Zentralvenöse Punktion -
nur noch mit Ultraschall?

 

 Buy Article Permissions and Reprints

Zusammenfassung.

Ultraschalltechniken können durch eine bessere Anpassung an den Gefäßverlauf die Punktion zentraler Venen verbessern. Um zu beantworten, ob die Forderung, zentralvenöse Punktionen in jedem Fall mit Ultraschall durchzuführen, berechtigt ist, wurden die bislang publizierten Studien zum Thema „ultraschallunterstützte zentralvenöse Punktion” (UZP) analysiert. Die Datenbank Medline wurde für den Zeitraum 1972 bis Mai 2000 mit den Schlüsselwörtern „Katheterisierung, Katheter, zentralvenöse Katheter, Vena jugularis interna, Vena subclavia, Vena axillaris, Vena femoralis, Ultraschall, Ultrasonografie, Site-Rite und Smart Needle” durchsucht. Für die V. jugularis interna fanden sich 29 prospektiv-randomisierte Studien, ergänzt durch 21 prospektive und drei retrospektive Studien sowie einige klinische Erfahrungsberichte, die Vorteile für die UZP feststellten. Für die V. subclavia stehen 4 befürwortenden prospektiven Studien zwei Studien gegenüber, die mit UZP keine besseren Ergebnisse erzielten. Bild gebende Verfahren stellen aufgrund der Visualisation der Gefäße und des Punktionsvorgangs den „Gold-Standard” dar. Mit Doppler-Geräten lassen sich jedoch ähnlich gute Resultate erzielen. Die Forderung, zentralvenöse Punktionen immer mit Unterstützung durch Bild gebende Ultraschallgeräte durchzuführen, erscheint unnötig und nicht realisierbar. Jeder Anästhesist und Intensivmediziner sollte zentralvenöse Punktionen auch ohne Ultraschallgerät durchführen können. Dem Beharren auf der „blinden” Punktionstechnik im Falle des Nichterfolgs sind jedoch für die Vena jugularis interna deutliche Grenzen gesetzt: Insbesondere Kinder, Patienten mit Gerinnungsstörungen und anatomischen Abweichungen sowie unerfahrene Ärzte profitieren von der UZP.

Central Venous Cannulation - Always with Ultrasound Support?

Ultrasound guided puncture (UGP) improves success and complication rates of central venous cannulation. By some authors UGP with imaging devices are strongly recommended for all cannulations of subclavian or internal jugular veins. In order to review the current literature a computer based abstract search in Medline was performed for the period from January 1972 to May 2000 limited by the key words “catheterization, central venous catheter, internal jugular vein, subclavian vein, axillary vein, femoral vein, ultrasound, ultrasonography, Site-Rite und Smart Needle”. UGP of the internal jugular vein was recommended in 29 prospective randomized studies, 21 prospective and three retrospective studies as well as in several clinical reports. UGP of the subclavian vein was supported by only 4 studies, whereas two studies did not show any improvement of puncture results with UGP. Due to the visualisation of the vessel and the cannula imaging techniques represent the “gold standard”. However, with conventional Doppler devices nearly the same success rates can be obtained. It does not seem to be justified to perform every central venous cannulation with Doppler or ultrasound support. Each anaesthetist and intensive care physician should be able to perform central venous cannulation without a Doppler or ultrasound device. However, in cases of abnormal anatomy UGP can be helpful to prevent complications. Especially children, patients with coagulation disorders and physicians with limited experience in central venous cannulation can benefit from UGP.

