Pediatric Vascular Access

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. These podcasts are designed to keep healthcare professionals current while on their commute. Stay Current is created and edited by Todd Ponsky, Nicholas Bruns, Ian Glenn, and Daniel Hayek in partnership with Globalcast MD and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to Stay Current in Pediatric Surgery. I'm Todd Ponsky, and today we're going to be discussing vascular access in children. With us today, we have the surgeon in Chief of Children's Hospital of Atlanta, Doctor Mark Wolkan. Dr. Wolkan is professor and chief of pediatric surgery at Emory University and past president of IPEG, the International Pediatric Endosurgery Group. Do. Wolkan, I first noticed a specialist at this topic when he presented a very interesting case of what to do in a case when you don't have any real good vascular access left, and he had a very innovative trick which I hope we'll get to later. Mark, thanks for joining us today. No, thanks, Todd. Thanks for the opportunity. Mark, let's start off with some basic questions. When you're deciding to put in a catheter in a patient, How do you determine the line size that you use for a baby versus an adolescent? As you note, a lot of this depends on what kind of catheter you're using, and you may be limited in size. But first, let's talk about the babies. You know, really in the micro preemie, if you're talking about a 1000 g baby or even even up to maybe a 2 kg baby, I tend to use three French soft silastic catheter, you know, assuming you're going to put a cuff catheter in like a Hickman or a Broviac, you know, while on one hand you A reasonable sized lumen so it's not going to clot off. A lot of these babies, if you put a line in that's as big as the vessel, you'll end up clotting the vessel or ending up with a thrombosis. I think that there's probably a lot more thrombosis that goes on than we realize. Let me ask you though, I, if I'm, and then this will lead to a next question, is do you do percutaneous or cut down on those patients? But if I'm doing a cut down in a little preemie, Um, and I think I can fit a bigger catheter. I do only because if there ever becomes a problem, you can change it over a wire. And it's not so easy to do it with those small ones. Is that not true? You can still get a little wire through that 3 French catheter, if you need to. A lot of times you don't, you know, it's interesting. I think we all do a whole lot less of these lines than we did in the past as our PICC line teams have gotten a lot more skilled at placing peripheral central access. You know, in the tiny little babies, I'll do a cut down on the neck, and the technique I use is I'll isolate the internal jugular vein. And then I actually just put it, make a needle hole with the needle that comes in the kit in the vein, and then I have the catheter already tunneled and trimmed. And I will slide the catheter into that needle hole so that you don't ligate the vein. I don't tie it off. I like that trick. And so you get your proximal distal control. You make a little nick with the needle and then pass the catheter into that needle hole. Exactly, exactly. And sometimes I don't even bother with distal control. It's usually not a factor because you're making such a small hole, because you're making such a small hole. And if you need to, you can always push on the baby's liver to, you know, or their upper abdomen to sort of. Push some blood on up if you need to descend the vein a little bit more because sometimes you'll you'll make the needle hole and it's actually hard to see where it is, but if you can get it to back bleed a little bit, it usually opens it up. Now doing this, you have to bevel the end of the catheter and in most circumstances I don't like to do that because it's a relatively weak study. It was associated with a little bit more catheter thrombosis than if you cut straight across the catheter, but in this case I think it's worth it to try to save the vein. And I've even gone back and had to do a second cut down on some of these kids, and the vein is in fact patent. So just to make sure, I want to make sure I understand your, let's actually, since we're talking about it, let's do this technique. Uh, what tricks do you have for external landmarks and then dissecting out the vessel and then tell me about, I want to get a little more specific about how you, when you actually place the catheter. So how do you, how do you identify where to make your incision? So I usually just go just about 1 centimeter above the clavicle between the two heads of the sternocleidomastoid and I dissect down between the two heads and the, and the vein is. Usually right there like you were saying, I'll go ahead and get a suture around it. You know, a lot of times we're doing these lines at the bedside in the NICU, but I get a suture around it and I'll take the suture and I'll hemostat that to the drape just to give me the exposure. Then I'll make my little nick on the chest wall. I tend to go medial, not over the sternum, but medial for my exit site. So I think sometimes. Laterally it gets caught up under the arm and it's easier for the nurses to put the dressings on if you go immediately, and that's, but I do place it probably halfway between the nipple and the sternum, make my little neck, tunnel the catheter up and then, uh, like I