You are in: eMedicine Specialties > Pediatrics: Surgery > General Surgery Central Venous AccessArticle Last Updated: Mar 5, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Floriano Putigna, DO, FAAEM, Staff Physician, Department of Emergency Medicine, Dwight D Eisenhower Army Medical Center, Fort Gordon, Georgia Floriano Putigna is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Osteopathic Association Coauthor(s): Robert Solenberger, MD, FAAP, FACS, Chief, Department of Surgery, Darnall Army Community Hospital Editors: G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; 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; Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Associate Professor, Department of Clinical Pediatrics, State University of New York at Stony Brook; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center Author and Editor Disclosure Synonyms and related keywords: central venous access, central lines, central venous catheters, CVCs, peripheral intravenous central catheters, PICCs, implantable access ports, IAPs, umbilical artery catheters, UACs, umbilical vein catheters, UVCs, venous access device, central venous access devices, CVADs, bloodstream infections, BSIs, catheter-related infections, central intravenous line, central IV line, osteomyelitis, human immunodeficiency virus, cystic fibrosis, meningitis INTRODUCTIONSection 2 of 12
  The need for vascular access in the pediatric patient is frequent; 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. History of the ProcedureThe 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.1 In the 1950s, Aubaniac used the subclavian vein to insert a central venous catheter (CVC).2 Since then, several more access routes of have been described. New equipment makes the use of CVADs increasingly safer and more common. ProblemCVADs come in many different sizes and brands that allow the clinician to choose the best device for their patient. However, the small sizes of the devices and of pediatric patients can complicate CVAD procedures in children. CVADs include peripheral intravenous central catheters (PICCs), CVCs, implantable access ports (IAPs), umbilical artery catheters (UACs), and umbilical vein catheters (UVCs). These devices can be placed in numerous sites, including the internal jugular vein (IJV), subclavian vein, femoral vein, peripheral veins leading to central access, and other surgical access sites. FrequencyApproximately 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 units (ICUs). The use of CVCs in the ICU is similar in adult and pediatric patients. ClinicalThe range of clinical presentations in patients receiving a CVC is broad. They may be hypovolemic or in shock with severely vasoconstricted peripheral sites. They may be an oncology patient or may have bacteremia and require continuous intravenous (IV) access for prolonged periods, thereby requiring an accessible IV site. Patients with bloodstream infections (BSIs) or catheter-related infections may have redness, exudate, swelling, or increased pain at the insertion site. They may only have an elevated temperature or abnormal vital signs if immunocompromised. INDICATIONSSection 3 of 12
The indications for central lines in children parallel the indications for adults. Central venous access devices (CVADs) are used to deliver larger volumes of irritating solutions, such as antibiotics, blood products, parenteral nutrition media, and sclerosing chemotherapeutic agents. If patients need prolonged IV access, a CVAD is preferred to a peripheral IV line. Central access is also indicated when peripheral access cannot be achieved; however, in an emergency situation, an intraosseous needle is probably the primary choice according to Pediatric Advanced Life Support (PALS) guidelines. Peripheral intravenous central catheters PICC lines have been used with great success in neonatal intensive care units (NICUs) and are considered a mainstay of vascular access in this setting. Although the lines are placed peripherally, usually in the antecubital or superficial saphenous vein, the distal tip remains in a large central vein. PICC lines are indicated in children who require intermediate-term IV access for prolonged home or hospital therapy, such as those with human immunodeficiency virus (HIV) infection, cystic fibrosis, osteomyelitis, meningitis, or cancer. The success of introducing the PICC line is greater if attempts at inserting noncentral peripheral lines are limited. Therefore, PICC placement should be attempted as soon as the need for intermediate-term access is apparent. Central venous catheters CVCs are inserted at femoral, subclavian, and IJV sites. These devices are preferred in children who have no peripheral access and in those who require long-term IV access. The subclavian route has been the preferred route for many years and allows the patient greatest mobility. The femoral line should be the primary route in children who are not sedated, somewhat combative, or receiving