Pediatric Surgery for Central Venous Access Workup

  • Author: Floriano Putigna, DO, FAAEM; Chief Editor: Marleta Reynolds, MD   more...
 
Updated: Jun 8, 2011
 

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.

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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]

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 hand-held units, such as the SonoSite 180 & Titan (SonoSite Inc, Bothell, WA), which are readily available and have proven easy to use.

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Contributor Information and Disclosures
Author

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, and American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, University of Miami, Leonard M Miller School of Medicine; Chief, Division of Pediatric Critical Care Medicine, Medical Manager, Urban Search & Rescue, South Florida TF-2, Medical Director, Holtz Children's Hospital Palliative Care Team, Medical Director, Tilli Kids – Pediatric Initiative of Hospice Care of SE Florida, Director, Pediatric Critical Care Transport, Holtz Children's Hospital/Jackson Memorial Hospital

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, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Marleta Reynolds, MD  Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Children's Memorial Hospital of Chicago

Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

References

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  9. 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. Jul 1999;91(1):71-7. [Medline].

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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. Central Venous Access Device Sizes Based on Age and Weight
Age (y)Weight (kg)GaugeFrenchLength (cm)
< 1, newborn4-8243.05-12
< 15-10223.0-3.55-12
1-310-15204.05-15
3-815-3018-204.0-5.05-25
>830-7016-205.0-8.05-30
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