Anaesthesia - paediatric cardiac invasive lines
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Invasive lines are required in cardiac surgical patients for monitoring and treatment. All lines have risks associated with insertion, use and removal and for each line this needs to be weighed against the benefit of such line.
Central Venous Lines (CVLs)
Minimise infection risk by:
- Adhering to the CLAB guidelines during insertion and ongoing use.
- Removing the line as soon as possible.
Minimise thrombosis risk by:
- Using the smallest possible line.
- Removing the line as soon as possible.
- Running a low dose heparin infusion through the line in patients <5kg.
Monitoring SVC pressure is advisable during CPB so that SVC obstruction can be detected and rectified. These lines are usually inserted via the R) IJV and ideally positioned at the SVC-RA junction (this may interfere with surgical cannulation of the SVC and may need to be pulled back during the surgery).
If an umbilical venous line is in situ and in good position this can be used as the perioperative CVL.
Upper body CVLs need to have their position confirmed by a CXR.
If there is limb swelling associated with an indwelling CVL the patient should have an ultrasound of the affected limb looking for venous occlusion. NB: following insertion of a femoral CVL it is not unusual to get some immediate leg swelling due to venous congestion - this IS NOT an indication to remove the line. The leg should be elevated and observed.
If thrombosis is confirmed the patient should be anticoagulated for 3-5 days prior to line removal if this is feasible. This is to minimize the risk of embolism occurring when the line is removed and is especially important if there is potential for R to L shunt - DO NOT do this on postoperative patients without discussion with the surgeon first.
The patient will then require either USS follow up without anticoagulation or anticoagulation for some time. If there is no thrombosis the line may or may not be removed.
Direct Atrial Lines
These are surgically placed at the time of operation. The commonest indication is for potential LV problems and the line is placed in the LA. These should be removed as soon as they are no longer required after discussion with the surgeon. They should not be removed in unstable patients as removal of these lines can cause major cardiovascular instability.
Direct Pulmonary Artery Lines
These are surgically placed at the time of operation and are used in patients with the potential to have postoperative pulmonary hypertension. They should be treated as per direct LA lines. They are rarely used.
The preferred site is the radial artery and failing this the femoral then brachial then axillary artery. Avoid the side of any previous modified Blalock-Taussig Shunt. Patients undergoing selective cerebral perfusion need an arterial line in the right upper limb.
It may be preferable to have 2 arterial lines in patients undergoing aortic surgery e.g. interrupted aortic arch. If only 1 arterial line is placed then ensure this is proximal to any obstruction. Two arterial lines are necessary in patients undergoing LA-FA bypass.
Any arterial line that causes distal blanching or ischaemia should be removed immediately and the limb closely observed. If there is inadequate distal perfusion inform the cardiac surgeon.
Single Ventricle Patients
Superior vena cava lines in patients who are going down the single ventricle route should be single lumen small bore lines that are removed ASAP to minimize the risk of vessel thrombosis. These lines are used for monitoring only and infusions are given via a femoral CVL or direct atrial line. Like all patients with a CVL great caution needs to be exercised to prevent embolism from these lines as in single ventricle patients it will result in systemic embolism.
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- Date last published: 07 June 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Anaesthesia
- Owner: D Buckley
- Editor: Michael Tan
- Review frequency: 2 years
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