Pediatric Surgery for Central Venous Access Treatment & Management
- Author: Floriano Putigna, DO, FAAEM; Chief Editor: Eugene S Kim, MD, FACS, FAAP more...
The preparation for inserting a central venous catheter (CVC) is similar for all of the techniques described below, with some distinct and important differences. All patients should be properly secured, sedated, or both to ensure minimal movement. With the exception of placing a central line in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU), virtually all children undergo general anesthesia for line placement, which differs from the use of local anesthesia and sedation in adults. It is critical that patients, especially small children, remain completely still during the accessing of the vein; movement of just a few millimeters of the needle can be the difference between success and failure.
The skin is cleansed with an antiseptic solution (eg, chlorhexidine-alcohol), and the entire area should be draped with sterile towels. A local anesthetic, such as 1% lidocaine (maximum, 5 mg/kg), can be used. Specific positioning is described in Intraoperative Details. A properly sized catheter should be chosen on the basis of the location of the catheter and the patient's age and weight (see Table 1 below).
Table 1. Central Venous Access Device Sizes Based on Age and Weight (Open Table in a new window)
|Age (y)||Weight (kg)||Gauge||French||Length (cm)|
Inferior jugular approach
The patient's head is rotated to the side opposite the insertion area. The three common internal jugular approaches are the central, anterior, and posterior methods. (See the images below.)
The central approach is performed by finding the superior apex of the triangle formed by the two heads of the sternocleidomastoid (SCM) and the clavicle. The needle advances at this apex and continues toward the ipsilateral nipple. A shallow angle is needed because of the small diameter of veins in children. The anterior approach is performed by introducing the needle at the medial edge of the SCM at the level of the thyroid cartilage and aimed toward the ipsilateral nipple. The posterior approach uses the lateral edge of the SCM approximately two thirds of the way from the mastoid process to the clavicle to insert the needle, which is aimed toward the sternal notch.
Once the catheter needle has pierced the skin, it is introduced and advanced with continuous negative pressure until enough blood is obtained and is then secured in place. If a needle-over-wire or Seldinger technique is used, it should be advanced so the catheter reaches the junction of the superior vena cava and right atrium.
The Seldinger technique is described as follows. After blood has been withdrawn, the syringe is removed, and a wire is inserted into the needle. This should be advanced with minimal resistance to the proximal vein. If the procedure is being performed in the operating room, fluoroscopy is generally utilized to guide the procedure and ensure proper wire placement into the right heart.
Then, the needle (with the wire in place) is removed. A small (2-mm) incision with a No. 11 blade is made over the wire to allow passage of a dilator over the wire. The dilator is removed, and the preflushed catheter is advanced over the wire and secured. The wire is removed, and all ports should be drawn back to show blood, then flushed. A sterile dressing, preferably a transparent one, should be placed.
In a child, the subclavian vein is approached differently than it would be in an adult. (See the image below.)
The patient should be in a steep Trendelenburg position to maintain venous dilation and to prevent an air embolus. A towel roll should be placed between the patient's shoulders, if necessary, to open the anterior aspect of the chest wall. The only disadvantage of this measure is that a shoulder roll may also narrow the space between the clavicle and first rib, thus making passage of the wire more difficult after needle access to the vein is obtained.
The needle should be inserted at the lateral third of the clavicle and 1-2 cm below it (or, in rare cases, >2 times the width of the clavicle). The authors' experience has been that a straight needle directed medially and inferiorly easily passes through the intercostal space into the pleural domes. By manually bending the needle into a gentle curve (ie, without acute angles) and by directing the needle with the tip constantly oriented in the cephalic direction toward the sternal notch, the curve keeps the tip above the first rib, avoid pneumothoraces, and enter the vein from above.
