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Pediatric Surgery for Central Venous Access Workup

  • Author: Floriano Putigna, DO, FAAEM; Chief Editor: Eugene S Kim, MD, FACS, FAAP  more...
Updated: Dec 07, 2015

Laboratory Studies

Routine laboratory studies do not play a major role in determining the need for central access unless directed by the patient's history and physical findings.

However, a relative contraindication to placing a central line is an abnormality of the coagulation studies (ie, increased prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]). This also holds true for a platelet count less than 10,000. If central access is needed despite these laboratory finding abnormalities, then a femoral site is preferred secondary to its ability to easily compress.


Imaging Studies

Plain radiography should be performed after central venous catheter (CVC) insertion to ensure its proper placement and to rule out iatrogenic injuries such as a pneumothorax.

An interesting technique for CVC insertion used with increased frequency with promising results is ultrasonographic guidance. Several studies have demonstrated the ease with which nonradiologist practitioners can use ultrasonography to access central veins.[7] Although skilled clinicians can successfully achieve access using landmarks alone, the anatomy may be distorted in obese patients. In these cases, ultrasonographic guidance is especially helpful.

In several studies, ultrasonography-guided approaches in the femoral, internal jugular, or subclavian veins were faster, easier, and caused fewer complications than the landmark technique alone.[8, 9, 10]

Ultrasonographic guidance is usually performed using a 7.5-MHz linear probe. Color Doppler can help differentiate the vein from the artery and can reduce the risk of an arterial puncture. By convention, the marker on the probe faces the patient's right or the patient's head, depending on the line being placed. The structures on the left side (as viewed) of the screen are always on the side of the marker. For example, in a right femoral line approach with the marker to the patient's right, the artery is on the left side of the screen, and the vein is to the right of the artery. Once again, by using color Doppler, the vessels can be easily distinguished.

In the authors' institution, we use small handheld units, such as the SonoSite 180 & Titan (SonoSite Inc, Bothell, WA), which are readily available and have proven easy to use.

Contributor Information and Disclosures

Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc., Maitland; Florida Hospital

Floriano Putigna, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.


Robert Solenberger, MD, FAAP, FACS Former Chief, Department of Surgery, Darnall Army Community Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Eugene S Kim, MD, FACS, FAAP Associate Professor of Surgery, Division of Pediatric Surgery, Keck School of Medicine of the University of Southern California; Attending Pediatric Surgeon, Children's Hospital Los Angeles

Eugene S Kim, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, Society of University Surgeons, Texas Medical Association, Children's Oncology Group

Disclosure: Nothing to disclose.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

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Femoral vein approach. Remember the mnemonic NAVEL for nerve, artery, vein, empty space, and lymphatics.
Umbilical vein, cannulation in the newborn.
Internal jugular vein, anterior approach.
Subclavian vein approach.
Internal jugular vein, central approach.
Internal jugular vein, posterior approach.
Table 1. Central Venous Access Device Sizes Based on Age and Weight
Age (y) Weight (kg) Gauge French Length (cm)
<1, newborn 4-8 24 3.0 5-12
<1 5-10 22 3.0-3.5 5-12
1-3 10-15 20 4.0 5-15
3-8 15-30 18-20 4.0-5.0 5-25
>8 30-70 16-20 5.0-8.0 5-30
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