# Vascular Access — GCMD Library living collection

Updated: n/a · 4 episodes · 44 cited statements

## Episodes
### Tools

### High-Yield Summaries
- [Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870) — video · 13:54 · [machine version](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870.md)

### In-depth Review
- [Pediatric Vascular Access](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112) — podcast · 35:43 · [machine version](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112.md)

### Work-up and Treatment

### Technique Videos/OP Notes
- [Open CVP Catheter Insertion Internal jugular vein Cutdown By Dr. Tamer Ashraf...](https://library.globalcastmd.com/watch/open-cvp-catheter-insertion-internal-jugular-vein-cutdown-by-dr-tamer-ashraf-4315) — video · [machine version](https://library.globalcastmd.com/watch/open-cvp-catheter-insertion-internal-jugular-vein-cutdown-by-dr-tamer-ashraf-4315.md)

### Updates
- [Central Line Placement at ECMO Decannulation: A Missed Opportunity](https://library.globalcastmd.com/watch/central-line-placement-at-ecmo-decannulation-a-missed-opportunity-3731) — article · [machine version](https://library.globalcastmd.com/watch/central-line-placement-at-ecmo-decannulation-a-missed-opportunity-3731.md)

## Chapters
- [0:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=13) Types of Central Venous Access Devices (Ep 1)
- [1:54](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=114) Site Selection and Contraindications (Ep 1)
- [2:57](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=177) Preoperative Workup and Imaging (Ep 1)
- [3:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=239) Patient Positioning and Equipment Selection (Ep 1)
- [5:12](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=312) Internal Jugular Access Technique (Ep 1)
- [6:42](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=402) Subclavian Access Technique (Ep 1)
- [7:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=466) Catheter Tip Positioning and Confirmation (Ep 1)
- [9:03](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=543) Complications and Line Infection Management (Ep 1)
- [10:20](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=620) Antimicrobial Lock Solutions (Ep 1)
- [12:08](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=728) Salvage Access Techniques (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=0) Introduction and series overview (Ep 2)
- [0:38](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=38) Catheter sizing and micro-preemie technique (Ep 2)
- [6:50](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=410) Catheter tip positioning and measurement (Ep 2)
- [10:22](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=622) Ultrasound guidance evidence and technique (Ep 2)
- [14:57](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=897) Device selection for oncology patients (Ep 2)
- [18:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1097) Vascular imaging and salvage techniques (Ep 2)
- [21:31](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1291) Site selection and femoral access (Ep 2)
- [23:58](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1438) Coagulopathy management and heparin protocols (Ep 2)
- [27:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1620) Ethanol lock for infection prevention and treatment (Ep 2)
- [28:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1706) Thoracoscopic salvage access technique (Ep 2)
- [31:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877) Skin preparation and catheter removal (Ep 2)
- [34:48](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=2088) Closing remarks (Ep 2)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- At Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access. — Alex Bondoc (clinical) [Ep 1 · 0:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=26)
- From a logistical standpoint, chest and neck central venous access is preferred over femoral access. — Alex Bondoc (clinical) [Ep 1 · 2:09](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=129)
- Contraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites. — Alex Bondoc (clinical) [Ep 1 · 2:39](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=159)
- Unless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement. — Alex Bondoc (clinical) [Ep 1 · 3:09](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=189)
- For patients requiring multiple lines (line number 4, 5, or 6), Doppler venous ultrasound of the jugulars is recommended, and in small children the SVC and subclavians can sometimes be visualized. — Alex Bondoc (clinical) [Ep 1 · 3:20](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=200)
- Pre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed. — Alex Bondoc (clinical) [Ep 1 · 3:37](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=217)
- For small children, neonates, and infants, positioning over a vertically oriented shoulder roll (parallel with the spine) provides hyperextension of the neck and allows shoulder weight to drop posteriorly, giving access to bilateral subclavians and jugulars. — Alex Bondoc (clinical) [Ep 1 · 3:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=239)
- Dr. Bonddo prefers using a micropuncture kit with a 21-gauge finder needle for small babies, which is smaller than the 18-gauge needle in standard tunnel line kits. — Alex Bondoc (clinical) [Ep 1 · 4:55](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=295)
- Using ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury. — Alex Bondoc (clinical) [Ep 1 · 5:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=325)
- For large-bore access like dialysis catheters, the patient should be stuck as low as possible on the neck, using the ultrasound probe (approximately 12mm diameter) levered against the clavicle as a landmark. — Alex Bondoc (clinical) [Ep 1 · 5:52](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=352)
- Low neck puncture leaves more catheter to curve in the neck; mid-neck puncture creates lax catheter that can lead to problems with neck turning and catheter displacement from the SVC. — Alex Bondoc (clinical) [Ep 1 · 6:22](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=382)
