Vascular Access
With Dr. Mark Wulkan · hosted by Dr. Todd Ponsky
Chapter 1 of 9 · Fundamentals
Neonatal catheter sizing
Catheter sizing and placement technique in neonates
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In micro-preemies up to 2 kg, using a 3-French soft silastic catheter prevents vessel thrombosis compared to larger catheters that can clot the vessel
There is probably more catheter-related thrombosis than clinicians realize
PICC line teams have become more skilled at placing peripheral central access in tiny babies, reducing the need for surgical central lines
For neonatal IJ cut-down, making a needle hole in the vein and sliding the catheter through it preserves vessel patency without ligation
Beveling the catheter end is associated with slightly more catheter thrombosis than cutting straight across, but may be worth it to preserve the vein
Deep atrial placement should be avoided, but superior atrial position is acceptable
Polyethylene lines (no longer on market) were associated with pericardial effusions, but silicone lines can also cause this complication
Leaving catheter tips slightly deep in micro-preemies accounts for growth, preventing the tip from migrating too proximal as the child grows
For oncology patients receiving highly toxic chemotherapy like Adriamycin that causes tissue necrosis if infiltrated, use a cuffed Broviac rather than a buried port
MRV is the gold standard imaging study for evaluating venous patency in patients with multiple prior lines
Even with some venous occlusion on imaging, a catheter can often still be placed if there is some flow, especially if the clot is not fresh
A glide wire can sometimes pass through a venous clot when standard wires cannot
When removing an infected line, wait for negative blood cultures (at least 48 hours) before placing a new central line
Placing a new central line in the face of active infection carries high risk of the new line becoming infected
Femoral access in neonates often results in leg swelling and should be avoided when possible
PT/PTT is not routinely needed before line placement unless the patient is anticoagulated or has liver failure
Platelet function assay (PFA) is the most helpful preoperative lab for assessing bleeding risk before line placement
For patients with elevated INR requiring central access, femoral or IJ lines are preferred over subclavian because pressure can be held if needed
Institutional protocol uses 10 units/mL heparin for accessed lines, 100 units/mL for locked ports, and 1000 units/mL for dialysis catheters
Prophylactic ethanol lock decreases line infection rates in high-risk patients such as bone marrow transplant recipients
For infected lines with gram-positive organisms, treatment with antibiotics through the catheter and ethanol lock can clear the infection
Gram-negative line infections can be cleared approximately 50% of the time with treatment, but reinfection risk remains
Fungal line infections, particularly Candida, require line removal
Antibiotic-coated temporary catheters have been shown to have decreased CLABSI rates
At the azygous-SVC junction, the superior vena cava almost always recanalizes even when proximal vessels are thrombosed
Silicone catheter deterioration (chalky, breaks easily) may be caused by betadine exposure, though this is speculative
Broviac cuffs are designed to break away with slow, steady traction and can be safely left in place after catheter removal
In 17-18 years of practice leaving cuffs behind, only one cuff developed an infection requiring removal
The atrial-caval junction is actually much deeper on chest X-ray than many surgeons estimate
A 2013 JACS study by Sanj Dutta and Sean St. Peter showed 65% first-stick success with ultrasound guidance versus 45% with landmark technique for pediatric central lines
In the adult literature, the number of needle sticks is a good marker for risk of complications
Success by three attempts was 95% in the ultrasound group versus 74% in the landmark group
The APSA Outcomes Committee meta-analysis in 2011 found Class A or B evidence that CHG-alcohol prep decreases line infections compared to betadine