said, you have to bevel the end of the catheter, do the little needle hole, and then, uh, gently place it in. So you are holding the vein up only with the one suture and it's angling. Down and you slide it in. That's a cool trick. I've never tried that. I've always had two, and I think it's tricky sometimes with the second tie because it's occluding the vessel. So that's a good trick, right? Let's say that's not successful and I end up taking an 11 blade and coming through it. I'll put a suture, a distal control suture on, but I don't pull it tight and I just leave it there. I only leave it there if I have to control, you know, the back bleeding a little bit when you're holding up the vein. And I'm assuming the vein is a bit collapsed. Is it hard to get just through the anterior wall, uh, or do you lift up the vein with a pickups while you, while you put the needle in? That's a great question. So I actually don't pick it up, uh, and it, but it can be easy to backwall it. So what I'll do is I'll place the needle very obliquely, almost parallel to the vein, as I insert it. Now if you do go through the back wall, it's not the end of the world. You can pull it back until then you can actually see that you're in the vein and then advance it a little bit to make sure that you're in the lumen. OK, and then you come back and I haven't had, you know, a couple of times I've had the catheter go right through, but not always, but most of the time you can finagle it down. You again, some of the really tiny babies that can't just, you know, in the vein starts to fray, then I'll go ahead and just tie off the vein and do it the traditional way. Yeah, but we started this out talking about the size catheter, and then I'll go to the 4 French cuffed line in the bigger babies, but in those tiny babies I tend to use the 3. Yeah, I do too in the. Preemies, I use the 2.7 French or I think it is, or 2. something. It depends on what brand. 11 comes in 2.7 and I think 4.2, and the other one is a just a straight 3 and a 4. I usually get proximal distal control. I lift it up, make a tiny nick. I don't tie anything down. Once I get it in place. I actually place a little stitch behind the catheter to close the venotomy, and if it's not bleeding, I don't, I just pull out my, my control sutures. So it's fun. To hear other ways of doing the same thing. Mark, how do you measure? How do you size the catheter tip to be accurately within the atrial cable junction? If I'm in the operating room and I have fluoro, I will take the line and line it up with the path of the guide wire under fluoro and put a hemostat or just take the scissors and see where it is and just make sure it's in the junction of the superior vena cava and the atrium and just cut it right there. And that's usually pretty accurate. In the little babies, it's a little more complicated because you don't have flora. You have to use external landmarks, but I tend to go about to the level of the nipple. For the little babies, it seems to me always at the level of the nipple. Once they get older, it's not so accurate, I think. What do you do, Mark, if you put it in and you were Wrong. It's, it's a little further in than you expected. I tend to place my cuffs high so I don't leave the cuff right at the exit site, so I have some wiggle room to pull it down and then usually you can always have some wiggle room to push it in a little bit further. So I'll just pull it down. Do you think it's a problem leaving it in a little further? Do you always pull it back, or are you saying to leave the tip of the line in further? Yeah, I guess what I'm getting at is I often will just leave it even if it's a little deeper than I wanted. If it's deep in the atrium, I'll pull it back, but I think that the superior atrium is fine. That being said, I have, you know, with, and I think this is more with polyethylene lines which are no longer on the market. I have seen some kids that have developed pericardial effusions from lines. And even especially in these tiny little babies, but you can also get it with silicon lines too. So you don't want it to be deep in the atrium, and you don't certainly don't want it to be flipping into the ventricle, but if you're in the superior atrium, I think it's fine. Sometimes if I'm, if I'm in the operating room and I'm looking at it, sometimes I'll deliberately leave a micro preemies just a little bit deep because those kids grow and you know they have to, and then before you know it, it's almost back up at the subclavian vein, you know, the interventional radiologist came and showed. me a great article that showed that we are, most of us put these too high where we think the atrial caval junction is actually much lower than we think, at least for me it was. I always thought it was sort of where that indentation was where it widens out, but it's actually, she, she showed us much deeper without that picture. But if you look online, there's pictures that show us where the atrial cable junction is on an X-ray, and I was surprised how deep it was. We talked. About a cut down, when would you do a percutaneous stick? I have a relatively low threshold to do a percutaneous stick now. For if I'm doing a broviac at the bedside in the NICU, I usually do a cut down just because then you know the direction it's going. I think it's more, I think you're more successful at getting it down in the atrium