Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations

In the United States, there's an estimated 5 million central venous catheter lines placed, and several of those are in the pediatric surgical patient, which is why today, we're gonna break down the basics. Here at Cincinnati, we deal with the bulk of some of the complex uh vascular access, as well as all the, um, catheter-based access for dialysis. That's Doctor Alex Bonddo. He's a pediatric transplant surgeon at Cincinnati Children's Hospital Medical Center. He's gonna walk us through really everything that you need to know about pediatric vascular access, so don't go anywhere. This is the Stay Current podcast. Before we get too far, let's review the types of central access. The first is central venous catheter. These are not tunneled. They're typically for temporary use in the hospital. They can have 1 to 3 lumens. We'll get more into the indications later. Next, there's a port, which is for long-term access on the order of months to years. The catheter is tunneled and there is a totally implantable reservoir for access. They're often used for things like chemotherapy, and they can have 1 or 2 lumens. The Broviac catheter is a tunneled line with a cuff, and it can be used for months to years for things like chemotherapy, parenteral nutrition, frequent blood transfusions. They can have one or two lumens. Finally, hemodialysis or Peresis catheters can be temporary if uncuffed, or permanent if cuffed. They're for uses as they're named, hemodialysis or pheresis. The catheters can have 1 to 3 lumens. With so many patients necessitating central access, it's important to keep in mind some guiding principles. For example, where do we place central access? From a purely logistical standpoint, um, chest and neck, central venous access is preferred. There's a fair amount of evidence to suggest an increase in the rate of complications and infection with femoral access. So that answers the question of where to put a line, but how about why? Well, the list of indications, it can be extensive, including a need for total parenteral nutrition, resuscitation, or hemodialysis, and really the list, it just goes on and on. As for contraindications, contraindications, if you have thrombosis, um, if you have collateralization, Uh, if you have central stenosis of the SVC, then you start having to do more exotic, uh, concurrent procedures or use the groins or go to a different access point. While some complications can't ever really be avoided, there are definitely some pre-procedural considerations to keep in mind when performing the workup for a patient who just needs IV access. Unless they have some other congenital anomaly, usually a cardiovascular anomaly, I wouldn't say that it's routine that you have to get, let's say an ultrasound would be our first screening test. But if there are, you know, this is line number 456. For a patient, then you're talking about starting, usually what we like to do is a Doppler venous ultrasound to look at the jugulars. You can sometimes, if the child is small enough, see the SVC and look at the subclavians. You might escalate that to a, a contrast enhanced axial image, either MR or CT venogram to understand and even then, sometimes we're prepared to do venography tran you know, um, on the table with fluoroscopy at the time of the operation. Let's say we finish the workup and we're ready to place a line. What's the first consideration? Starting out from a positioning standpoint is critical. What I would tell you is, especially in small children, neonates and infants, is that The more versatile way to position the patient is over a vertically oriented shoulder roll. If you put it straight up and down parallel with the spine, you get not only hyperextension of the neck, but you get the weight of the shoulders to drop posteriorly. That will give you access to all four, you know, all the The subclavians bilaterally and the jugulars bilaterally. Great, so positioning is critical to making the percutaneous stick easier for the surgeon, but pediatric patients, they come in all shapes and sizes. So what happens when you have a really small neonate? Is there a certain needle we should be using? For really small babies, many surgeons would prefer a cut-down. Doctor Boondock does have a suggestion for a needle you can use if you do place a line percutaneously. I like to use a micropuncture kit. The micropuncture kit comes with a 21 gauge finder needle, which is a lot different than the 18 gauge needle that comes with some tunnel blind kits. OK, so they're positioned on the OR table with a vertical shoulder roll. We have a micropuncture needle kit. We're ready to place this line, but first I gotta ask, do we want to use ultrasound or external landmarks? Using an ultrasound for an IJ, um, central line, uh, attempt is the number one preferred way of doing things. It's certainly the safest, uh, the lowest risk of pneumothorax, the lowest risk of, um, injuring the artery of the carotid. Got it. So once you see the IJ on ultrasound, where on the neck do you want to puncture? Especially for large bore access like a dialysis catheter, is to stick the patient as low as you can on the neck. Usually, what I try to do is I take the ultrasound probe. The ultrasound probe is about 12 millimeters in diameter. So if you just sort of lever it against the clavicle, you have a pretty reasonable spot where you can um follow your needle in and you're sticking them pretty low. Wait, why so low? Why not in the mid portion of the neck? That leaves more of the catheter to curve in the neck. And so that's where I, in my opinion, you run into problems with patients who, if they, when, if and when they turn their neck, or the more lax amount of catheter in the neck. I've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times. Let's say we've lost both IJ access sites or the patient is in a cervical collar, but the patient still needs central venous access right now. Then we should consider a subclavian line, and that's more of an anatomic placement. At the junction of the medial, the median and the medial aspects of the clavicle, I usually go at least 1 finger breadth or, you know, almost 1 centimeter inferiorly and lateral, um, and stick away because if you stick too close to the bone, you're not gonna be able to lever under the