cardiopulmonary resuscitation (CPR). A femoral site is the best location for a patient receiving CPR because it does not interfere with chest compressions or defibrillation. Implantable access ports IAPs (eg, Mediport, Port-A-Cath) are to be used when vascular access is prolonged and when the following must be minimized: risk of infection, daily activities, alterations in body image, and dressing changes.3 IAP devices must be surgically implanted, usually in the operating room. Umbilical artery catheters and umbilical vein catheters Accessing the umbilical system is useful in the first few days of life. The umbilical vein can be used for access during the first 5-7 days but is rarely used beyond 7 days. Both and UACs and UVCs can be used: UAC is used for blood pressure monitoring, and UVC is used for central venous pressure monitoring. These vascular access sites are recommended in a neonatal emergency or if prolonged medication administration and blood draws are needed. Surgical venous access sites, such as the azygous, hemiazygous, inferior epigastric, or lumbar veins, should be considered only if all other options have failed and only if experienced clinicians have deemed it necessary to access these vessels. An interventional radiologist can be of assistance in minimizing the procedures (eg, thoracotomy, cut down) required to access these sites. RELEVANT ANATOMYSection 4 of 12
After the decision has been made to place a central venous access device (CVAD), a clear understanding of the anatomy is needed for each of the different approaches. The 4 main approaches to central venous access discussed here include the internal jugular, subclavian, femoral, and PICC methods. Internal jugular approach The IJV parallels and is lateral to the internal carotid artery in the neck (see Media files 3, 5-6). It lies in the carotid sheath, which includes the carotid artery and vagus nerve. The IJV is a branch of the brachiocephalic vein. Subclavian approach The subclavian artery lies posterior and somewhat superior to the brachiocephalic vein. These 2 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 is located more cephalic than it is in adults, meaning 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 Media file 1). 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, and lymphatics. Peripheral intravenous central catheter approach The relevant anatomy for inserting a PICC line include the superficial veins to be used. These are primarily located in the arms (cephalic and basilica veins), scalp (superficial temporal vein), or neck (external jugular vein). The umbilical system consists of 2 arteries and 1 vein (see Media file 2). The vein is usually at the 12-o'clock position and is larger with thinned walls. 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. The vein travels to the inferior vena cava or it could turn to the portal system. The umbilical artery turns inferiorly then continues to the pelvis, where it meets the internal iliac artery continuing cephalad to the bifurcation of the aorta. CONTRAINDICATIONSSection 5 of 12
Contraindications for inserting a central venous catheter include an infection or burn over the desired insertion site, a known venous thrombosis of the vessel, an uncorrected coagulopathy, an obstruction of the vein by a tumor or mass, an abnormal vessels, an ability to achieve the same objectives with a peripheral line, and a lack of consent in a nonemergency setting. A relative contraindication is bacterial septicemia because cultures are generally recommended to be sterile for 36-48 hours prior to CVC insertion. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Preoperative detailsThe preparation for inserting a CVC is similar for all of the techniques described below, with some distinct and important differences. All patients should be properly secured, sedated, or both to ensure minimal movement. The skin is cleansed with an antiseptic solution, such as povidone-iodine solution, and the entire area should be draped with sterile towels. A local anesthetic, such as 1% lidocaine (maximum, 5 mg/kg), can be used. Specific positioning is described in Intraoperative Details. A properly sized catheter should be chosen on the basis of the location of the catheter and the patient's age and weight (see the table below). CVAD sizes based on age and weight