rather than going off to, you know, the subclavians. Or bouncing back up to the other side or something like that with the cut down, but if I'm doing a temporary line, like sometimes the, the neonatologist will need a line just for, you know, a week or for a few days, then if it's one of the percutaneous kits, I'll go ahead and put those in percutaneous, and I'll, I'll do an IJ or subclade. And so do you always use ultrasound for your percutaneous sticks of the of the IJ. So if I'm doing an IJ stick, certainly if I'm in the operating room where we have the ultrasound machine, I use the ultrasound machine. You know, it's interesting that you bring this up. Ultrasound in the adult world seems to have become the standard of care for line placement. Now there's always the out for the subclavian line, but the question is, you know, is an ultrasound. Guided IJ safer than a subclavian, and while the answer to that question is still up for debate, there was a recent article in Jax from 2013 from Sanj Dutta and Sean St. Peter and others that showed that you have fewer sticks if you are placing a line with an ultrasound guidance, and that was compared to subclavian or blind or landmark IJ. And what they found is that the number of times that you get the vein on the first stick is much higher with ultrasound guidance and than the percutaneous landmark stick. And now their study was not powered to show complications because they didn't really have any major complications in either group. I believe they had about 150 patients. In the adult literature, anyhow, the number of sticks is a pretty good marker for. The risk of complications. So you could use the number of sticks as a proxy. Yeah, and that study changed my practice. I use an ultrasound every single time. Yeah, I mean, the bottom line is that 65%, well, their results were that 65% of the patients in the ultrasound group had one stick, whereas only 45% in the landmark group. And with and if you look at the number, the success by 3 attempts, it was 95% in the ultrasound group versus 74% in the landmark group. You know, we like to say that, you know, gosh, we're really good at this, these were all lines done by pediatric surgeons. I think it is trending. I think talking to people more and more they're doing the ultrasound guidance. In fact, we just saw a new ultrasound. You and may even already have this where it shows you the depth. The gauge and a little track that can help you guide the needle right into the vein. It's actually pretty slick. We don't have that yet, but right now I find that the ultrasound is really a great way to get access. Sometimes you sort of have to go past the vein and come back a little bit to get the blood return. Do you find that too, or no? It happens sometimes, but I think that if you, if you watch the needle go in, it's like you can just watch the needle go right in and you put it in the vein. It's also, it's a great way to do femoral lines, you know, even in an emergent situation. You know, it's come to the, at least in our hospital, we have the little portable ultrasounds all over the place now, so they're pretty available. But I do want to mention that point again that in as the as you start doing these in really little babies, the percutaneous stick, their veins are not as tightly distended as an adult vein. Just because you go in and you don't get a return, it doesn't mean. You're not in, you might just be through it, and if you come back and you might find that you're in the vein, you know, when you're, let's, you know, getting away from the babies for a minute, when you're doing a line in a cancer patient, how do you, does your institution use meta ports, Broviacs, or how do you guys decide? We basically will use a subcutaneous port like a port a cath or a meta port or something like that for most chemotherapy, for most intermittent chemotherapy. Now there are certain diagnoses. So if the patient has ALL and they're going to be getting some highly toxic or highly chemotherapy that's going to be a real problem if it infiltrates, then we'll put in a broviac. Usually this is guided by the oncologist. I mean they usually tell us what they want and like I said, the standard in our institution is if you're getting You know, something like Adriamycin or something like that that's going to really necrosis the skin or cause a big problem if there is an infiltrate, then we go ahead and use a cuffed line as opposed to a buried line. Now we don't use the double lumen. Ports very much so if someone has a need for two lumens, we'll also use a double lumen Broviac. And then obviously the bone marrow transplant patients, a lot of those will get perm cath. And what's a perm cath? That's the long term dialysis catheter that they use it for pheresis to harvest stem cells, OK, because in the bone marrow transplant patients we end up putting in 3 lines, so a double lumen and then a single lumen on top of that, and I, I know I've been at 2 institutions and both places have asked us to do that, and that was new for me because I had never done that before, but now they're like 3 lumens in some patients. Yeah, what's your rule, or do you not have one on how small of a patient can get a meta port versus a Broviac? So we've had babies that need chemotherapy, and there are some mini ports on the market that you can put in a baby. It's a 5 French line. Uh, the