- For subclavian access, the insertion point is at the junction of the median and medial aspects of the clavicle, at least one finger breadth (approximately 1cm) inferiorly and laterally, to allow levering under the bone. — Alex Bondoc (clinical) [Ep 1 · 6:56](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=416)
- When approaching the clavicle during subclavian access, the needle should be kept flat with downward pressure on the skin rather than angling at 30 degrees. — Alex Bondoc (clinical) [Ep 1 · 7:14](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=434)
- For subclavian access, the needle should be aimed directly at the sternal notch initially, then angled wider toward the angle of the mandible in a radial motion if unsuccessful. — Alex Bondoc (clinical) [Ep 1 · 7:34](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=454)
- The right triangle technique for catheter tip positioning uses the trachea as the theoretical midline continued from the carina, with the right main stem bronchus as the hypotenuse; the catheter tip should be within this triangle to ensure atriocaval junction placement. — Alex Bondoc (clinical) [Ep 1 · 8:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=484)
- Post-procedural chest X-ray is not routinely ordered for single-stick, uncomplicated line placement using fluoroscopy, based on data from Children's Mercy Hospital Kansas City. — Alex Bondoc (clinical) [Ep 1 · 8:38](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=518)
- Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury. — Alex Bondoc (clinical) [Ep 1 · 9:06](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=546)
- For line infection management, the first clinical decision is whether the patient is septic from the line; if septic and in the ICU, source control requires bedside line removal under light sedation. — Alex Bondoc (clinical) [Ep 1 · 9:41](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=581)
- For non-septic line-dependent patients with complex vascular access, the organism and antibiotic sensitivity are determined, serial blood cultures are obtained, and the line may be salvaged if sustained culture negativity is achieved. — Alex Bondoc (clinical) [Ep 1 · 10:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=604)
- Traditional locking solutions are predominantly antibiotic locks, but they lead to development of bacterial resistance. — Paul Wales (clinical) [Ep 1 · 10:35](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=635)
- Ethanol locks are antimicrobial without resistance development and kill both planktonic bacteria (floating in the lumen) and sessile bacteria (embedded in biofilm along the catheter wall). — Paul Wales (clinical) [Ep 1 · 10:56](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=656)
- Kite lock is a 4% tetrasodium EDTA solution that is antimicrobial without resistance, and has antifibrinolytic and antithrombotic properties. — Paul Wales (clinical) [Ep 1 · 11:24](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=684)
- Kite lock is licensed for pediatric use in Canada, Europe, and Australia, but availability varies by region. — Paul Wales (clinical) [Ep 1 · 11:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=719)
- For patients with exhausted femoral, IJ, and subclavian access options, translumbar line placement through the back musculature into the intrahepatic IVC is an alternative approach performed with interventional radiology. — Alex Bondoc (clinical) [Ep 1 · 12:19](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=739)
- For emergency vascular access via facial vein cutdown, a horizontal incision is made just lateral to the sternocleidomastoid at the angle of the mandible with the head turned to the patient's left, and the facial vein is typically the first large vein encountered. — Alex Bondoc (clinical) [Ep 1 · 12:48](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=768)
- For facial vein cutdown, the catheter should be beveled hard to allow blind passage without wire guidance, theoretically allowing it to follow a path without bumping against the vessel wall. — Alex Bondoc (clinical) [Ep 1 · 13:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=784)
- In micro-preemies (1000g to 2kg), a 3-French soft silastic catheter is preferred because larger catheters as big as the vessel can cause vessel thrombosis. — Mark Wulkan (clinical) [Ep 2 · 1:30](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=90)
- Needle-hole venotomy technique: isolate the internal jugular vein, make a needle hole with the kit needle, and slide the pre-tunneled catheter into that hole without ligating the vein, preserving it for future access. — Mark Wulkan (clinical) [Ep 2 · 2:33](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=153)
- Beveling the catheter end is associated with slightly more catheter thrombosis than cutting straight across, but may be worth it to preserve the vein in micro-preemies. — Mark Wulkan (clinical) [Ep 2 · 3:23](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=203)
- Subcutaneous ports (port-a-cath, meta-port) are used for most intermittent chemotherapy; cuffed lines (Broviac) are used for highly toxic agents like Adriamycin that cause tissue necrosis if infiltrated. — Mark Wulkan (guideline) [Ep 2 · 13:36](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=816)
- Bone marrow transplant patients often require three lumens: a double-lumen perm-cath plus a single-lumen line. — Mark Wulkan (clinical) [Ep 2 · 14:32](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=872)
- The smallest mini-port available is 5-French and can be placed in a 7-8 kg infant, though it requires special order. — Mark Wulkan (clinical) [Ep 2 · 14:57](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=897)
- MRV is the gold standard for pre-operative vascular imaging in patients with multiple prior lines or history of DVT. — Mark Wulkan (guideline) [Ep 2 · 15:34](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=934)
- A glide wire can sometimes pass through venous thrombosis when a standard wire cannot, finding a channel through the clot. — Mark Wulkan (clinical) [Ep 2 · 17:53](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1073)
