Central Venous Access in the Pediatric Patient Workup

Updated: Jan 27, 2020
  • Author: Floriano Putigna, DO, FAAEM; Chief Editor: Eugene S Kim, MD, FACS, FAAP  more...
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Workup

Laboratory Studies

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

However, one relative contraindication for placing a central line is an abnormality on coagulation studies (ie, increased prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]). A platelet count lower than 10,000/μL is also a relative contraindication. If central access is needed despite these laboratory abnormalities, then a femoral site is preferred by virtue of the vessel's easy compressibility.

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Imaging Studies

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

Ultrasonography (US) is increasingly being employed to guide CVC insertion. Several studies have demonstrated the ease with which nonradiologist practitioners can use US to access central veins. [10] Although skilled clinicians can successfully achieve access using landmarks alone, the anatomy may be distorted in obese patients. In these cases, US guidance is especially helpful.

In several studies, US-guided approaches in the femoral, internal jugular, or subclavian veins were faster, easier, and caused fewer complications than the landmark technique alone. [11, 12, 13]

US guidance usually involves the use of 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 ultrasound 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 their institution, the authors prefer small handheld units, such as the SonoSite 180 & Titan (SonoSite Inc, Bothell, WA), which are readily available and have proved easy to use.

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