Literatur

• 1 Caridi J G, Hawkins I F. Ultrasound guidance of the internal jugular vein for central venous access.  JVIR. 1997;  8 216-217
  PubMedGoogle Scholar
• 2 Denys B G, Uretsky B F. Anatomical variations of internal jugular vein location: Impact on central venous access.  Crit Care Med. 1991;  19 1516-1519
  CrossrefPubMedGoogle Scholar
• 3 Schregel W, Straub H, Cunitz G, Ulmer W T. Ultraschall-Doppler-Sonographie: Ein einfaches Verfahren zur Verbesserung der Vena-jugularis-interna-Punktion.  Anaesthesist. 1985;  34 93-97
  PubMedGoogle Scholar
• 4 Armstrong P J, Sutherland R, Scott D HT. The effect of position and different manoeuvres on internal jugular vein diameter size.  Acta Anaesth Scan. 1994;  38 229-231
  PubMedGoogle Scholar
• 5 Alderson P J, Burrows F A, Stemp L I, Holtby H M. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients.  Br J Anaesth. 1993;  70 145
  CrossrefPubMedGoogle Scholar
• 6 McIntyre A S, Levison R A, Wood S, Phillips R K, Lennard-Jones J E. Duplex doppler ultrasound identifies veins suitable for insertion of central feeding catheters.  JPEN. 1992;  16 264-267
  PubMedGoogle Scholar
• 7 Böck U, Möllhoff T, Förster R. Antwort zum Leserbrief von Herrn Prof. Dr. Schregel.  Ultraschall in Med. 1999;  20 2-3
  PubMedGoogle Scholar
• 8 Legler D, Nugent M. Doppler localization of the internal jugular vein facilitates central venous cannulation.  Anesthesiology. 1984;  60 481-482
  CrossrefPubMedGoogle Scholar
• 9 Schregel W, Straub H, Singbartl G. Unidirectional 8-MHz continuous wave Doppler equipment can facilitate catheterization of the internal jugular vein.  J Ultrasound Med. 1986;  5 421-424
  PubMedGoogle Scholar
• 10 Defalque R J. Percutaneous catheterization of the internal jugular vein.  Anesth Analg. 1974;  53 116-119
  PubMedGoogle Scholar
• 11 Scherhag A, Klein A, Jantzen J P. Cannulation of the internal jugular vein using 2 ultrasonic techniques: A comparative controlled study.  Anaesthesist. 1989;  38 633-638
  PubMedGoogle Scholar
• 12 Gratz I, Afshar M, Kidwell P. Doppler-guided cannulation of the internal jugular vein: A prospective, randomized trial.  J Clin Monit. 1994;  10 185-188
  PubMedGoogle Scholar
• 13 Vucevic M, Tehan B, Gamlin F. The “smart needle”. A new Doppler ultrasound-guided vascular access needle.  Anaesthesia. 1994;  49 889-891
  PubMedGoogle Scholar
• 14 Gilbert T B, Seneff M G, Becker R B. Facilitation of internal jugular venous cannulation using an audio-guided Doppler ultrasound vascular access device: Results from a prospective, dual-center, randomized, crossover clinial study.  Crit Care Med. 1995;  23 60-65
  PubMedGoogle Scholar
• 15 Verghese S, McGill W A. Approaches to internal jugular vein cannulation in infants: Seeing, hearing vs. feeling.  Anaesth Analg. 1995;  80 525
  PubMedGoogle Scholar
• 16 Pozzoli M, Galli F, Capomolla S, Forni G, Cobelli F, Tavazzi L. (Usefulness of ultrasonographic techniques in catheterization of the internal jugular vein in patients with chronic heart feature.)  G Ital Cardiol. 1994;  24 1211-1221
  PubMedGoogle Scholar
• 17 Kayashima K, Fukutome T. A reliable method for internal jugular vein catheterization for neonates and infants using a small-caliber Doppler probe.  Masui. 1996;  45 1424-1429
  PubMedGoogle Scholar
• 18 Nemcek A A. The use of ultrasound as an adjunct to the performance of vascular procedures.  J Vasc Interv Radiol. 1996;  7 869-875
  PubMedGoogle Scholar
• 19 Lee K, Chinyanga M. Use of a modified Doppler flow detector for percutaneous cannulation of the internal jugular vein.  Can Anaesth Soc J. 1985;  32 548
