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.
History of the Procedure
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.  In the 1950s, Aubaniac used the subclavian vein to insert a central venous catheter (CVC).  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 peripherally inserted 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.
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.  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. 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 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 (eg, trauma), when peripheral and central access cannot be expeditiously obtained, the intraosseous route is the next best choice for obtaining vascular access.
Peripherally inserted 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 inserted peripherally, usually in the cephalic vein in the upper extremity or the saphenous vein in the lower extremity, the distal tip is placed in a large central vein.
In NICUs specifically, PICC placement has now largely supplanted the routine placement of higher-risk central venous catheters, both percutaneous and cutdown. PICC lines are indicated in children who require intermediate-term IV access for prolonged home or hospital therapy, such as patients with chronic infections, cancer, and parenteral nutrition dependency.
The success of placing a PICC line is improved if attempts to insert peripheral IVs are avoided. 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 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 affords the patient the greatest mobility. The internal jugular vein, either via cutdown or via percutaneous access, is also a popular site in children that is amenable to ultrasound-guided placement.
The femoral vein is not often used as the primary site for central venous access. The rare occasions for using the femoral site include the following  :
Placement of a temporary hemodialysis or pheresis catheter
Inaccessibility of other primary central veins as a consequence of thrombosis or stenosis
During cardiopulmonary resuscitation (CPR), in that this approach does not interfere with chest compressions or defibrillation
Implantable access ports
Lower risk of infection
Little to no impediment of daily activities
Minimal alterations in body image
No routine dressing changes
IAP devices are surgically implanted in the operating room, usually under fluoroscopic guidance.
The most common indications for port placement in children include the following:
Patients with cancer
Patients who need long-term antibiotics
Patients in whom long-term IV access is needed (eg, those with cystic fibrosis and sickle cell disease)
Umbilical artery catheters and umbilical vein catheters
Accessing the umbilical vascular 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 UACs and UVCs can be used. The UAC courses from the umbilical artery to the internal iliac artery and is used for hemodynamic monitoring. The UVC courses through the ductus venosus and the inferior vena cava (IVC) and can be used for delivering fluids, pressors, and IV medications, as well as for central venous pressure monitoring.
The umbilical vascular access site is commonly used in the early neonatal time period and subsequently discontinued after longer-term vascular access is established.
After the decision has been made to place a CVAD, a clear understanding of the anatomy is needed for each of the different approaches. The four main approaches to central venous access discussed here include the internal jugular, subclavian, femoral, and PICC techniques.
Internal jugular approach
The internal jugular vein (IJV) lies parallel and lateral to the carotid artery in the neck. (See the images below.) It lies within the carotid sheath, which includes the carotid artery and vagus nerve. The IJV is a branch of the brachiocephalic vein.
The subclavian artery lies posterior and somewhat superior to the brachiocephalic vein. These two 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.
The femoral vein is a branch of the external iliac vein. See the image below.
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.
Peripherally inserted central catheter approach
The relevant anatomy for inserting a PICC line includes the superficial veins to be used. These are primarily located in the arms (cephalic and basilic veins), scalp (superficial temporal vein), or neck (external jugular vein).
The umbilical system consists of two arteries and one vein (see the image below). The vein is usually at the 12-o'clock position and is larger with thinner 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 IVC, 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 CVC include the following:
Infection or burn over the desired insertion site
Known venous thrombosis of the vessel
Obstruction of the vein by a tumor or mass
Ability to achieve the same objectives with a peripheral line
Lack of consent in a nonemergency setting
Among patients who are receiving chemotherapy, those who are neutropenic with a low absolute neutrophil count (ANC) are also advised to wait prior to central line placement.
A relative contraindication is bacterial septicemia; it is generally recommended that cultures be sterile for 36-48 hours prior to CVC insertion.
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