Collection
Pediatric Vascular Access
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
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, Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations · 6:22
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
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All surgeons need to know about vascular access. Here we review some preoperative, operative, and postoperative considerations of pediatric vascular access with Dr. Alex Bondoc from Cincinnati Children's Hospital, including indications, con
video13:54 · Sep 2022
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Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
In the United States, approximately 5 million central venous catheter lines are placed annually, with several thousand in pediatric surgical patients.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position0:13 ↗
At Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access.
clinicalAlex Bondoc0:26 ↗
Central venous catheters are non-tunneled, typically for temporary hospital use, and can have 1 to 3 lumens.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position1:00 ↗
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.
Host summaryThe host summarizing the discussion — not the host's own clinical position1:10 ↗
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.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position1:25 ↗
Hemodialysis or pheresis catheters can be temporary (uncuffed) or permanent (cuffed), and can have 1 to 3 lumens.
Host summaryThe host summarizing the discussion — not the host's own clinical position1:40 ↗
From a logistical standpoint, chest and neck central venous access is preferred over femoral access.
clinicalAlex Bondoc2:09 ↗
There is evidence suggesting an increased rate of complications and infection with femoral access compared to chest and neck access.
Host summaryThe host summarizing the discussion — not the host's own clinical position2:17 ↗
Contraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites.
clinicalAlex Bondoc2:39 ↗
Unless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement.
clinicalAlex Bondoc3:09 ↗
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.
clinicalAlex Bondoc3:20 ↗
Pre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed.
clinicalAlex Bondoc3:37 ↗
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.
clinicalAlex Bondoc3:59 ↗
For very small neonates, many surgeons prefer a cut-down approach over percutaneous access.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position4:43 ↗
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.
clinicalAlex Bondoc4:55 ↗
Using ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury.
clinicalAlex Bondoc5:25 ↗
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.
clinicalAlex Bondoc5:52 ↗
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.
clinicalAlex Bondoc6:22 ↗
Subclavian line placement should be considered when both IJ access sites are lost or the patient is in a cervical collar.
Host summaryThe host summarizing the discussion — not the host's own clinical position6:42 ↗
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.
clinicalAlex Bondoc6:56 ↗
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.
clinicalAlex Bondoc7:14 ↗
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.
clinicalAlex Bondoc7:34 ↗
The catheter tip should typically be positioned at the junction between the right atrium and superior vena cava.
Host summaryThe host summarizing the discussion — not the host's own clinical position7:46 ↗
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.
clinicalAlex Bondoc8:04 ↗
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.
clinicalAlex Bondoc8:38 ↗
Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury.
clinicalAlex Bondoc9:06 ↗
Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation over extended periods.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position9:21 ↗
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.
clinicalAlex Bondoc9:41 ↗
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.
clinicalAlex Bondoc10:04 ↗
Traditional locking solutions are predominantly antibiotic locks, but they lead to development of bacterial resistance.
clinicalPaul Wales10:35 ↗
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