Central Venous Access in the Pediatric Patient

Updated: Jan 25, 2018
  • Author: Floriano Putigna, DO, FAAEM; Chief Editor: Eugene S Kim, MD, FACS, FAAP  more...
  • Print
Overview

Background

The need for vascular access in the pediatric patient is frequent [1] ; 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. [2]  In the 1950s, Aubaniac used the subclavian vein to insert a central venous catheter (CVC). [3]  Since then, several more access routes of have been described.

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

Advances in equipment have made the use of CVADs safer and more common. CVADs come in many different sizes and brands that allow the clinician to choose the best device for each patient. However, the small sizes of the devices and of pediatric patients can complicate CVAD procedures in children.

Future research is likely to focus on the material used in CVADs, as well as on means of preventing infection and occlusion. Ultrasonography is becoming an increasingly useful adjunct in the placement of central lines. [4, 5] Pediatric and emergency medicine training programs will benefit from teaching and using ultrasonography for central line placements. [6]

Next:

Anatomy

After the decision has been made to place a CVAD, a suitable approach is chosen. 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.

Internal jugular vein, anterior approach. Internal jugular vein, anterior approach.
Internal jugular vein, central approach. Internal jugular vein, central approach.
Internal jugular vein, posterior approach. Internal jugular vein, posterior approach.

Subclavian approach

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 has a more cephalic location than it does in adults; 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. (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, Lymphatics).

Femoral vein approach. Remember mnemonic NAVEL: ne Femoral vein approach. Remember mnemonic 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, whereas 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.

Umbilical vein cannulation in newborn. Umbilical vein cannulation in newborn.

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

Previous
Next:

Epidemiology

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 unit (ICU). The use of CVCs in the ICU is similar in adult and pediatric patients.

Previous
Next:

Prognosis

The outcome and prognosis of patients with a CVAD directly depends on the complications (see Treatment, Complications). If 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.

Previous