- Femoral lines in babies often result in leg swelling and DVT, so they are avoided in that population. — Mark Wulkan (clinical) [Ep 2 · 22:03](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1323)
- Institutional heparin lock protocol: 10 units/mL for accessed lines (ports or cuffed lines), 100 units/mL for buried ports, and 1000 units/mL for dialysis catheters (which is withdrawn before use). — Mark Wulkan (guideline) [Ep 2 · 24:40](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1480)
- Ethanol lock therapy has substantially decreased line removal rates and has very high success rates for treating line infections. — Todd Ponsky (clinical) [Ep 2 · 25:31](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1531)
- For gram-positive line infections, ethanol lock plus antibiotics through the catheter can clear the infection; for gram-negative infections, success rate is approximately 50%; for fungal infections (Candida), the line must be removed. — Mark Wulkan (guideline) [Ep 2 · 26:16](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1576)
- Antibiotic-coated and heparin-coated temporary catheters have been shown to decrease catheter-associated bloodstream infection rates. — Mark Wulkan (epidemiological) [Ep 2 · 27:41](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1661)
- Thoracoscopic-guided trans-mediastinal puncture technique: advance a needle through the thrombosed IJ track into the superior vena cava under thoracoscopic visualization; the SVC almost always recanalizes where the azygous vein enters. — Mark Wulkan (clinical) [Ep 2 · 28:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1706)
- For thoracoscopic salvage access in larger patients (17-year-old mentioned), the standard kit needle may not be long enough and an extra-long spinal needle is required. — Mark Wulkan (clinical) [Ep 2 · 29:53](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1793)
- There is speculation (without definitive evidence) that betadine exposure causes silicone catheter deterioration, making old lines chalky and difficult to remove. — Mark Wulkan (opinion) [Ep 2 · 31:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877)
- Broviac cuffs placed far from the exit site are designed to break away with slow, steady traction, allowing bedside removal without cuff excision. — Mark Wulkan (clinical) [Ep 2 · 32:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1966)
- In 17-18 years of practice, only one retained cuff developed infection requiring incision and drainage. — Mark Wulkan (clinical) [Ep 2 · 33:14](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1994)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- In the United States, approximately 5 million central venous catheter lines are placed annually, with several thousand in pediatric surgical patients. — Rod Gerardo summarizing the discussion [Ep 1 · 0:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=13)
- Central venous catheters are non-tunneled, typically for temporary hospital use, and can have 1 to 3 lumens. — Rod Gerardo summarizing the discussion [Ep 1 · 1:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=60)
- Ports are for long-term access (months to years), have tunneled catheters with totally implantable reservoirs, are often used for chemotherapy, and can have 1 or 2 lumens. — The host summarizing the discussion [Ep 1 · 1:10](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=70)
- Broviac catheters are tunneled lines with cuffs, used for months to years for chemotherapy, parenteral nutrition, or frequent blood transfusions, and can have 1 or 2 lumens. — Rod Gerardo summarizing the discussion [Ep 1 · 1:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=85)
- Hemodialysis or pheresis catheters can be temporary (uncuffed) or permanent (cuffed), and can have 1 to 3 lumens. — The host summarizing the discussion [Ep 1 · 1:40](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=100)
- There is evidence suggesting an increased rate of complications and infection with femoral access compared to chest and neck access. — The host summarizing the discussion [Ep 1 · 2:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=137)
- For very small neonates, many surgeons prefer a cut-down approach over percutaneous access. — Rod Gerardo summarizing the discussion [Ep 1 · 4:43](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=283)
- Subclavian line placement should be considered when both IJ access sites are lost or the patient is in a cervical collar. — The host summarizing the discussion [Ep 1 · 6:42](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=402)
- The catheter tip should typically be positioned at the junction between the right atrium and superior vena cava. — The host summarizing the discussion [Ep 1 · 7:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=466)
- Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation over extended periods. — Rod Gerardo summarizing the discussion [Ep 1 · 9:21](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=561)
- The atrial-caval junction is actually much deeper on chest X-ray than most surgeons think, not at the visible indentation where the silhouette widens. — Mark Wulkan summarizing a resource [Ep 2 · 9:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=553)
- A 2013 JACS study by Sanj Dutta, Sean St. Peter and others showed ultrasound guidance achieved first-stick success in 65% of patients versus 45% with landmark technique, and 95% success by three attempts versus 74%. — Mark Wulkan summarizing a resource [Ep 2 · 10:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=625)
- In the adult literature, the number of needle sticks is a good proxy marker for the risk of complications. — Mark Wulkan summarizing a resource [Ep 2 · 11:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=685)
- The APSA Outcomes Committee meta-analysis in 2011 found Class A or B evidence that chlorhexidine-alcohol prep decreases line infections compared to betadine. — Mark Wulkan summarizing a resource [Ep 2 · 31:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877)

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