  PubMedGoogle Scholar
• 20 Mallory D L, McGee W T, Shawker T H, Brenner M, Bailey K R, Evans R G, Parker M M, Farmer J C, Parillo J E. Ultrasound guidance improves the success rate of internal jugular vein cannulation. A prospective, randomized trial.  Chest. 1990;  98 157-160
  PubMedGoogle Scholar
• 21 Troianos C A, Jobes D R, Ellison N. Ultrasound guided cannulation of the internal jugular vein.  Anesthesiology. 1990;  73 451
  PubMedGoogle Scholar
• 22 Troianos C A, Jobes D R, Ellison N. Ultrasound guided cannulation of the internal jugular vein. A prospective randomized study.  Anesth Analg. 1991;  72 823-826
  PubMedGoogle Scholar
• 23 Denys B G, Uretsky B F. Access to the internal jugular vein: Comparison between the landmark and ultrasound guided method.  Amer Heart Assoc. 1990;  November 1990
  PubMedGoogle Scholar
• 24 Denys B G, Uretsky B F. An ultrasound method for safe and rapid central venous access.  New Engl J Med. 1991;  324 566
  PubMedGoogle Scholar
• 25 Koski E M, Suhonen M, Mattila M A. Ultrasound-facilitated central venous cannulation.  Crit Care Med. 1992;  20 424-426
  PubMedGoogle Scholar
• 26 Alderson P J, Burrows F A, Holtby H M. The use of ultrasound to facilitate central venous cannulation in young children.  Anesthesiology. 1992;  77 A1196
  PubMedGoogle Scholar
• 27 Soyer P, Lacheheb D, Levesque M. High-resolution sonographic guidance for transjugular liver biopsy.  Abdom Imaging. 1993;  18 360-362
  PubMedGoogle Scholar
• 28 Denys B G, Uretsky B F, Reddy P S. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique.  Circulation. 1993;  87 1557-1562
  PubMedGoogle Scholar
• 29 Armstrong P J, Cullen M, Scott D HT. The “Site-Rite” ultrasound machine - an aid to internal jugular vein cannulation.  Anaesthesia. 1993;  48 319-323
  PubMedGoogle Scholar
• 30 Johnson R, O'Donnell J, Fielder K. Ultrasound guidance for cannulation of the internal jugular vein (IJV) in the critically ill. A randomized prospektive study.  Crit Care Med. 1994;  22 A28
  PubMedGoogle Scholar
• 31 Heatly T, Berger R. Comparison of the conventional landmark technique and an ultrasound-guided approach for the placement of central venous indwelling catheters.  Am J Respir Crit Care Med. 1995;  151 A333
  PubMedGoogle Scholar
• 32 Teichgräber U KM, Benter T, Gebel M, Manns M P. A sonographically guided technique for central venous access.  Am J Roentgenol. 1997;  169 731-733
  PubMedGoogle Scholar
• 33 Slama M, Novara A, Safavian A, Ossart M, Safar M, Fagon J Y. Improvement of internal jugular vein cannulation using an ultrasound-guided technique.  Int Care Med. 1997;  23 916-919
  CrossrefPubMedGoogle Scholar
• 34 Lin B S, Kong C W, Tarng D C, Huang T P, Tang G J. Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survery in uraemic patients.  Nephrol Dial Transplant. 1998;  13 134-138
  PubMedGoogle Scholar
• 35 Hayashi H, Tsuzuku M, Amano M. Simplified echo guided internal jugular vein puncture: A comparison to the landmark-guided technique.  Anesth Analg. 1998;  86 SCA89
  PubMedGoogle Scholar
• 36 Böck U, Mollhoff T, Forster R. Ultraschallgesteuerte versus anatomisch orientierte Punktion der Vena jugularis interna zur zentralvenösen Katheterisierung. Eine randomisierte Studie.  Ultraschall in Med. 1999;  20 98-103
  PubMedGoogle Scholar
• 37 Schregel W. Zum Artikel: Böck U, Mollhoff T, Forster R. Ultraschallgesteuerte versus anatomisch orienterte Punktion der Vena jugularis interna zur zentralvenösen Katheterisierung.  Ultraschall in Med. 1999;  20 273-274