bone. Um, and so, that's the important thing is once you're sticking and you approach the clavicle, You don't want to turn your needle at a, you know, at a harder angle, like a 30 degree angle. What you really want to do is keep your needle flat and push down on the patient's skin. The direction you're pointing the needle in is also super important. I typically aim directly at the sternal notch, and then if I can't get it from the sternal notch, then I start angling wider towards the angle of the mandible, moving in sort of a In a radial motion. So typically we want the tip of the catheter to be at the junction between the right atrium and the superior vena cava. Often chest X-ray or fluoroscopy are used in the operating room to make sure that the tip is in the right location. And if you have trouble finding where the catheter tip is located, Doctor Banak has another tip for you. What I was taught by our PIC nurses is that if you think of the trachea as the midline of the patient on an X-ray or on fluoroscopy, and you draw that theoretical midline, you continue it from the carina all the way down. And then the right main stem bronchus acts as a hypotenuse of a right triangle, and you connect that theoretical midline to the hypotenuse. If you leave the tip of your catheter in that triangle, in the area of that triangle, that will always be the atrial cable junction. Another common option is to use fluoroscopy for line placement. I would tell you, I don't routinely order X-rays if it's a single stick, uncomplicated, using fluoroscopy. That's based on some data out of Children's Mercy Hospital at Kansas City. Scroll down under the media player, we're gonna give you a link to the article below. Now, if something seems strange, obviously, don't hesitate to get a confirmatory post-procedural X-ray to confirm line placement. What are some post-procedural complications we need to keep aware of? Pneumothorax, um, hemothorax, um, uh, injuring the artery, either the subclavian artery or the carotid artery, um, and then sort of very, very exceedingly rare things like klothorax or thoracic duct injury. And then you have your long-term complications like thrombosis or catheter displacement or kinking. If it's a really, really long time, you got to consider actual degradation of that line. But one long-term complication that you really gotta be diligent about is Lyme infection. So how do you approach this patient? Your first clinical decision point is, is the patient septic from this line? If the patient is septic from the line, it's source control, right? The patient's in the ICU and sick. Go to the bedside, with under light sedation, pull the cuff, get the line out. What if the patient is not septic, but they are line dependent or they have complex vascular access issues? Then we figure out what is growing, um, can we treat it? Is it sensitive, and then we do serial blood cultures, and that if you can achieve, um, uh, culture negativity, And sustained culture negativity, that line might be salvaged. The decision to remove a line or treat medically has become rather nuanced, especially for some patients with chronic central access needs. Societal guidelines can be found online, and often our infectious disease colleagues are consulted for complex cases. You know, locking solutions have been around for a long time, but they are predominantly antibiotic locks. That's Doctor Paul Wales. He's the director of the intestinal rehabilitation program at the Cincinnati Children's Hospital Medical Center. And frankly, the problem with them is that you develop resistance. So that led some providers to utilize ethanol locks. Antimicrobial, it doesn't have any resistance, and it'll kill bacteria that are both planktonic, meaning floating around in the, in the lumen, or sessile, meaning that they're embedded in a biofilm along the wall of the catheter. Problem is, the price of the ethanol in these locks skyrocketed, leaving Doctor Wales and his team searching for other solutions. They found one in Canada. And it's called kite lock. And what it is, it's a 4% tetrosodium EDTA uh uh chemical. What are the benefits of kite lock? It's antimicrobial, uh, so there's no resistance to it. It's uh antifibrinolytic and uh antithrombotic. We'll give you links to all Doctor Will's publications on different types of locking solutions and some information about kite lock, but keep in mind you can't get this product everywhere. It has been licensed in Canada for pediatric use. It's now licensed in Europe. And it's licensed in Australia. Let's finish up by talking about some less common scenarios. For example, what if we have a patient where we've exhausted all of our options for femoral, IJ, or subclavian cannulation, but they still need central access. Something we consider is a. Translumbar line where um the IR doctors, you know, we work together again where they'll get access and you actually have to tunnel through the, the, the back musculature into the intrahepatic cava and then send a line up that way. Now a different scenario, the patient is crashing right in front of you, and you have to get immediate access. One rarely used technique is just to cut down. My thought was you turn the baby's head to the right, you know, to the baby's left, and usually right at the angle of the mandible, you can make a horizontal incision, just lateral to sternocleidomastoid, and oftentimes the first big vein that pops up is the facial vein. And, you know, you just, you, you, what we do is, or what I was taught to do is you bevel the catheter really hard because you don't really have any other way, you know, you're not putting a wire down that, you're just blindly passing the catheter. So if you put the bevel on it, theoretically it, you know, it'll follow a path, it won't, you know, it won't bump up against um the vessel if it's cut flush. Thank you, Doctor Boondock and Doctor Wales. That is a wrap on vascular access for the pediatric surgical patients. If you like this episode, leave us a comment, leave us a rating, whether you're watching us on YouTube, listening on your favorite podcast player, or the best way to get our content, the Stay Current Pediatric Surgery app. It's free on the Apple App Store and the Google Play Store. But until then, I'm Rod from Cincinnati Children's, and remember, knowledge. Should be free.