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Central venous access in PICU

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General Points

  1. Uses include delivery of irritant or potent drugs (eg inotropes, high osmolarity nutritional solutions), measurement of central venous pressure and oxygen saturation, difficult peripheral venous access and repeated blood sampling.
  2. Maximum sterile precautions decrease the risk of catheter related blood stream infections (CRBSI).
  3. Transparent dressing covers should be used.
  4. There is no evidence that routine replacement of central venous catheters (or of PICC or haemodialysis catheters) reduces the risk of CRBSI's.
  5. In patients with a clinical picture of sepsis who require their catheters to be changed, except in exceptional circumstance, rewiring of a line to the same site is not acceptable (source of infection is usually colonisation of the skin tract).
  6. Choice of vein: femoral, internal jugular and subclavian veins. Decision based upon age and size of child, coagulation status, objectives of cannulation and the training of the operator. Patients returning from the operating room often have internal jugular catheters. In other patients femoral catheters are the most common because of the lack of intrathoracic complications and lower risk of bleeding, especially in the coagulopathic patient.
  7. Ultrasound guidance is available, using either a Site Rite (there is a spare battery on the charger) or cardiac ultrasound machine (with vascular probe). Both are kept in the store room.
  8. Position should be confirmed and pneumothorax excluded by CXR for Internal Jugular and Subclavian catheters. Line tips need to be intrathoracic and should ideally lie at the RA/SVC junction. Catheters within the RA need to be pulled back to the RA/SVC junction.
  9. Xrays are not routinely required for femoral catheters. However, if a femoral line is difficult to insert, or if blood is not freely aspirated back from both lumens immediately after insertion a lateral abdominal XR should be done to exclude line placement in an ascending lumbar vein (this is more common on the left).

Procedure

  1. All catheters are inserted using a Seldinger technique. Especially in young infants, the needle often passes through the vein without aspirating blood on the way in. Always then withdraw the needle slowly while still applying gentle suction and you may aspirate blood on the way back.
  2. Femoral Vein
    1. Externally rotate and evert the leg at the hip while elevating the hips with a rolled towel. The femoral vein is located medial to the femoral artery and runs under the inguinal ligament to the umbilicus.
    2. The needle should be inserted below the inguinal ligament (to avoid retroperitoneal bleeding) and medial to the femoral artery aiming for the umbilicus.
  3. Internal Jugular Vein
    1. Position the child 20° head down, with a towel under the shoulders and the head turned away from the side to be cannulated. The internal jugular vein is located just lateral and anterior to the carotid artery at the junction of the sternal and clavicular heads of the sternocleidomastoid muscle (which forms the apex of a triangle above the clavicle).
    2. The needle is inserted at the apex of the triangle, lateral to the carotid pulse at an angle of 45° and directed towards the ipsilateral nipple with continuous gentle suction. Do not palpate the artery while advancing the needle as this will also compress the vein.
  4. Subclavian Vein
    1. Position the child with the head midline and a rolled towel longitudinally between the shoulder blades and 20° head down. The subclavian vein runs under the medial part of the clavicle and towards the sternal notch.
    2. The needle should be inserted at the midclavicular point or just lateral, "walked" under the clavicle and directed medially towards the sternal notch aspirating gently.

Catheter type and size guide

Lumens Size Length  Weight Appropriate site
Double 4F 5cm <5 kg IJ/SC/Femoral
  4F 8cm 5-20 kg IJ/SC/Femoral
  4F 13cm >20 kg Femoral
Triple 4.5F 6cm <5-8 kg IJ/SC/Femoral
  4.5F 12.5cm <10-20 kg Femoral
  5.5F 5cm <5 kg IJ/SC/Femoral
  5.5F 8cm 5-20 kg IJ/SC/Femoral
  5.5F 13cm >20 kg IJ/SC/Femoral
  7F 16cm >40-50 kg IJ/SC/Femoral
Quad 8.5F 16cm >40-50 kg IJ/SC/Femoral
  • Use double lumen catheters for all children <5kg. If very haemodynamically unstable, a 4.5F triple lumen may be used.
  • For children who are 5-10kg the choice between double and triple lumen will depend on level of illness and haemodynamic stability.
  • Use triple lumen for children over 10kg and quad lumen in teenagers. More lumens increase the risk of infection and probably also thrombosis.
  • Swan sheaths (5F or 8.5F) can be used to provide large bore access to a central vein in children with, or at risk of, major haemorrhage.

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Document Control

  • Date last published: 18 January 2010
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Fiona Miles
  • Editor: John Beca
  • Review frequency: 2 years