smallest one, that's the smallest one I've seen. And you know, you can get that in a, you know, in a 7 8 kg kit. That 5 French port for us is a special order, but they're certainly great for those, for those little ones. Mark, if you've had a patient who has had Had numerous lines in the past. Do you routinely get vascular studies before going to the operating room? You know, I'm going to hedge here and say it depends. A lot of it depends on whether the last line was easy, hard, or otherwise, and what kind of lines they've had and if it's been, you know, years and years and years. But if there's, if there's any question, we get a lot, we get a study up front, especially if there's a, if there's a history of a clot or a history of a DVT. Uh, then we'll get, then we'll go ahead and get a study. The gold standard for us is a is an MRV, and I think that gives you the most information. If it's somebody that you want to do a quick and easy study, occasionally we'll use ultrasound, and we have very good sonographers, and you know, I think that we get good information from that, but the ultimate, the ultimate test is an MRV, and then we'll guide our, our approach from there. Now one of the things that we found is that just because there is, you know, it depends on how fresh the clot is, just because there is, there may be some occlusion doesn't always mean that you're not gonna get a line by it, especially if there's some flow, uh, and if somebody really needs a line, you can get a catheter through it. There's some tricks for that, you know, for example, I just recently put a line in a kid for chemotherapy who had had multiple lines in the past, and the last one was taken out for infection, and this kid had, I guess it had easy access in the past, but I actually went, tried to go on the same side as the line that had come out just because the parents wanted it there because that's where the scar was. And I couldn't get access, so I went to the other side and I did a subclavian stick, and lo and behold, the standard wire would not go past the superior vena cava. And what I did is I took a glide wire and you can take the actually, you know, I said I did a subclavian stick. I actually did an IJ with ultrasound guidance on the right side is what I did, but I used a glide wire. Then I was able to pass the glide wire through the clot. That's a trick that one of our interventional radiologists taught me is that sometimes you can get the slippery wires right past the clot. That's counterintuitive. I would have thought the stiffer the better, but probably just slides on the side of it, huh. I think it finds it finds the hole. I mean there must be something going through and it found the hole and we got the line and it was all fine, you know. I misspoke on that last one. I said I did a subclavian out of habit, so I still occasionally do subclavian lines, you know, I, I haven't totally converted to the IJ, but for the, I, I think I'm getting there, uh, for the most part I'm starting to do more and more IJs. You know, one of the challenges with doing the ultrasound guided IJ is how do you curve the line right so that it doesn't kink up in the neck. Exactly, and I worry about that. But when I, when I tunnel it, I go wide, I go lateral, right, so that you have more and more gentle curve. So I've been putting my lines in around the sternum, and most of that came from because the meta ports I like to put over the sternum because they don't flip, but they. kink more when you do that. And if you do the lateral thing, which I heard you say you don't like because it can get in the way of the arm, it has a much more gentle curve and less kinking. Even when I go wide, I find it's tricky, and I, I've heard people with all these tricks, some people say do it right over the clavicle, cause then it uses the clavicle as sort of a A wide curve, but I have not found a good trick, and I think even going wide it can happen, especially in the double lumen catheters where they're stiffer. Yeah, no, the double lumen catheters are real tricky. And again, while it looks like the ultrasound placed lines may be better, there are cases again it's risk benefit ratio, and you know, I think that sometimes it's, it's better, the patient's better off with a subclavian line. When you have a patient that has an infected line and they still need IV access, what is your protocol? Do you exchange over a wire? Do you put in a PICC line temporarily and then wait till you have negative cultures? What do you guys do there in Atlanta? We'll pull the line. If the patient has peripheral access, we'll just use peripheral access if we can. If they need a central line, then we'll, we have put in place PICC lines. I'm always anxious putting another central line in the face of infection because the chances are that line's going to get infected. Yep. But you can do a PICC line, but usually we'll just try to ride peripheral IVs, even if you can keep it out for a day or two. I think that's a benefit with a patient on antibiotics and then put another line in. Uh huh. So ideally, ideally they'd have negative blood cultures, right? So you wait for the blood cultures to be negative, so you need at least 48 hours, yeah. OK, what's your first line? Let's say you got a 6-year-old never been accessed before. Where's your first choice line, a right IJ? Yes, OK, what's your second? Well, I, you know, I