jugular vein and ipsilateral subclavian vein in the center of the ultrasound image
(15, 16).

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 Two different ultrasound machines were used at random in this study: the SonoSite Edge II with an
approximately 4-cm wide, 1-cm thick linear probe L25x (FUJIFILM SonoSite Inc., Bothell, WA, USA),
and the LOGIQ e with an approximately 5-cm wide, 1-cm thick linear probe L12 (GE Medical Systems,
Accepted Article
Milwaukee, WI, USA).

Validation analysis of the ideal CVC insertion depth introduced from the current study

After retrospectively determining the body characteristic parameter (height, weight, or age) that
exhibited the strongest relationship to ideal CVC insertion depth, the patients’ data were analyzed
again to verify validity of ideal CVC insertion depth. Ideal CVC depth of insertion for each patient
(“theoretical ideal CVC insertion depth”) was calculated according to the retrospective analysis, then
the difference between the “theoretical ideal CVC insertion depth” and the “measured ideal CVC
insertion depth” was examined in each patient by drawing scatter plots.

Statistical Analysis

Numerical data are presented as the mean ± standard deviation (SD). Scatter plots were generated
to determine the association between ideal CVC depth of insertion and body height, body weight, and
2
patient age (months). Equations, coefficients of determination (R ), and 95% confidence intervals (CI)
were calculated. Statistical significance was determined as P < 0.05 using Student’s paired t-test.
When referring to data, N indicates the number of patients studied.

Results

Ideal CVC insertion depth compared to body height when using the right internal jugular vein
approach

A total of 386 patients (male/female = 227/159, height = 45–182 cm) were enrolled. A scatter plot
showing association between ideal CVC depth of insertion and body height (Figure 2) revealed that
2
ideal CVC depth of insertion (cm) was calculated as 0.062 × (body height [cm]) + 2.24 (R = 0.762).
This formula is similar to those reported in previous studies (4). Ideal CVC depth of insertion was
subsequently analyzed for every 10-cm increase in body height. Ideal CVC insertion depths in
relationship with % of body height (BH) in the right internal jugular vein approach were as follows: BH
≤ 59 cm: N = 49, 11.07 ± 1.82% (mean ± SD), 95% CI 10.56–11.58; BH 60–69 cm: N = 76, 9.74 ±
1.41%, 95% CI 9.43–10.06; BH 70–79 cm: N = 39, 8.99 ± 1.34%, 95% CI 8.57–9.42; BH 80–89 cm: N
= 29, 8.60 ± 0.94%, 95% CI 8.26–8.94; BH 90–99 cm: N = 56, 8.72 ± 1.12%, 95% CI 8.42–9.01; BH
100–109 cm: N = 34, 8.28 ± 1.33%, 95% CI 7.83–8.73; BH 110–119 cm: N = 25, 8.13 ± 0.86%, 95%

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 CI 7.80–8.47; BH 120–129 cm: N = 21, 7.69 ± 1.13%, 95% CI 7.21–8.18; BH 130–139 cm: N = 13,
7.48 ± 0.75%, 95% CI 7.07–7.88; BH ≥ 140 cm: N = 44, 7.67 ± 1.15%, 95% CI 7.33–8.01 (Figure 3).
Accepted Article
To determine whether there is a difference in ideal CVC depth of insertion between patients
undergoing Glenn/Fontan operation and those undergoing other operations, the 386 patients who
underwent the right internal jugular vein approach were further separated into two groups:
Glenn/Fontan operation (N = 88, male/female = 50/38, height = 56–182 cm) and non-Glenn/Fontan
operation group (N = 298, male/female = 177/121, height = 45–181 cm). According to the scatter plot
(S 1), the ideal CVC insertion depth in the Glenn/Fontan operation patients (cm) was 0.064 × (body
2
height [cm]) + 2.17 (R = 0.699), and that in the non-Glenn/Fontan operation patients (cm) was
2
calculated as 0.062 × (body height [cm]) + 2.22 (R = 0.773). Ideal CVC depth of insertion was further
evaluated for every 10-cm increase in body height in both groups. The difference in ideal CVC
insertion depth between Glenn/Fontan operation groups and non-Glenn/Fontan operation groups was
not statistically significant for all body height groups (S 2). Based on this information, subsequent
investigations were performed on all patients regardless of the type of operation.

A total of 386 CVCs were inserted during the right internal jugular vein approach by 16
anesthesiologists. The anesthesiologist who inserted the most CVCs using this approach (N = 108)
was designated as anesthesiologist A. Ideal CVC insertion depths of these 108 CVCs and the
remaining 278 CVCs inserted by the other 15 anesthesiologists were compared for every 10-cm
increase in body height. Ideal CVC depth of insertion was not significantly different between
anesthesiologist A and the other anesthesiologists in all body height groups (S 3).

