Placing Central Venous Catheters: Gold Standard for Adult and Silver Standard for Pediatric Patients?

To the Editor: Andropopoulos, et al (1) presented recommendations for the insertion length of central venous catheters (CVC) in pediatric patients. However, these guidelines are based on somewhat weak anatomical landmarks. In fact, the “midline between mastoid process and sternal notch” in figure 1 is not at puncture site 1 but directly above the puncture sites 2 and 3. As we know from regional anesthesia, even bony anatomical landmarks do not guarantee a successful needle positioning or a working regional block, respectively. However, the efficacy of a regional block is easy to identify pre operatively. However, a chest radiograph can identify the position of a CVC, which is mostly undertaken post operatively. Therefore, the anesthetist has to rely on a CVC intraoperatively, without knowing the exact position of the tip. This is a disadvantage, since incorrect placement of the tip is linked to potentially harmful complications. In adults, the use of atrial electrocardiography has become the gold standard to assure correct placement of the CVC tip. Endocavitary ECG has already been successfully used in children even with a body weight of less than 2 kg (2–9). Why should pediatric patients not deserve the same gold standard? Using this simple and cheap technique, no recommendations based on landmarks are required. Alexander Reich, MD, DEAA Michael Booke, MD, PhD