say a right IJ, but you know it could be a right subclavian too. You would do a right subclavian before a left subclavian, you know, I don't think it makes any difference. And you know some people argue about the. Left subclavian having a gentler curve, but the flip side of that is the left subclavian, also the catheter, if you don't put it deep enough, can be up against the side of the SVC, and I have seen one kid develop a pleural effusion with erosion of the line into the chest. I'd just go to the right side first, either IJ or subclavian, and you know, I think in 2015, my first choice is an ultrasound guided IJ, and that's what I do always as my first choice. Any tricks when you do a left IJ of getting it to be in the right position? It always seems to me that I seem to measure it wrong. I move it too high or too low. Talking about position or just getting it over. I mean, I think sometimes the left IJ can even be a challenge just getting into this. vena cava usually you can usually you can manipulate the neck so that it's almost a straight diagonal line into the superior vena cava and that's what I I think that's the trick there but as far as length, you know, I just go down to the clavicle over and then down and sometimes you end up too deep and uh but you can always pull it back a little bit. Do you ever use the external jugular vein? I don't. You know, I, for those of you that don't know, during part of my training, I spent some time with Mark Rowe in Pittsburgh doing his critical care fellowship, and he loved that EJ, and you know, I've done lots of those cutdowns, but I, you know, it's really hard to get the catheter to thread down the right place. A lot of times they'll want to go down the subclavian. Yeah, and it's funny, my partners love it. They have great success with it, and it seems when I try to do it. It goes down the arm or goes the wrong way, so I agree. I'll use it when I need to. What about femoral access? I think femoral access to some degree is underrated, although I do worry that you get DVTs with femoral access. But we really try to stay away from it in the babies because a lot of them will end up with a swollen leg. In the pediatric ICU we will use femoral lines, and I think again I do an ultrasound percutaneous technique and usually our intensivists can get them, you know, can get them, but we'll, you know, if they want a bigger catheter occasionally we'll do it and we actually do eCOcanulation. We'll do percutaneous emocannulation using ultrasound guidance and if you're doing a VVECMO on a big kid. With multiple cannula, you can use that technique. What's the trick for, for people that don't do a lot of groin cutdowns? Do you have a trick or do you, um, do you have landmarks you like to use? So I found it very rare that I've had to do a groin cut down. Uh, you can almost always percutaneously access the vein, uh, especially with ultrasound guidance. If you do a cut down, you know, I basically cut down over the sainofemoral junction, and then you can thread the catheter right through the saphenous vein into the femoral vein. Do you get any preoperative labs for your catheter placements? So most of our catheter placements are oncology patients, and a lot of them have had preoperative labs. PT PTT is probably Not worthwhile unless the patient was anticoagulated or you have some reason to think that their INR is going to be up because they have liver failure or something like that. More important is platelet function, and I think a platelet function assay or a PFA is probably the most helpful. Platelet count can help you also, and you get that only in those situations where you would have a reason to worry about it, yeah, yeah, only when you have a reason to worry. It's not a routine thing. Now in some of our patients, some of our oncology patients, you know, we'll give them platelets, and they may have a platelet count of 20,000, and we may give them some platelets and not necessarily check it after, um, but we'll, you know, give them, figure out what they need and then give it to them on their way down to the OR and have it running in the operating room. If you need to, you know, obviously you need to put a line in and you have a patient who has an elevated INR. And you're trying to correct them and it's hard to correct them, my first choice again would be either a femoral line or an IJ where you can hold pressure if you need to. I stay away from the subclavian in those situations because you can't really if you, if you stick the artery by accident or even just getting into the vein, you can get bleeding and that can be a problem. So Mark, what concentration of heparin Use when you lock the line at the end of the case. So our protocol at our hospital is 10 units of heparin per mL for lines that are accessed. So an access port or a cuffed line or a temporary CVL. If it is a port that we are locking without access, it's 100 units per mL. And if it's a dialysis catheter, we actually use 1000 units per mL. Now they withdraw that before they, before they obviously, before anyone injects anything in it, and we have special little warning labels on it, but those catheters require more to prevent thrombosis. Now we are moving over, you know, like many children's hospitals, we're all trying to decrease our Lyme infection rate and narcolepsy rate. We are starting to use more ethanol lock as well. Talk