Malposition of CVC tips inserted during the left supraclavicular approach using the real-time
ultrasound-guided technique

A total of 298 CVCs (male/female = 177/121) were inserted during the left supraclavicular approach.
However, among these 298 CVCs, 15 (5.0%) were inserted into the coronary sinus via the persistent
left superior vena cava (PLSVC) (S 4A), 11 (3.7%) were inserted in the direction toward the right
brachiocephalic vein (S 4B), and another 10 (3.4%) were inserted in a position touching the lateral
wall of the SVC (S 4C). Therefore, 262 patients were enrolled for the comparison of ideal CVC
insertion depth to body height in the left supraclavicular approach. Tip malposition occurred without
any relationship with insertion depth.

Ideal CVC insertion depth compared to body height when using the left supraclavicular
approach

A total of 262 patients (male/female = 149/113, height = 45–173 cm) were enrolled. A scatter plot
was performed to determine the association between ideal CVC depth of insertion and body height of
patients (Figure 4); ideal CVC depth of insertion (cm) was calculated as 0.062 × (body height [cm]) +

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 2
2.52 (R = 0.754). Ideal CVC depth of insertion was further analyzed for every 10-cm increase in body
height. Ideal CVC insertion depths in relationship with % of BH in the left supraclavicular approach
were as follows: BH ≤ 59 cm: N = 100, 10.96 ± 1.66%, 95% CI 10.64–11.29; BH 60–69 cm: N = 59,
Accepted Article
9.97 ± 1.57%, 95% CI 9.57–10.37; BH 70–79 cm: N = 30, 9.66 ± 0.91%, 95% CI 9.33–9.98; BH 80–
89 cm: N = 13, 9.16 ± 0.82%, 95% CI 8.71–9.60; BH 90–99 cm: N = 20, 9.20 ± 1.16%, 95% CI 8.70–
9.71; BH 100–109 cm: N = 14, 8.77 ± 1.19%, 95% CI 8.15–9.40; BH 110–119 cm: N = 10, 8.58 ±
1.24%, 95% CI 7.81–9.35; BH 120–129 cm: N = 3, 8.31 ± 0.15%, 95% CI 8.15–8.48; BH 130–139 cm:
N = 4, 7.68 ± 0.37%, 95% CI 7.32–8.04; BH ≥ 140 cm: N = 9, 7.65 ± 0.59%, 95% CI 7.27–8.03
(Figure 3). A total of 262 CVCs were inserted during the left supraclavicular approach by 15
anesthesiologists. The anesthesiologist who inserted the most CVCs using this approach (N = 88)
was also designated as anesthesiologist A. The ideal insertion depths of these 88 and the remaining
174 CVCs inserted by the other 14 anesthesiologists were compared for every 10-cm increase in
body height. No significant difference was seen in all body height groups (S 5).

Comparison of ideal CVC insertion depth in the right internal jugular vein approach and in the
left supraclavicular approach

Ideal CVC insertion depths calculated with the scatter plot in the right internal jugular vein approach
(Figure 2) and in the left supraclavicular approach (Figure 4) were similar, as shown in the following
equations:

ideal CVC insertion depth (cm) in the right internal jugular vein approach

2
= 0.062 × (body height [cm]) + 2.24 (R = 0.762) and

ideal CVC insertion depth (cm) in the left supraclavicular approach

2
= 0.062 × (body height [cm]) + 2.52 (R = 0.754).

Ideal CVC insertion depths were compared for every 10-cm increase in body height; no significant
difference was found between the two approaches in all body height groups (S 6).

Ideal CVC insertion depth compared to body height when using the right supraclavicular
approach

A total of 96 patients (male/female = 49/47, height = 47–181 cm) were enrolled. A scatter plot was
generated to determine the association between ideal CVC depth of insertion and patient height
2
(Figure 5); ideal CVC insertion depth (cm) was calculated as 0.034 × (body height [cm]) + 2.98 (R =
0.746). Ideal CVC insertion depth was further analyzed for every 10-cm increase in body height. For
each body height range, ideal CVC insertion depths in relationship with % of BH in the right
supraclavicular approach were as follows: BH ≤ 59 cm: N = 18, 8.90 ± 1.20%, 95% CI 8.35–9.46; BH

