Central Venous and Arterial Access in the Pediatric Patient
Rennier A. Martinez
Difficult pediatric vascular access issues arise often and unexpectedly.
These issues tend to be related to small vessels, intravascular depletion, lack of cooperation, and other unique anatomic and physiologic qualities of the pediatric population.
There are different indications for obtaining vascular access.1
Most difficult accesses can be obtained percutaneously aided either by ultrasound (US) or fluoroscopy guidance; however, open access may be needed in certain situations.2
As with any surgical procedure, no matter how simple, complications arise and the pediatric surgeon must know how to manage them.
RELEVANT ANATOMY
Preoperatively the surgeon must decide what type of access to obtain and the size and number of lumens required.
In neonates the femoral vein lies posterior (rather than medial) to the femoral artery. This requires a different US-guided approach than in older children or adults.2
Common access sites:
Blood sampling: heel, antecubital arteries/veins, scalp arteries/veins, femoral veins (last resort)
Peripheral venous access: hand veins (dorsum), antecubital veins, cephalic vein at wrist, long greater saphenous at ankle, femoral veins
Central venous access: subclavian, internal jugular (IJ) or external jugular, femoral, umbilical vein and artery
Intraosseous (IO): anterior tibia, distal femur (Figure 5.1)
 Figure 5.1 Upper extremity veins. The upper extremity veins are paired into deep and superficial drainage. The superficial veins tend to be larger and the dominant system of the upper extremity. The superficial system comprises the cephalic and basilic veins at the forearm. The cephalic vein extends along the lateral forearm. The cephalic vein joins the axillary vein at the humeral head or clavicle. The cephalic vein can be paired. The basilic vein runs through the medial forearm and continues to the upper arm. The basilic vein joins the brachial vein at the mid-upper arm to form the axillary vein. The median antebrachial vein runs on the ventral forearm and drains the palmar venous plexus. The deep veins (radial and ulnar veins) are small and paired, communicate with each other, and accompany the forearm arteries. SC, subclavian; C, cephalic; A, axillary; BR, brachial; B, basilic; R, radial; I, interosseous; U, ulnar. (Reprinted with permission from Dyer R. Handbook of Basic Vascular and Interventional Radiology. New York, NY: Churchill Livingstone; 1993:160.) |
VENOUS CATHETERS
Peripheral Venous Access
This type of access is adequate for intravenous (IV) hydration, most medications, and often blood sampling.2
It is the first access obtained in most inpatients.
It can become quite difficult to obtain in volume depleted, restless, small pediatric patients, ie, emergency situations.
In these cases, a surgeon’s expertise may be requested.
In cases where peripheral intravenous (PIV) access has failed, IO or cutdown techniques become quick and efficient alternatives.
Common peripheral target veins are in dorsum of hand, forearm, dorsum of foot, medial ankle, and scalp (neonates).
Scalp veins and external jugular veins are easily accessible but hard to maintain because of patient movements.
Techniques Aiding Peripheral Cannulation
They include warming extremity, transillumination, and epidermal vasodilators.1
US can be used to cannulate cephalic and basilic veins.
Intraosseous Access
If PIV access fails, then IO is the fastest and most effective route of administering fluids, drugs, or blood in children <6 years of age.8
Most effective in children <6 years of age because the bone marrow is better perfused.
For children >6 years of age, venous cutdown should be performed if percutaneous attempts fail.
Best IO access sites are midline of anterior tibia below tibial tuberosity or distal femur.
Angle needle 60° from horizontal and point toward middle of tibia/femur depending on the bone chosen
Once cortex is penetrated, aspirate to ensure proper position
IO access is faster and safer than emergency central venous catheter (CVC) placement1
Contraindications: diseases of the bone or ipsilateral extremity fractures
Complications: 1% complication rate; subperiosteal or subcutaneous infiltration (most common); fracture, growth plate injury, fat embolism, compartment syndrome, and osteomyelitis rare3
Remove needle as soon as better access obtained
Venous Cutdown
With increased IO access use, venous cutdown as well as emergency CVC placement has been almost eliminated.1,2
However, this set of skills is still essential for any pediatric surgeon.
Best target vessel is long saphenous vein near medial malleolus, although cephalic vein at the deltopectoral groove is another good target (Figure 5.2).
Ankle cutdown: short transverse incision proximal and anterior to medial malleolus
Exposed vein is encircled with a silk suture, and an appropriate angiocatheter is introduced. No need to ligate or transect vein8
Central Venous Catheters
This type of catheter is used less with the advent of peripherally inserted central catheters (PICCs). Indications range from emergent to long-term use.
Many different types of CVCs are available, and the pediatric surgeon must know each type and indications for each.
Main determinants of catheter selection are intended duration and frequency of use.2
CVCs designed for long-term use include the tunneled lines, ie, Broviac and Hickman catheters.
These are ideal for continuous infusion of medications or for total parenteral nutrition (TPN).2
If long-term intermittent use is desired (chemo), then ports are typically used.
Both types of catheters allow for more than one lumen is so desired.
CVCs designed for acute or emergent use are the nontunneled lines.
Tunneling allows for longer duration by reducing chances of infection.
Hemodialysis (HD) lines follow similar indications.
US guidance for insertion is gold standard.
Most common access sites include, but are not limited to, IJ, facial, external jugular, subclavian, saphenous, and common femoral veins.
Less common sites include gonadal, intercostal, azygous, and hemiazygous veins and the right atrium (RA).9
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