Stabilization of the needle once the vein has been accessed is a paramount consideration, particularly in smaller patients. A Kelly clamp or a large needle driver can be used to secure its position fully while disconnecting the syringe. This, with the subsequent passage of the Seldinger wire, prevents the tip of the needle from twisting out of the vein. The needle should be directed just superior to the sternal notch under the clavicle. Care should be taken to remove the needle before it is redirected to avoid laceration of the vessels. Once blood is obtained and the needle is secure, the Seldinger technique is used, as is described in the internal jugular approach.
The femoral approach is performed after the child is placed in a supine position. A frog-leg position may be helpful in smaller children. (See the image below.)
Palpation of the femoral artery (lateral to the vein) is a key feature in this procedure. The femoral artery is palpated with one finger, and the needle is introduced just medial to the finger at an angle of 30-45° at 1 cm below the inguinal ligament. The needle should be directed toward the umbilicus. Once blood is returned, the catheter can be advanced and secured or the Seldinger technique can be used for a longer CVC, as described in the inferior jugular approach.
The peripherally inserted central catheter (PICC) line is inserted at any peripheral site that has direct access to the central circulation. Once a site has been determined and the patient prepared, an 18-gauge needle is used to puncture the skin site to ease insertion of the introducer. The length of these catheters can be greater than 30 cm; therefore, one must measure the distance from the insertion site to the right nipple. This measure maintains the catheter tip at the superior vena cava–right atrium junction.
Once the introducer is advanced and blood return is achieved, the catheter is grasped 1 cm proximal to its distal tip and introduced 1 cm at a time until it reaches the preset location. The introducer needle is then withdrawn and peeled away from the catheter. It should be secured and rechecked for its ability to be easily flushed.
After the umbilical stump is properly prepared, a purse-string suture is placed at the junction of the skin and the cord to ensure hemostasis and anchoring of the line. (See the image below.)
The cord is cut 1 cm from the skin with the vein and arteries coming into view. The preflushed catheter is advanced into the vein 1-2 cm beyond the point where blood is easily returned; this is a total of 4-5 cm in a full-term infant. If pushed further than this, it may enter the ductus venosus and then into the inferior vena cava. The catheter is then secured in place with tape.
If lines are to be in place for a prolonged period, an implantable venous device (eg, Mediport) can be used. The port catheter is inserted mainly via the subclavian vein and tunneled under the skin to an adjacent site, where the reservoir is inserted in a subcutaneous pocket and anchored to the pectoralis fascia with suture. Such ports contain a silicone diaphragm that may be accessed as many as 2000 times by using a special side-hole needle (Huber needle).
After placement of the central line, meticulous care should be directed towards the line dressing. For externalized lines or accessed ports, a chlorhexidine patch can be used to lower infection rates. An occlusive and transprent dressing is also recommended for infection prevention, as well as for visualizing the exit site and ensuring that there is no ongoing blood loss. Using extra measures, such as extra tape and arm boards, is vital to prevent the patient from removing the device.
Once the lines are secured, the patient's vital signs should be assessed, and a focused physical examination should be performed to look for complications or iatrogenic injuries. Postoperative radiography should also be performed to rule out pneumothorax and confirm baseline position of the catheter.
The intravenous (IV) lines should be flushed with a heparinized solution after each blood draw to prevent clotting of the catheter. The lines should be checked on a daily basis to detect early infection and line sepsis. Patient's vital signs should be monitored for this purpose as well.
A full discussion of complications is outside the scope of this article; however, the main problems and the most recent useful therapies for these problems are discussed below.
All complications described below can be reduced by preparing well, using proper sedation and restraints, applying adequate local anesthesia, following strict aseptic techniques in placing and caring for the line, understanding the associated anatomy, and using ancillary radiographic studies (eg, ultrasonography, fluorography) when available.
Bloodstream infections (BSIs) are a risk with any CVC[12, 13] and are estimated to occur in 7.7 per 1000 patients in the PICU. In the NICU, the rate of BSIs is 11.3 cases per 1000 babies with birth weights of less than 1000 g and 4 cases per 1000 babies with birth weights of more than 2500 g.