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 60–69 cm: N = 15, 8.09 ± 1.03%, 95% CI 7.57–8.61; BH 70–79 cm: N = 13, 7.82 ± 0.94%, 95% CI
7.31–8.33; BH 80–89 cm: N = 7, 7.54 ± 0.72%, 95% CI 7.00–8.07; BH 90–99 cm: N = 7, 6.34 ± 0.70%,
95% CI 5.82–6.86; BH 100–109 cm: N = 6, 5.95 ± 0.53%, 95% CI 5.52–6.37; BH 110–119 cm: N = 6,
Accepted Article
5.65 ± 0.43%, 95% CI 5.31–5.99; BH 120–129 cm: N = 4, 5.69 ± 0.05%, 95% CI 5.63–5.76; BH 130–
139 cm: N = 6, 5.53 ± 0.44%, 95% CI 5.18–5.89; BH ≥ 140 cm: N = 14, 5.46 ± 0.60%, 95% CI 5.14–
5.78 (Figure 3). A total of 96 CVCs were inserted during the right supraclavicular approach by 9
anesthesiologists. The anesthesiologist who inserted the most CVCs using this approach (N = 56)
was designated as anesthesiologist B. The ideal depths of these 56 and the remaining 40 CVCs
inserted by other 8 anesthesiologists were compared for every 10-cm increase in height, and no
statistically significant difference was observed (S 7).

Ideal CVC insertion depth compared to body weight and age (months) when using the right
internal jugular vein approach and left supraclavicular approach

A total of 292 patients (male/female = 172/120, weight = 2.3–94 kg) and 205 patients (male/female =
122/83, weight = 1.8–41 kg) were enrolled to investigate the relationship between body weight and
ideal CVC depth of insertion for the right internal jugular vein approach and the left supraclavicular
approach, respectively. According to the scatter plots generated to determine the association between
ideal CVC depth of insertion and body weight (data not shown), ideal CVC depth of insertion (cm) was
2
calculated as 2.52 × log(body weight [kg]) + 1.95 (R = 0.738) in the right jugular vein approach and
2
as 2.11 × log(body weight [kg]) + 3.10 (R = 0.667) in the left supraclavicular approach. A total of 290
patients (male/female = 170/120, age = 0–216 months) and 205 patients (male/female = 122/83, age
= 0–146 months) were enrolled to investigate the relationship between age (months) and ideal CVC
depth of insertion for the right internal jugular vein approach and the left supraclavicular approach,
respectively. According to the scatter plots generated to determine the association between ideal
CVC depth of insertion and patient age (months) (data not shown), ideal CVC depth of insertion (cm)
2
was calculated as 0.0336 × (age [months]) + 6.37 (R = 0.687) in the right jugular vein approach and
2
as 0.0507 × (age [months]) + 6.19 (R = 0.604) in the left supraclavicular approach. However, these
formulae are too complex to be practical, and they analyze all patients with different body weights or
ages (months) together. Therefore, we attempted analysis of ideal CVC depth of insertion using
several multiplication factors. However, the results provided even more complex formulae than those
for the comparison based on the body height (data not shown). The further attempt to use more
complex multiplication factors was also not effective to determine a simple relationship or to improve
2
coefficients of determination (R ), and introducing a more complicated calculation did not meet the
aim of this study. Therefore, we concluded that body height of the patient was the best parameter to
determine a simple and practical method to predict the ideal CVC insertion depth. Accordingly, the
relationship of ideal CVC insertion depth with body weight or age (months) was not investigated for
the right supraclavicular approach.

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 Validation analysis of ideal CVC insertion depth introduced from the current study

The theoretical ideal CVC insertion depth in each patient was calculated according to Figure 3. The
Accepted Article
difference between theoretical ideal CVC insertion depth and the measured ideal CVC insertion depth
of insertion was examined in each patient by drawing scatter plots. Figure 6A shows the difference in
each patient based on the three approaches in absolute value (cm), and Figure 6B in relation to the %
of body height. The difference between the theoretical ideal CVC insertion depth and the measured
ideal CVC insertion depth in each patient was less than 4% of the body height in all patients (Figure
6B).

Discussion

Regardless of puncture site, correct location of the CVC tip is important (1, 2). The present study
aimed to determine a simple and practical method for physicians in clinical practice to predict the ideal
CVC depth of insertion and thus appropriate positioning of the CVC tip after puncturing the right
internal jugular or the left (or right) supraclavicular vein using an ultrasound-guided insertion
technique.