  PubMedGoogle Scholar
• 38 Verghese S T, McGill W A, Patel R I, Sell J E, Midgley F M, Ruttimann U E. Ultrasound-guided internal jugular venous cannulation in infants. A prospective comparison with the traditional palpation method.  Anesthesiology. 1999;  91 71-77
  CrossrefPubMedGoogle Scholar
• 39 Andropoulos D B, Stayer S A, Bent S T. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients.  Anesth Analg. 1999;  89 65-70
  PubMedGoogle Scholar
• 40 Yonei A, Nonoue T, Sari A. Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein.  Anesthesiology. 1986;  64 830-831
  CrossrefPubMedGoogle Scholar
• 41 Scherhag A, Klein A, Jantzen J P. Die Vena jugularis interna-Kanülierung mit Hilfe zweier Ultraschall Verfahren. Eine vergleichende, kontrollierte Untersuchung.  Anaesthesist. 1989;  38 633-638
  PubMedGoogle Scholar
• 42 Sauer W, Luft D, Risler T, Renn W, Eggstein M. Bedeutung der Sonographie für die Applikation zentralvenöser Katheter.  Dtsch Med Wochenschr. 1988;  113 1423-1427
  PubMedGoogle Scholar
• 43 Suslavich F, Suslavich N. Sonographic guidance of central venous catheterization.  Anesth Analg. 1990;  70 397
  PubMedGoogle Scholar
• 44 Etheridge S P, Berry J N, Krabill K A, Braunlin E A. Echocardiographic-guided internal jugular venous cannulation in children with heart disease.  Arch Pediatr Adolesc Med. 1995;  149 77-80
  PubMedGoogle Scholar
• 45 Docktor B, So C B, Saliken J C, Gray R R. Ultrasound monitoring in cannulation of the internal jugular vein: Anatomic and technical considerations.  Can Assoc Radiol J. 1996;  47 195-201
  PubMedGoogle Scholar
• 46 Gordon A C, Saliken J C, Johns D, Owen R, Gray R R. US-guided puncture of the internal jugular vein: complications and anatomic considerations.  J Vasc Interv Radiol. 1998;  9 333-338
  PubMedGoogle Scholar
• 47 Sadler D J, Gordon A C, Klassen J, Saliken J C, So C B, Gray R R. Image-guided central venous catheters for apheresis.  Bone Marrow Transplant. 1999;  23 179-182
  CrossrefPubMedGoogle Scholar
• 48 Teichgräber U KM, Benter T, Schultz H J. Ultraschallgesteuerte Punktionstechnik von zentralvenösen Gefäßen in Ein-Personen-Technik.  Ultraschall in Med. 2000;  21 132-136
  PubMedGoogle Scholar
• 49 Kumwenda M J. Two different techniques and outcomes for insertion of long-term tunnelled haemodialysis catheters.  Nephrol Dial Transplant. 1997;  12 1013-1016
  PubMedGoogle Scholar
• 50 Nadig C, Leidig M, Schmiedeke T, Hoffken B. The Use of ultrasound for the placement of dialysis catheters.  Nephrol Dial Transplant. 1998;  13 978-981
  PubMedGoogle Scholar
• 51 Denys B G, Uretsky B F. The use of ultrasound to access the internal jugular vein: A prospective study of 300 patients.  Circulation. 1990;  82 68-71
  PubMedGoogle Scholar
• 52 Gallieni M, Cozzolino M. Uncomplicated central vein catheterization of high risk patients with real time ultrasound guidance.  Internt'l J Artif Org. 1995;  18 117-121
  PubMedGoogle Scholar
• 53 Smid J C, Bosman G, Belopavlovic M. Cannulation of the internal jugular vein (IJV) with real time echography. Poster presented at World Congress of Anesthesiologists 1996: April 14 - 20
• 54 Hrics P, Wilber S, Blanda M P, Gallo U. Ultrasound-assisted internal jugular vein catheterization in the ED.  Am J Emerg Med. 1998;  16 401-403
  CrossrefPubMedGoogle Scholar
• 55 Lewis B M, Lossef S V, Barth K H, Spies J B. Improved success rates for PICC line insertion using a dedicated 9.0 MHz ultrasound unit.  JVIR. 1998;  9 2223-2224
  PubMedGoogle Scholar