Intraoperative detailsThe patient's head is rotated to the side opposite the insertion area. The 3 common internal jugular approaches are the central (see Media file 5), anterior (see Media file 3), and posterior (see Media file 6) methods. The central approach is performed by finding the superior apex of the triangle formed by the 2 heads of the sternocleidomastoid (SCM) and the clavicle. The needle advances at this apex and continues toward the ipsilateral nipple. A shallow angle is needed because of the small diameter of veins in children. The anterior approach is performed by introducing the needle at the medial edge of the SCM muscle at the level of the thyroid cartilage and aimed toward the ipsilateral nipple. The posterior approach uses the lateral edge of the SCM approximately two thirds of the way from the mastoid process to the clavicle to insert the needle, which is aimed toward the sternal notch. Once the catheter needle has pierced the skin, it is introduced and advanced with continuous negative pressure until enough blood is obtained and is then secured in place. If a needle-over-the-wire or Seldinger technique is used, it should be advanced so the catheter reaches the junction of the superior vena cava and right atrium. Subclavian approach In a child, the subclavian vein (see Media file 4) is approached differently than in an adult. The right side is preferred in children because the dome of the right lung is more caudal than the left. The patient should be in a 15-20° Trendelenburg position to maintain venous dilation and to prevent an air embolus. A towel roll should be placed between the patient's shoulders to open the anterior aspect of the chest wall. The needle should be inserted at the lateral third of the clavicle and 1-2 cm below it (or, in rare cases, >2 times the width of the clavicle). The authors' experience has been that a straight needle directed medially and inferiorly easily passes through the intercostal space into the pleural domes. By manually bending the needle into a gentle curve (ie, without acute angles) and by directing the needle with the tip constantly oriented in the cephalic direction toward the sternal notch, the curve keeps the tip above the first rib, avoid pneumothoraces, and enter the vein from above. Stabilization of the needle once the vein has been accessed is paramount, particularly in smaller patients. A Kelly clamp or large-needle driver can be used to totally secure its position while disconnecting the syringe. This, with the subsequent passage of the Seldinger wire, prevents the tip of the needle from twisting out of the vein. The needle should be directed just superior to the sternal notch under the clavicle. Care should be taken to remove the needle before it is redirected to avoid laceration of the vessels. Once blood is obtained and the needle is secure, the Seldinger technique is used, as is described in the internal jugular approach. Femoral approach The femoral approach (see Media file 1) is performed after the child is placed in a frog-leg position with his or her legs bound by soft restraints. Palpation of the femoral artery (lateral to the vein) is a key feature in this procedure. The femoral artery is palpated with one finger, and the needle is introduced just medial to the finger at an angle of 30-45° at 1 cm below the inguinal ligament. The needle should be directed toward the umbilicus. Once blood is returned, the catheter can be advanced and secured or the Seldinger technique can be used for a longer CVC, as described in the inferior jugular approach. Peripheral approach The PICC line is inserted at any peripheral site that has direct access to the central circulation. Once a site has been determined and the patient prepared, an 18-guage needle is used to puncture the skin site to ease insertion of the introducer. The length of these catheters can be greater than 30 cm; therefore, one must measure the distance from the insertion site to the right nipple. This measure maintains the catheter tip at the superior vena cava–right atrium junction. Once the introducer is advanced and blood return is achieved, the catheter is grasped 1 cm proximal to its distal tip and introduced 1 cm at a time until it reaches the preset location. The introducer needle is then withdrawn and peeled away from the catheter. It should be secured and rechecked for its ability to be easily flushed. Umbilical approach After the umbilical stump is properly prepared (see Media file 2), a purse-string suture is placed at the junction of the skin and the cord to ensure hemostasis and anchoring of the line. The cord is cut 1 cm from the skin with the vein and arteries coming into view. The preflushed catheter is advanced into the vein 1-2 cm beyond the point where blood is easily returned; this is a total of 4-5 cm in a full-term infant. If pushed further than this, it may enter the ductus venosus and then into the inferior vena cava. The catheter is then secured in place with tape. Implantable device If lines are to be in place for a prolonged period, an implantable venous device (eg, Mediport) can be used. The port catheter is inserted mainly via the subclavian vein and tunneled under the skin to an adjacent site, where it is inserted in the subcutaneous tissue. The site is usually in the anterior part of the chest. Such ports contain a diaphragm that may be accessed as many as 2000 times by using a special side-hole needle (Huber needle). Postoperative detailsUsing extra measures, such as extra tape and arm boards, is vital to prevent the patient from removing the device. Once the lines are secured, the patient's vital signs should be assessed, and a focused physical examination should be performed to look for complications or iatrogenic injuries. Postoperative radiography should also be performed to rule out pneumothorax and confirm the position of the catheter. Follow-upThe IV lines should be flushed with a heparinized solution after each blood draw to prevent clotting of the catheter. The lines should be check on a daily basis to detect early infection and line sepsis. Patient's vital signs should be monitored for this purpose as well. COMPLICATIONSSection 8 of 12