The relationship of ideal CVC insertion depth with body height, body weight, and patient age
(months) was investigated in the right internal jugular vein approach and the left supraclavicular
approach initially, because it has been reported that CVC cannulation using the left supraclavicular
approach is more successful than that using the right supraclavicular approach in infants (17, 19, 20).
The investigation based on body height in the right internal jugular vein approach resulted in a
complex formula similar to previous studies (4) (Figure 2). The formula derived through the
investigation based on body height in the left supraclavicular also proved to be complicated (Figure 4).
This study further analyzed ideal CVC insertion depth by subgrouping the patients based on 10-cm
steps in body height and showed that there is an ideal CVC depth of insertion for each body height for
the right internal jugular vein approach and the left supraclavicular approach; demonstrated with a
visually simple bar graph (Figure 3). In addition, the current study showed that: a) the ideal CVC
depth of insertion was not significantly different between patients who underwent Glenn/Fontan and
non-Glenn/Fontan operations (S1 and 2); b) the ideal CVC depth of insertion was independent of the
anesthesiologist's experience regardless of the approach used (S3 and S5); and c) ideal CVC
insertion depths showed no significant difference between the right internal jugular vein approach and
left supraclavicular approach for each 10-cm increase in body height (S6). Only relationships
concerning the ideal CVC depth of insertion to body height were investigated in the right
supraclavicular approach. A scatter plot also provided a complex formula (Figure 5). The ideal CVC
depth of insertion was analyzed for every 10-cm increase in body height; furthermore, each body
height has a unique ideal CVC depth of insertion and is significantly shorter during the right internal
jugular vein approach and left supraclavicular approach (Figure 3), independent of the
anesthesiologist's experience using this approach (S 7). Moreover, Figure 3 clearly shows the

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 tendency of the relationship of ideal CVC depth of insertion to the % of body height to not change
significantly when body height exceeds 100 cm. This may be because the ratio of the upper body
does not change with further increases in body height.
Accepted Article
In this study, 36 of 298 CVCs (12.1%) inserted using the real-time ultrasound-guided left
supraclavicular approach had malposition of the tips without any relationship to the insertion depth (S
4), including 15 CVCs (5.0%) inserted into the coronary sinus via the PLSVC, although the frequency
of the PLSVC is reported to be 0.3% in the general population (21). The reason for this higher
frequency of the PLSVC could be that this study investigated pediatric patients with congenital heart
diseases. On the other hand, CVCs inserted using the right supraclavicular approach had no
malposition of the tip in this study. This is likely related to the merging angle of the target vein to the
SVC.

CVCs can be placed according to the results of the current study based on the % of body height
(Figure 3) at a depth based on the integral value (cm) or in 0.5 cm increments, based on how it is
performed in daily clinical practice. For example, during the right internal jugular approach, the depth
would be 5.5 cm in a patient with a body height of 50 cm (ideal CVC insertion depth is calculated as
5.53 cm), 6.5 cm or 7.0 cm for a body height of 75 cm (ideal CVC insertion depth is calculated as 6.74
cm), and so forth. Placing an object like a towel roll or cushion under the patient’s back before the
puncture can influence the CVC insertion depth slightly; however, it is also expected that its influence
would be offset by determining the fixation depth as an integral value (cm) or in 0.5 cm increments in
clinical settings. Indeed, this study showed that ideal CVC depth of insertion is not dependent on the
experience of the inserting anesthesiologist, despite likely differences in puncture method habits. This
may be because the puncture needle is inserted into the skin using a similar approach during the real-
time ultrasound-guided technique (14-19), so that the puncture points of the needle to the skin are not
significantly different among the anesthesiologists. This may be an advantage of the real-time
ultrasound-guided insertion technique.

Based on our clinical experience, we recommend that the CVCs should be inserted at least 5 cm
deep, even if the ideal CVC depth of insertion is calculated to be shorter than 5 cm, so that the
proximal lumen is definitely inserted in the central vein, especially for patients who are shorter than 55
cm during the right supraclavicular approach (Figure 3). Figure 6B shows that the difference between
the location of inserted CVC tips and the theoretical ideal CVC depth of insertion was less than 2% of
the body height (including patients shorter than 55 cm) during the right supraclavicular approach,
even though CVCs were indeed inserted 5 cm deep in these patients. In addition, interestingly, the
difference tends to be larger in the right internal jugular vein approach than in the supraclavicular
approach (Figure 6B). This may be because in the real-time ultrasound-guided supraclavicular
approach, the puncture needle is inserted using the long-axis view, maintaining the confluence of the
internal jugular vein and ipsilateral subclavian vein in the center of the ultrasound image (15, 16). This
can be considered as an advantage of the real-time ultrasound-guided supraclavicular approach over
the internal jugular vein approach.