• 56 Geddes C C, Waldbaum D, Fox J G, Mactier R A. Insertion of internal jugular hemodialysis cannulae by direct ultrasound guidance - a prospective comparison of experienced and inexperienced operators.  Clin Nephrol. 1998;  50 320-325
  PubMedGoogle Scholar
• 57 Hatfield A, Bodenham A. Portable ultrasound for difficult central venous access.  Brit J Anaesth. 1999;  82 822-826
  PubMedGoogle Scholar
• 58 Conz P A, Dissegna D, Rodighiero M P, La Greca G. Cannulation of the internal jugular vein: Comparison of the classic Seldinger technique and an ultrasound guided method.  J Nephrol. 1997;  10 311-313
  PubMedGoogle Scholar
• 59 Farrell J, Gellens M. Ultrasound-guided cannulation versus the landmark-guided technique for acute hemodialysis access.  Nephrol Dial Transplant. 1997;  12 1234-1237
  PubMedGoogle Scholar
• 60 Eckhardt W F, de Bros F M. Ultrasound-assisted internal jugular vein cannulation improves the safety of central venous access in high risk surgical patients.  Crit Car Med. 1994;  22 A19
  PubMedGoogle Scholar
• 61 Lefrant J Y, Cuvillion P, Benezet J F, Dauzat M, Eledjam J J. Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study.  Anesthesiology. 1998;  88 1195-1201
  PubMedGoogle Scholar
• 62 Bold R J, Winchester D J, Madary A R, Gregurich M. Prospective, randomized trial of Doppler-assisted subclavian vein catheterization.  Arch Surg. 1998;  133 1089-1093
  PubMedGoogle Scholar
• 63 Lobe T E, Schropp K P, Rogers D A, Rao B N. A “smart needle” to facilitate difficult access in pediatric patients.  J Pediatr Surg. 1993;  28 1401-1402
  PubMedGoogle Scholar
• 64 Petzoldt R, Lutz H, Ehler R. Puncture of veins and arteries assited by ultrasound.  Ultrasound Med Biol. 1977;  2 331-333
  CrossrefPubMedGoogle Scholar
• 65 Petzold R. Ultrasound-guided puncture of the subclavian vein.  Int Care Med. 1980;  7 39-40
  CrossrefPubMedGoogle Scholar
• 66 Peters J L, Belsham P A, Garrett C P, Kurzer M. Doppler ultrasound technique for safer percutaneous catheterization of the infraclavicular subclavian vein.  Am J Surg. 1982;  143 391-393
  CrossrefPubMedGoogle Scholar
• 67 Sukigara M, Yamazaki T, Hatanaka M, Nagashima N, Omoto R. Ultrasonic real time guidance for subclavian venipuncture.  Surg Gynecol Obstet. 1988;  167 239-242
  PubMedGoogle Scholar
• 68 Fukutome T, Tanigawa K, Fukunaga A F. Subclavian venipuncture: A new device using a Doppler probe.  Anesth Analg. 1987;  66 1338-1339
  PubMedGoogle Scholar
• 69 Lameris J S, Post P J, Zonderland H M, Gerritsen P G, Kappers-Klunne M C, Schutte H E. Percutaneous Hickman catheters: comparison of sonographically guided and blind techniques.  Am J Roentgenol. 1990;  155 1097-1099
  PubMedGoogle Scholar
• 70 Mansfield P F, Hohn D C, Fornage B D. Complications and failures of subclavian-vein catheterization.  N Engl J Med. 1994;  331 1735-1738
  CrossrefPubMedGoogle Scholar
• 71 Thompson D R, Gualtieri E, Deppe S, Sipperly E. Greater success in subclavian vein cannulation using ultrasound for inexperienced operators.  Crit Care Med. 1994;  22 180
  PubMedGoogle Scholar
• 72 Gualtieri E, Deppe S A, Sipperly M, Thompson D R. Subclavian venous catheterization: Greater success rate for less experienced operations using ultrasound guidance.  Crit Care Med. 1995;  23 692-697
  CrossrefPubMedGoogle Scholar
• 73 Haire W D, Lynch T G, Lieberman R P, Edney J A. Duplex scans before subclavian vein catheterization predict unsuccessful catheter placement.  Arch Surg. 1992;  127 229-230
  PubMedGoogle Scholar