A full discussion of complications is outside the scope of this article; however, the main problems and the most recent useful therapies for these problems are discussed below. All complications described below can be reduced by preparing well, using proper sedation and restraints, applying adequate local anesthesia, following strict aseptic techniques in placing and caring for the line, understanding the associated anatomy, and using ancillary radiographic studies (eg, ultrasonography, fluorography) when available.7 Bloodstream infections BSIs are a risk with any CVC and are estimated to occur in 7.7 per 1000 patients in the pediatric ICU. In the NICU, the rate of BSIs is 11.3 cases per 1000 babies with birth weights of less than 1000 g and 4 cases per 1000 babies with birth weights of more than 2500 g. BSIs increase mortality rates, which are estimated to be 12-25%. The average cost per episode of BSI is $25,000. The etiology of most BSIs in children is coagulase-negative staphylococci, which account for approximately 37% of all cases in pediatric ICUs. Exposure to lipids has been identified as an independent risk factor for both coagulase-negative staphylococcal bacteremia in very-low–birth weight infants and candidemia in the NICU. Gram-negative bacteria account for 25% of all BSIs reported in pediatric ICUs, whereas enterococci and Candida species accounts for 10% and 9%, respectively. In one study, a flush solution containing an antibiotic (vancomycin and ciprofloxacin) and heparin substantially decreased complications, both infectious and thrombotic, compared with heparin alone.8 The prevalence of resistant organisms did not increase. Catheters impregnated with chlorhexidine and silver sulfadiazine have been shown to reduce catheter-related infections. Rates decreased from 7.6 cases per 1000 catheter days to 1.6 cases per 1000 catheter days. Thrombotic complications are particularly prevalent in the pediatric population because of the small luminal diameter of the vessels used. More than 3.5 patients per 10,000 hospital admissions develop catheter-related deep vein thrombosis; cancer is the underlying diagnosis in 50% of these patients.9 As many as 16% of these patients develop pulmonary embolisms (PEs); the upper extremities are the predominant areas. Direct thrombolysis with urokinase, using the lumen of a PICC line to facilitate the insertion of an infusion catheter, has been shown to be an easy and effective means to remedy the thrombosis.10 Catheter-related occlusions Catheter-related occlusions can occur in as many as 25% of lines placed in children. The result is an inability to use the catheter to administer vital medications and perform blood draws. Restoring patency is preferred to replacement because it is faster and less expensive. In Europe, fibrinolytic therapy has been used for more than 20 years to restore patency in CVC occlusions. Recombinant tissue-type plasminogen activator (rt-PA) is an alternative to fibrinolytic therapy. In one study of 320 occlusion events, patency was restored in 71% of CVC occlusions after the first infusion, in 86.8% after the second infusion, and in 90.6% after the third infusion.11 Doses of 0.02-0.03 mg/kg have been used. Essentially, 1 mL of solution is inserted into the line and left for 4 hours. The fibrinolytic is then drawn out of the line, and a flush is attempted with saline. This may be repeated if unsuccessful. Other complications Other well-described complications include pneumothorax, arterial canalization, nerve injury, infection, bleeding, hematoma formation, loss of the wire or catheter intravascularly, air embolization, and pain. OUTCOME AND PROGNOSISSection 9 of 12
The outcome and prognosis of patients with a central venous access device (CVAD) directly depends on the complications discussed above. If the complications are minimized, the outcome related to placement of these lines is excellent. FUTURE AND CONTROVERSIESSection 10 of 12
Future research should focus on the material used in central venous access devices (CVADs) as well as on means to prevent infection and occlusion. As ultrasonography becomes more widely available, it will be a useful adjunct in the placement of central lines. Pediatric and emergency medicine training programs should begin teaching and using ultrasound for central line placements.12 MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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