Pediatric Surgery for Central Venous Access 

The need for vascular access in the pediatric patient is frequent; however, placement of a peripheral line may not be feasible or appropriate. The options available to clinicians have increased over the years; central venous access devices (CVADs) are now used with greater frequency. This article discusses the various options available for central venous access and their advantages, disadvantages, and complications.

The history of cannulation of a central venous structure can be traced back to 1929, when Forssmann described advancing a plastic tube near the heart by puncturing his own arm.^[1] In the 1950s, Aubaniac used the subclavian vein to insert a central venous catheter (CVC).^[2] Since then, several more access routes of have been described. New equipment makes the use of CVADs increasingly safer and more common.

CVADs come in many different sizes and brands that allow the clinician to choose the best device for their patient. However, the small sizes of the devices and of pediatric patients can complicate CVAD procedures in children.

CVADs include peripheral intravenous central catheters (PICCs), CVCs, implantable access ports (IAPs), umbilical artery catheters (UACs), and umbilical vein catheters (UVCs). These devices can be placed in numerous sites, including the internal jugular vein (IJV), subclavian vein, femoral vein, peripheral veins leading to central access, and other surgical access sites.

Frequency

Approximately 5 million CVC insertions are performed every year in the United States. This rate accounts for 15 million CVC days each year in the intensive care units (ICUs). The use of CVCs in the ICU is similar in adult and pediatric patients.

The range of clinical presentations in patients receiving a CVC is broad.^[3] They may be hypovolemic or in shock with severely vasoconstricted peripheral sites. They may be an oncology patient or may have bacteremia and require continuous intravenous (IV) access for prolonged periods, thereby requiring an accessible IV site.

Patients with bloodstream infections (BSIs) or catheter-related infections may have redness, exudate, swelling, or increased pain at the insertion site. They may only have an elevated temperature or abnormal vital signs if immunocompromised.

The indications for central lines in children parallel the indications for adults. Central venous access devices (CVADs) are used to deliver larger volumes of irritating solutions, such as antibiotics, blood products, parenteral nutrition media, and sclerosing chemotherapeutic agents. If patients need prolonged intravenous (IV) access, a CVAD is preferred to a peripheral IV line. Central access is also indicated when peripheral access cannot be achieved; however, in an emergency situation, an intraosseous needle is probably the primary choice according to Pediatric Advanced Life Support (PALS) guidelines.

Peripheral intravenous central catheters

Peripheral intravenous central catheters (PICC) lines have been used with great success in neonatal intensive care units (NICUs) and are considered a mainstay of vascular access in this setting. Although the lines are placed peripherally, usually in the antecubital or superficial saphenous vein, the distal tip remains in a large central vein. PICC lines are indicated in children who require intermediate-term IV access for prolonged home or hospital therapy, such as those with human immunodeficiency virus (HIV) infection, cystic fibrosis,^[4]osteomyelitis, meningitis, or cancer.

The success of introducing the PICC line is greater if attempts at inserting noncentral peripheral lines are limited. Therefore, PICC placement should be attempted as soon as the need for intermediate-term access is apparent.

Central venous catheters

CVCs are inserted at femoral, subclavian, and internal jugular vein (IJV) sites. These devices are preferred in children who have no peripheral access and in those who require long-term IV access. The subclavian route has been the preferred route for many years and allows the patient greatest mobility. The femoral line should be the primary route in children who are not sedated, somewhat combative, or receiving cardiopulmonary resuscitation (CPR). A femoral site is the best location for a patient receiving CPR because it does not interfere with chest compressions or defibrillation.

Implantable access ports

Implantable access ports (IAPs), such as Mediport and Port-A-Cath, are to be used when vascular access is prolonged and when the following must be minimized: risk of infection, daily activities, alterations in body image, and dressing changes.^[5] IAP devices must be surgically implanted, usually in the operating room.

An expertise-based randomized trial compared the insertion techniques of venous cutdown approach with puncture of subclavian vein for implantation of totally implantable access ports (TIAP). The results found that while both techniques can be safe and effective, the percutaneous approach took more time, required a higher dose of radiation, and is associated with risk of pneumothorax.^[6]

Umbilical artery catheters and umbilical vein catheters

Accessing the umbilical system is useful in the first few days of life. The umbilical vein can be used for access during the first 5-7 days but is rarely used beyond 7 days.

Both and umbilical artery catheters (UACs) and umbilical vein catheters (UVCs) can be used: UAC is used for blood pressure monitoring, and UVC is used for central venous pressure monitoring.

These vascular access sites are recommended in a neonatal emergency or if prolonged medication administration and blood draws are needed. Surgical venous access sites, such as the azygous, hemiazygous, inferior epigastric, or lumbar veins, should be considered only if all other options have failed and only if experienced clinicians have deemed it necessary to access these vessels. An interventional radiologist can be of assistance in minimizing the procedures (eg, thoracotomy, cut down) required to access these sites.

After the decision has been made to place a central venous access device (CVAD), a clear understanding of the anatomy is needed for each of the different approaches. The 4 main approaches to central venous access discussed here include the internal jugular, subclavian, femoral, and peripheral intravenous central catheter (PICC) methods.

Internal jugular approach

The internal jugular vein (IJV) parallels and is lateral to the internal carotid artery in the neck.

It lies in the carotid sheath, which includes the carotid artery and vagus nerve. The IJV is a branch of the brachiocephalic vein.

Subclavian approach

The subclavian artery lies posterior and somewhat superior to the brachiocephalic vein. These 2 vessels are separated by the anterior scalene muscles. The subclavian vein begins distal to the branch point of the IJV. It crosses under the clavicle at the medial to proximal third of the clavicle. The subclavian artery is located deep and slightly superior to the vein.

In children, the subclavian vein is located more cephalic than it is in adults, meaning that it dives under the clavicle closer to the medial third.

Deep to the vessels lies the first rib, which is just superficial to the pleura and lung.

Femoral approach

The femoral vein is a branch of the external iliac vein.

It crosses deep to the medial third of the inguinal ligament. A common mnemonic for the anatomy of the femoral vessels from lateral to medial is NAVEL: nerve, artery, vein, empty space, and lymphatics.

Peripheral intravenous central catheter approach

The relevant anatomy for inserting a PICC line include the superficial veins to be used. These are primarily located in the arms (cephalic and basilica veins), scalp (superficial temporal vein), or neck (external jugular vein).

The umbilical system consists of 2 arteries and 1 vein.

The vein is usually at the 12-o'clock position and is larger with thinned walls. The arteries are located inferiorly with thicker walls. Occasionally, a persistent urachus may be encountered and mistaken for the vein. However, a return of urine quickly reveals the error.

The vein travels to the inferior vena cava or it could turn to the portal system. The umbilical artery turns inferiorly then continues to the pelvis, where it meets the internal iliac artery continuing cephalad to the bifurcation of the aorta.

Contraindications for inserting a central venous catheter (CVC) include an infection or burn over the desired insertion site, a known venous thrombosis of the vessel, an uncorrected coagulopathy, an obstruction of the vein by a tumor or mass, an abnormal vessels, an ability to achieve the same objectives with a peripheral line, and a lack of consent in a nonemergency setting.

A relative contraindication is bacterial septicemia because cultures are generally recommended to be sterile for 36-48 hours prior to CVC insertion.