• 74 Fry W R, Clagett G C, O'Rourke P T. Ultrsound-guided central venous access.  Arch Surg. 1999;  134 738-740
  PubMedGoogle Scholar
• 75 Hull J E, Hunter C S, Luiken G A. The Groshong catheter: initial experience and early results of imaging-guided placement.  Radiology. 1992;  185 803-807
  CrossrefPubMedGoogle Scholar
• 76 Post P J, Lameris J S, Zonderland H M, Gerritsen G P, Kappers-Klunne M C, Schutte H E. (Placing of Hickman catheters under ultrasonic guidance.)  Ned Tijdschr Geneeskd. 1992;  136 747-749
  PubMedGoogle Scholar
• 77 Kawamura R, Okabe M, Namikawa K. Subclavian vein puncture under ultrasonic guidance.  JPEN. 1987;  11 505-506
  PubMedGoogle Scholar
• 78 Switzer D F, Nanda N C, Harris P, Breen W. The alue of two-dimensional echocardiography and pulsed Doppler technique in facilitating percutaneous catheterization of the subclavian vein.  Pacing Clin Electrophysiol. 1988;  11 13-22
  PubMedGoogle Scholar
• 79 Nolsoe C, Nielsen L, Karstrup S, Lauritsen K. Ultrasonically guided subclavian vein catheterization.  Acta Radiol. 1989;  30 108-109
  PubMedGoogle Scholar
• 80 Ubhi S S, Rees Y, Veitch P S. Ultrasound guided subclavian vein catheterization.  Ann R Coll Surg Engl. 1991;  73 227-228
  PubMedGoogle Scholar
• 81 Sha K, Simokawa M, Kawaguchi M, Iwasaka T, Kurehara K, Kitaguchi K, Furuya H. Use of transesophageal echocardiography probe imaging to guide internal jugular vein cannulation.  Anesth Analg. 1998;  87 1032-1033
  PubMedGoogle Scholar
• 82 Schwartz S M, Beekman R, Crowley D C, Lloyd T R. Randomized trial of an 20-gauge Doppler guided introducer needle for vascular access in infants. CardioVascularDynamics Inc Literaturübersicht
• 83 Blank R, Rupprecht H J, Schorrlepp M, Kopp H, Rahmani R. Stellenwert der Ultraschall-Doppler-gesteuerten Punktion der Leistengefäße mittels „Smart Needle” im Rahmen der Herzkatheteruntersuchung.  Z Kardiol. 1997;  86 608-614
  CrossrefPubMedGoogle Scholar
• 84 Kwon T H, Kim Y L, Cho D K. Ultrasound-guided cannulation of the femoral vein for acute hemodialysis access.  Nephrol Dial Transplant. 1997;  12 1009-1012
  PubMedGoogle Scholar
• 85 Hartle E, Colon P, Carsten R, Schwab S J. Ultrasound guided cannulation of the femoral vein for acute hemodialysis access.  J Am Soc Neprhol. 1993;  4 352
  PubMedGoogle Scholar
• 86 Schregel W, Höer H, Radtke J, Cunitz G. Ultraschallunterstützte Punktion der Vena axillaris bei Intensivpatienten.  Der Anästhesist. 1994;  43 674-679
  PubMedGoogle Scholar
• 87 Fyke F E. Doppler guided extrathoracic introducer insertion.  Pacing Clin Electrophysiol. 1995;  18 1017-1021
  PubMedGoogle Scholar
• 88 Lewinshohn G, Leonoy E, Klinowski E. Ultrasound guided central cannulation via the axillary vein.  Medicine Intensive. 1993;  17 222
  PubMedGoogle Scholar
• 89 Nash A, Burrell C J, Ring N J, Marshall A J. Evaluation of an ultrasonically guided venepuncture technique for the placement of permanent pacing electrodes.  PACE. 1998;  21 452-455
  PubMedGoogle Scholar
• 90 Gayle D E, Bailey J R, Haisty W K, Simmons T W, Fitzgerald D M, Crossley G H. A novel ulrasound-guided approach to the puncture of the extrathoracic subclavian vein for surgical lead placement.  Pacing Clin Electrophysiol. 1996;  19 700-A537
  PubMedGoogle Scholar
• 91 Randolph A G, Cook D J. Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature.  Crit Care Med. 1996;  24 2053-2058
  CrossrefPubMedGoogle Scholar

Prof. Dr. W. Schregel

Abteilung für Anästhesiologie und Intensivmedizin
St. Josefshospital Uerdingen

Kurfürstenstraße 69
47829 Krefeld