Pediatric Vascular Access

In micro-preemies (1000g to 2kg), a 3-French soft silastic cuffed catheter is preferred because larger catheters that fill the vessel lumen increase the risk of vessel thrombosis.

A needle-hole venotomy technique for neonatal IJ access involves isolating the vein, making a needle puncture without formal venotomy, and advancing a beveled catheter through the puncture site to preserve vein patency for future access.

Beveling the catheter tip for needle-hole venotomy was associated with slightly more catheter thrombosis in one study compared to straight-cut catheters, but the technique is justified to preserve the vein.

When ultrasound-guided needle placement appears to be in the vein but no blood return is obtained in small infants, the needle may have passed through the collapsed vein and withdrawing it slightly may establish access.

For oncology patients receiving vesicant chemotherapy such as Adriamycin that causes tissue necrosis if infiltrated, a cuffed external catheter (Broviac) is preferred over a subcutaneous port.

Bone marrow transplant patients at the speaker's institution receive three central line lumens: a double-lumen catheter plus a single-lumen catheter.

MRV is the gold standard imaging study for evaluating central venous patency in patients with multiple prior lines or history of thrombosis.

A glide wire can sometimes be advanced through a partially occluded superior vena cava when a standard guide wire will not pass.

When tunneling from an IJ access site, placing the exit site laterally creates a more gentle curve and reduces catheter kinking compared to medial or sternal exit sites.

For infected central lines, if the patient has peripheral IV access, the infected line should be removed and peripheral access used temporarily rather than exchanging over a wire, which risks infecting the new line.

Ideally, blood cultures should be negative for 48 hours before placing a new central line after removal of an infected catheter.

Femoral venous access in neonates frequently results in leg swelling and should be avoided in this population.

Routine preoperative coagulation studies (PT/PTT) are not indicated for central line placement unless the patient is anticoagulated or has liver failure; platelet function assay (PFA) is more useful when coagulopathy is suspected.

Standard heparin lock concentrations are 10 units/mL for accessed catheters (ports and cuffed lines), 100 units/mL for non-accessed buried ports, and 1000 units/mL for dialysis catheters.

Prophylactic ethanol lock therapy is being used in some bone marrow transplant patients to reduce catheter-related bloodstream infection rates.

For catheter-related infections with gram-positive organisms, treatment with antibiotics through the catheter plus ethanol lock can successfully clear the infection approximately 50% of the time; for gram-negative infections, clearance rate is lower.

Catheter-related fungal infections (Candida) require line removal; salvage attempts are not appropriate.

Implementation of ethanol lock therapy substantially reduced the number of line removals for infection at the speaker's institution.

For patients with complete central venous occlusion, thoracoscopic-assisted needle puncture of the SVC can be performed by advancing a needle through the thrombosed IJ tract under direct visualization; the SVC almost always recanalizes at the azygous vein junction.

For thoracoscopic SVC access in larger adolescents, the standard line kit needle may not be long enough and an extra-long spinal needle may be required.

Some older silicone catheters become chalky and friable over time, possibly due to betadine exposure, making removal difficult.

Cuffed catheters (Broviacs) can be removed at the bedside by applying slow, steady traction until the cuff breaks away from the catheter; the cuff is left in situ and does not require surgical removal.

In 18 years of practice using bedside cuffed catheter removal with retained cuff, the speaker encountered only one cuff that developed infection requiring surgical removal.

If a cuffed catheter breaks during bedside removal, the retained segment with cuff will not migrate because tension is only on the exit side; the segment can be retrieved by local exploration.