BSIs increase mortality, which is estimated to be in the range of 12-25%. The average cost per episode of BSI is $25,000.
The etiology of most BSIs in children is coagulase-negative staphylococci, which account for approximately 37% of all cases in PICUs. Exposure to lipids has been identified as an independent risk factor for both coagulase-negative staphylococcal bacteremia in very-low–birth weight infants and candidemia in the NICU. Gram-negative bacteria account for 25% of all BSIs reported in PICUs, whereas enterococci and Candida species account for 10% and 9%, respectively.
In one study, a flush solution containing an antibiotic (vancomycin and ciprofloxacin) and heparin substantially decreased complications, both infectious and thrombotic, compared with heparin alone. The prevalence of resistant organisms did not increase.
Catheters impregnated with chlorhexidine and silver sulfadiazine have been shown to reduce catheter-related infections. Rates decreased from 7.6 cases per 1000 catheter days to 1.6 cases per 1000 catheter days.
Thrombotic complications are particularly prevalent in the pediatric population because of the small luminal diameter of the vessels used. More than 3.5 patients per 10,000 hospital admissions develop catheter-related deep vein thrombosis; cancer is the underlying diagnosis in 50% of these patients. As many as 16% of these patients develop pulmonary embolism (PE); the upper extremities are the predominant areas. Direct thrombolysis with urokinase, using the lumen of a PICC line to facilitate the insertion of an infusion catheter, has been shown to be an easy and effective means to remedy the thrombosis.
Catheter-related occlusions can occur in as many as 25% of lines placed in children. The result is an inability to use the catheter to administer vital medications and perform blood draws.
Restoring patency is preferred to replacement because it is faster and less expensive. In Europe, fibrinolytic therapy has been used for more than 20 years to restore patency in CVC occlusions. Recombinant tissue-type plasminogen activator (rt-PA) is an alternative to fibrinolytic therapy. In one study of 320 occlusion events, patency was restored in 71% of CVC occlusions after the first infusion, in 86.8% after the second infusion, and in 90.6% after the third infusion. Doses of 0.02-0.03 mg/kg have been used. Essentially, 1 mL of solution is inserted into the line and left for 4 hours. The fibrinolytic is then drawn out of the line, and a flush is attempted with saline. This may be repeated if unsuccessful.
Other well-described complications include the following:
Loss of the wire or catheter intravascularly
Central lines can also migrate either into a noncentral vein or even out of the vein altogether.
Outcome and Prognosis
The outcome and prognosis of patients with a central venous access device (CVAD) directly depends on the complications discussed above. If the complications are minimized, the outcome related to placement of these lines is excellent. In addition, meticulous and sterile care of the CVAD can also prevent line infections.
Future and Controversies
Future research should focus on the material used in central venous access devices (CVADs) as well as on means to prevent infection and occlusion. As ultrasonography becomes more widely available, it will be a useful adjunct in the placement of central lines. Pediatric and emergency medicine training programs should begin teaching and using ultrasound for central line placements.
Forssmann W. Die Sondierung rechten Herzens. Klin Wschr. 1929. 8:2080.
Aubaniac R. [Subclavian intravenous injection; advantages and technic]. Presse Med. 1952 Oct 25. 60(68):1456. [Medline].
Lomonte C, Basile C. [Management of central venous catheter: prevention of thrombosis and bacteremia.]. G Ital Nefrol. 2009 Jan-Feb. 26(1):73-80. [Medline].
Miller JW, Vu DN, Chai PJ, Kreutzer JH, John JB, Vener DF, et al. Upper body central venous catheters in pediatric cardiac surgery. Paediatr Anaesth. 2013 Nov. 23(11):980-8. [Medline].
Soucy P. Experiences with the use of the Port-a-Cath in children. J Pediatr Surg. 1987 Aug. 22(8):767-9. [Medline].
