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], or 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.

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.^[12]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.^{[13, 14, 15]}

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.

Treatment & Management

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Media Gallery

Femoral vein approach. Remember mnemonic NAVEL: nerve, artery, vein, empty space, and lymphatics.
Umbilical vein cannulation in newborn.
Internal jugular vein, anterior approach.
Subclavian vein approach.
Internal jugular vein, central approach.
Internal jugular vein, posterior approach.

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Author

Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc, and 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.

Coauthor(s)

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

Robert Solenberger, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Society of General Surgeons

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 Director, Division of Pediatric Surgery, Vice Chair, Department of Surgery, Cedars Sinai Medical Center; Professor of Surgery and Pediatrics, Division of Pediatric Surgery, Division of Hematology, Oncology, Blood and Marrow Transplantation, Keck School of Medicine of the University of Southern California

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, American Surgical Association, Association for Academic Surgery, Children's Oncology Group, Society of Laparoscopic and Robotic Surgeons, Society of University Surgeons, Texas Medical Association

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.

Sections Central Venous Access in the Pediatric Patient
Overview
Presentation
Workup
Treatment
Media Gallery
Tables
References

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

Central Venous Access in the Pediatric Patient Workup

Laboratory Studies

Imaging Studies

References

Tables

Contributor Information and Disclosures

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