to me about that. In our HEMOC patients, Lyme, especially the bone marrow transplant patients, are very susceptible to Lyme infections. A lot of it's from translocation, from GI flora, and there's, we have a whole program that involves everything from mouth care to how you, how you change the dressing and everything else. And in those patients, or actually in any patients, there is evidence that using the ethanol lock will decrease your Lyme infection rate. So. I want to understand this because we obviously use the ethanol lock for treatment of infected catheters, but you're talking about using it as your primary lock when you place it. Yeah, now we don't do that in the operating room. The he on the oncology floor, they're starting to use that in some of their patients. That's interesting. So prophylactic patients would get it even without an infection. Yeah, talk to me about when you have an infected line. Are your, is your institution using ethanol locks instead of removing the catheter? Yeah, so part of it depends on what it's infected with. If it's gram positive, we will, you know, do ethanol lock. We'll treat with antibiotics through the catheter and try to clear the catheter. If it's gram negatives or yeast, the chances of clearing it are much less. Now. Some kids are a little tenuous, and if it's gram negative, you can clear it maybe if you're lucky half the time, but then you run the risk of reinfecting. If you can't, which we might try. If it's fungus, if it's Canada, we just take the line out. There's really no choice. Do you know the protocol offhand offhand for the ethanol lock that you guys are using? I don't. OK. And I don't know ours either. I, I, I know that there are several available online. If you look up ethanol lock protocols for those of you who aren't using this yet. Um, I know at our institution we've copied some of the, the ones that have been published, and it has to do with, um, how often you do it. Is it once a day? Is it, is it for how many days do you do it? For what, what volume, what concentration? I believe it's 70% ethanol, and, uh, I don't remember exactly. I think we do it for 5 days, but I think I'm guessing there. But that is a great thing. And when we started doing that, the number of line removals substantially dropped, and the success rate is just incredibly high with the ethanol lock. Are there catheters that are antibiotic coated? There are antibiotic coated. Cathetters and we actually have some for our temporary lines and those catheters have been shown to have a decreased clapsy rate. Are there heparin coated lines? Yeah, there's heparin coated lines and some of them are coated with various antiseptics or antibiotics. And they all seem to decrease the complication rate. OK, now the heparin coated lines are, it's coding on the outside, not on the inside as far as I know. So Mark, I wanna ask you because you know what, what excited me that you showed, and I still believe it or not have not tried it yet even though. One of these days I will tell me um about what you do when there's absolutely no vascular access left in the patient with no vascular access where you need to get a line there's very limited options you can go. With interventional radiology doing a translumbar stick or a trans hepatic stick into the inferior vena cava, I mean, any of these things are a big deal, but those are also not very comfortable lines. This is a technique that I first performed with Keith Jorgeson. When I was a fellow in Birmingham, so this was in the late 90s and we had a kid that had basically everything thrombosed. I don't remember exactly what the underlying diagnosis was, but what we did is under thoracoscopic visualization, we took a needle through the neck along the thrombosed. IJ into the superior vena cava and basically advanced the needle until we got blood back and really at the where the azygous vein comes into the superior vena cava the SVC almost always recantalizes and so basically once you have the needle there and the needle was going through the media. Medstinum, so it was never outside the mediastinum, but you can see it through the mediastinal pleura going in and we, and we approached it from the neck just like you were doing a landmark IJ stick. So once you get blood back, you pass your guide wire, and then it's like doing any other line. Two questions. Number 1, And I've seen your video, and it really helps to see the video. I guess the fear is, would you accidentally puncture through the vessel into the chest? Is that seem like it's a likely thing to happen, or having done the procedure, is that usually pretty safe? It seems pretty safe. I mean, you go through and you know, I can tell you the first couple of times I did this, my heart rate was up too, but it's really, it's pretty straightforward. You want to make sure that you don't. Hit the artery or anything like that, but once you get into the mediastinum and you can see that needle going subpleurally, it's very comfortable, and you can just sort of just go down until you see where the SPC is, and it's not subtle. You can see it pretty easily. Now one of the tricks, some of the things we've run into is the last kit I did this on was a hemophiliac who was 17 years old. The needle that came with the line kit was not long enough, so I had to get an extra long spinal needle. In order to get To the superior vena cava, that's