Pediatric Vascular Access

In micro-preemies (1000g to 2kg), a 3-French soft silastic catheter is preferred because larger catheters as big as the vessel can cause vessel thrombosis.

Needle-hole venotomy technique: isolate the internal jugular vein, make a needle hole with the kit needle, and slide the pre-tunneled catheter into that hole without ligating the vein, preserving it for future access.

Beveling the catheter end is associated with slightly more catheter thrombosis than cutting straight across, but may be worth it to preserve the vein in micro-preemies.

Subcutaneous ports (port-a-cath, meta-port) are used for most intermittent chemotherapy; cuffed lines (Broviac) are used for highly toxic agents like Adriamycin that cause tissue necrosis if infiltrated.

Bone marrow transplant patients often require three lumens: a double-lumen perm-cath plus a single-lumen line.

The smallest mini-port available is 5-French and can be placed in a 7-8 kg infant, though it requires special order.

MRV is the gold standard for pre-operative vascular imaging in patients with multiple prior lines or history of DVT.

A glide wire can sometimes pass through venous thrombosis when a standard wire cannot, finding a channel through the clot.

Femoral lines in babies often result in leg swelling and DVT, so they are avoided in that population.

Institutional heparin lock protocol: 10 units/mL for accessed lines (ports or cuffed lines), 100 units/mL for buried ports, and 1000 units/mL for dialysis catheters (which is withdrawn before use).

Ethanol lock therapy has substantially decreased line removal rates and has very high success rates for treating line infections.

For gram-positive line infections, ethanol lock plus antibiotics through the catheter can clear the infection; for gram-negative infections, success rate is approximately 50%; for fungal infections (Candida), the line must be removed.

Antibiotic-coated and heparin-coated temporary catheters have been shown to decrease catheter-associated bloodstream infection rates.

Thoracoscopic-guided trans-mediastinal puncture technique: advance a needle through the thrombosed IJ track into the superior vena cava under thoracoscopic visualization; the SVC almost always recanalizes where the azygous vein enters.

For thoracoscopic salvage access in larger patients (17-year-old mentioned), the standard kit needle may not be long enough and an extra-long spinal needle is required.

There is speculation (without definitive evidence) that betadine exposure causes silicone catheter deterioration, making old lines chalky and difficult to remove.

Broviac cuffs placed far from the exit site are designed to break away with slow, steady traction, allowing bedside removal without cuff excision.

In 17-18 years of practice, only one retained cuff developed infection requiring incision and drainage.