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Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
With Dr. Alex Bondoc & Dr. Paul Wales · hosted by Dr. Rod Gerardo
Chapter 1 of 10 · Fundamentals
Device types
Types of Central Venous Access Devices
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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
At Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access.
From a logistical standpoint, chest and neck central venous access is preferred over femoral access.
Contraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites.
Unless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement.
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.
Pre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed.
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.
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.
Using ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury.
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.
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.
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.
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.
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.
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.
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.
Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury.
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.
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.
Traditional locking solutions are predominantly antibiotic locks, but they lead to development of bacterial resistance.
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).
Kite lock is a 4% tetrasodium EDTA solution that is antimicrobial without resistance, and has antifibrinolytic and antithrombotic properties.
Kite lock is licensed for pediatric use in Canada, Europe, and Australia, but availability varies by region.
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.
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.
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.
In the United States, approximately 5 million central venous catheter lines are placed annually, with several thousand in pediatric surgical patients.
Central venous catheters are non-tunneled, typically for temporary hospital use, and can have 1 to 3 lumens.
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.
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.
Hemodialysis or pheresis catheters can be temporary (uncuffed) or permanent (cuffed), and can have 1 to 3 lumens.
There is evidence suggesting an increased rate of complications and infection with femoral access compared to chest and neck access.
For very small neonates, many surgeons prefer a cut-down approach over percutaneous access.
Subclavian line placement should be considered when both IJ access sites are lost or the patient is in a cervical collar.
The catheter tip should typically be positioned at the junction between the right atrium and superior vena cava.
Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation over extended periods.