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 There are various other points of view and reports regarding the ideal location of the CVC tip. For
example, some reports have recommended the third intercostal space based on chest radiographs
(22); however, this method requires chest radiography directly after insertion of the CVC to confirm
Accepted Article
the location of the CVC tip. A method using transthoracic echocardiography (TTE) for evaluation of
the location of the CVC tip is simple and can provide information concerning the CVC tip position in
real-time (6, 23). However, this study focused on determining a simpler and more practical method
usable in daily clinical practice to predict the ideal CVC depth of insertion using only the real-time
ultrasound-guided insertion technique without any other measurement procedures. Therefore, this
study defined the level of the carina tracheae as the ideal location of the CVC tip, as numerous
reports have suggested calculation formulae for ideal CVC insertion depth defining the level of the
carina tracheae as the ideal CVC tip location (3-6). For the same reasons, we have compared ideal
CVC depths of insertion between patients for Glenn/Fontan operations and those for other operations
by defining the level of the carina tracheae as the ideal location of the CVC tip. However, whether the
CVC tip should be placed higher up in the SVC for Glenn/Fontan operations could be decided pro re
nata, as Figure 3 indicates the CVC depth of insertion based on a CVC tip location around the level of
the carina tracheae.

The current study enrolled a large population of pediatric patients with congenital heart disease who
underwent cardiovascular surgery. Further investigations are necessary to determine whether the
present results are generalizable to patients without congenital heart disease as well as in adults.

Conclusions

The current study created a visually simple and practical bar graph to predict ideal CVC insertion
depth solely using the real-time ultrasound-guided insertion technique without other measurement
procedures for the right internal jugular vein approach, left supraclavicular approach, and right
supraclavicular approach (Figure 3); this may be applicable to the adult patient, as Figure 3 shows
that ideal CVC insertion depth does not undergo a major change in patients taller than 100 cm. Figure
3 enables physicians in clinical practice in all fields to determine ideal CVC depth of insertion using
only the real-time ultrasound-guided insertion technique at a glance; a chart could be printed out and
placed on an easily accessible wall.

Preliminary data for this study were presented as a poster presentation at the Euroanaesthesia
meeting, on 02 June 2018, Copenhagen, Denmark.

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 Disclosures

1. Necessary ethical approval: The ethics committee of Ärztekammer Nordrhein, Düsseldorf,

Accepted Article
Germany had waived the need for approval by retrospective studies on 22 February 2011 (registration
number: 27-2011).

2. Financial support and sponsorship: none

3. Conflicts of interest: none

References

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Accepted Article
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 Figure Caption
Accepted Article
Figure 1: Ideal central venous catheter (CVC) depth was calculated by measuring the distance
between the level of the carina tracheae and the CVC tip on the first postoperative chest radiograph.

(A) The CVC tip is at the level of carina tracheae; ideal CVC insertion depth = insertion depth of CVC.

(B) The CVC tip is shallower than the level of carina tracheae; ideal CVC insertion depth = insertion
depth of CVC + measured distance between the CVC tip and the carina tracheae.

(C) The CVC tip is deeper than the level of carina tracheae; ideal CVC insertion depth = insertion
depth of CVC −measured distance between the CVC tip and the carina tracheae.

Figure 2: A scatter plot showing the association between ideal central venous catheter (CVC) depth
of insertion and body height using the right internal jugular vein approach.

Ideal CVC depth of insertion (cm) for the right internal jugular vein approach was calculated as 0.062
2
× (body height [cm]) + 2.24 (R = 0.762).

Figure 3: Ideal depths of central venous catheter (CVC) inserted with a real-time ultrasound-guided
technique using the right internal jugular vein approach, left supraclavicular approach, and right
supraclavicular approach.

Figure 4: A scatter plot showing the association between ideal central venous catheter (CVC) depth
of insertion and body height using the left supraclavicular approach.

Ideal CVC depth of insertion (cm) for the left supraclavicular approach was calculated as 0.062 ×
2
(body height [cm]) + 2.52 (R = 0.754).

Figure 5: A scatter plot showing the association between the ideal central venous catheter (CVC)
depth of insertion and body height using the right supraclavicular approach.

Ideal CVC depth of insertion (cm) for the right supraclavicular approach was calculated as 0.034 ×
2
(body height [cm]) + 2.98 (R = 0.746).

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 Figure 6: A scatter plot showing the difference between theoretical ideal central venous catheter
(CVC) insertion depth and measured ideal CVC insertion depth in three approaches in each patient
(A) in absolute value (cm) and (B) as a % of body height.
Accepted Article
The difference between the theoretical ideal CVC insertion depth and the measured ideal CVC
insertion depth in each patient is less than 4% of the body height in all patients. This difference tends
to be larger in the right internal jugular vein approach than in the supraclavicular approach.

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Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.