Fallon SC, Larimer EL, Gwilliam NR, Nuchtern JG, Rodriguez JR, Lee TC, et al. Increased complication rates associated with Port-a-Cath placement in pediatric patients: location matters. J Pediatr Surg. 2013 Jun. 48(6):1263-8. [Medline].
Skippen P, Kissoon N. Ultrasound guidance for central vascular access in the pediatric emergency department. Pediatr Emerg Care. 2007 Mar. 23(3):203-7. [Medline].
Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006 Nov. 48(5):540-7. [Medline].
Verghese ST, McGill WA, Patel RI, et al. Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology. 1999 Jul. 91(1):71-7. [Medline].
Bruzoni M, Slater BJ, Wall J, St Peter SD, Dutta S. A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population. J Am Coll Surg. 2013 May. 216(5):939-43. [Medline].
Casado-Flores J, Barja J, Martino R. Complications of central venous catheterization in critically ill children. Pediatric Critical Care Med. 2001. 2(1):57-62. [Medline].
Goede MR, Coopersmith CM. Catheter-related bloodstream infection. Surg Clin North Am. 2009 Apr. 89(2):463-74. [Medline].
Newman N, Issa A, Greenberg D, Kapelushnik J, Cohen Z, Leibovitz E. Central venous catheter-associated bloodstream infections. Pediatr Blood Cancer. 2012 Aug. 59(2):410-4. [Medline].
Henrickson KJ, Axtell RA, Hoover SM, et al. Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: A randomized, multicenter, double-blind trial. J Clin Oncol. 2000 Mar. 18(6):1269-78. [Medline].
Massicotte MP, Dix D, Monagle P, Adams M, Andrew M. Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications. J Pediatr. 1998 Dec. 133(6):770-6. [Medline].
Chaitowitz, I; Heng, R; Bell, K. Managing peripherally inserted central catheter-related venous thrombosis: How I do it. Australasian Radiology. April 2006. 50(2):132-135.
Jacobs BR, Haygood M, Hingl J. Recombinant tissue plasminogen activator in the treatment of central venous catheter occlusion in children. J Pediatr. 2001 Oct. 139(4):593-6. [Medline].
Skippen P, Kissoon N. Ultrasound guidance for central vascular access in the pediatric emergency department. Pediatr Emerg Care. 2007 Mar. 23(3):203-7. [Medline].
Knebel P, Lopez-Benitez R, Fischer L, et al. Insertion of Totally Implantable Venous Access Devices: An Expertise-Based, Randomized, Controlled Trial (NCT00600444). Ann Surg. 2011 Jun. 253(6):1111-7. [Medline].
Cairo MS, Spooner S, Sowden L, et al. Long-term use of indwelling multipurpose silastic catheters in pediatric cancer patients treated with aggressive chemotherapy. J Clin Oncol. 1986 May. 4(5):784-8. [Medline].
Chan BK, Rupasinghe SN, Hennessey I, Peart I, Baillie CT. Retained central venous lines (CVLs) after attempted removal: An 11-year series and literature review. J Pediatr Surg. 2013 Sep. 48(9):1887-91. [Medline].
Chiang VW, Baskin MN. Uses and complications of central venous catheters inserted in a pediatric emergency department. Pediatr Emerg Care. 2000 Aug. 16(4):230-2. [Medline].
Dolcourt JL, Bose CL. Percutaneous insertion of silastic central venous catheters in newborn infants. Pediatrics. 1982 Sep. 70(3):484-6. [Medline].
Frey AM. Pediatric peripherally inserted central catheter program report: a summary of 4,536 catheter days. J Intraven Nurs. 1995 Nov-Dec. 18(6):280-91. [Medline].
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003 Mar 20. 348(12):1123-33. [Medline].
Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia, PA: WB Saunders Co; 1998. 295-301.
Stovroff M, Teague WG. Intravenous access in infants and children. Pediatr Clin North Am. 1998 Dec. 45(6):1373-93, viii. [Medline].