a good, and I can see that that's not unlikely to happen given the distance you have to travel. Do you, I'm sorry, you said you use an ultrasound on the neck while you're getting in or no? No, because there's nothing to see, I guess with the with the clotted vein show. Up on ultrasound or no? You might see it. It would be non-compressible. You might see, you might see something there. I guess it would help you stay away from the artery. Artery, yeah. But I have not used ultrasound in that case. OK. And I do, it's a pretty low stick, but it is, like I said, it's a, it's a little. It's a little disconcerting when you're putting the needle for that blind period through the thoracic inlet. Mark, can you talk to me about what skin prep you use when you're going to do the procedure? So we've converted our institution over to a CHG alcohol-based prep for central lines, and there's the ABSA Outcomes Committee looked at this and did a little meta-analysis in 2011. And they're looking at ways to decrease Lyme infections and Lyme complications, and basically they said that there was Class A or B evidence that this decreases Lyme infections. There's a lot of studies out there about betadine versus the CHG, alcohol preps versus. The betadine alcohol preps, and you know I think that betadine in most of those studies came out 3rd. The other two were fairly equivalent. Now one of the interesting things is for those of us who have been around a while and maybe even some of the new guys that are inheriting other patients, you know, occasionally you take out some of the, you go to take out some lines or ports that have been in a while, and the line, the silicone is chalky and it breaks off and it's really hard to get out in those situations there's there's, we can talk about some of the tricks that you use to get them out, but there's some speculation, and again I haven't seen evidence of this, but there's some speculation that those lines were deteriorating because of exposure to betadine. So that may be another reason to use CHG. You know, you mentioned removing the line for your Broviac catheters. Do you take them to the operating room to remove the cuff? In general, no, we'll take them out at the bedside and we put my, I place my cuff far away from the skin, and they're designed to break away. So if you have slow, steady pressure, the cuff will eventually break away, and I leave the cuff behind. I do know of, you know, I've been in practice now 17 years, 18 years. I've had one cuff. That hadn't developed an infection and needed to be IND, and I think it was actually ended up closer to the exit site than I thought it was. What's interesting is our oncologists sort of have mandated that we take our HEMO patients to the OR because it's sort of it's a kinder, gentler thing. I think that may be a little bit of overkill. So those kids end up going to the OR. And if the cuff's right there at this exit site, I'll go ahead and take it out, but if it's not, I leave it. I leave it. I don't go hunting for it or make a counterincision to take the cuff out. In the little babies, we just do it at the bedside and in the nursery and just pull the lines out. I had two questions for you. So number one is, so first of all, I had always taken these cuffs out and. Till I came to Akron Children's where I learned about just pulling them and leaving the cuff, and I get scared every time. And in your 18 years, have you had a catheter break? Yes. What happened? Did it stick to the cuff, or did it, I mean, I'm talking about break when you were pulling it. If the catheter breaks, you know, it's rare, and you've got to feel for the silicone. You know, it's stretchy up to a point, and then when it stops, the little fibers are straight and you don't want to go any further. But I have had one that broke off, numbed it up, and reached up with a hemostat. It was a little baby and was able to grab the cuff and pull it down and stuff out too, so it didn't migrate into the, no, but it's not going to. Remember that cuff stuck there and it's not going to break on the other side. Your tension is on the exit side, so it shouldn't be a problem. So if it breaks you just go in and get it. It shouldn't just migrate out, OK, yeah, it's not going to migrate and worst case scenario if it's up really high, so you put a pressure dressing on it or put a Tegaderm and a 2x2 over it and take them to the OR and then take it out, right, right, it should, it should, it shouldn't be a big deal. So my second question was, you do the same thing which I think you already answered pretty much in the, the 3 French catheters. You'll still just pull them and leave the cuff, OK. Oh yeah, yeah. Fantastic. Mark, this was a great discussion. It's amazing. We talked a lot about a lot of basic stuff. As, as this is probably the simplest thing we do, it can sometimes be the most nerve-wracking and challenging cases as well. Uh, we certainly hit on a lot of the things we could probably talk about 100 more questions, but uh I appreciate you taking time out of your day to talk about this and hopefully we'll have you on future podcasts. Oh, thanks, Todd. This is great. Thank you. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen to Stay Current in Pediatric Surgery by subscribing on the iTunes Store or by downloading the Globalcast MD podcast app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.