Central venous vascular access

Abstract

In children, central venous catheters are most often used for cardiovascular monitoring, emergency vascular access, intermittent blood removal for laboratory analysis, fluid and drug administration, plasmapheresis, hemodialysis, and long-term chemotherapy. This chapter provides an overview of choices in central venous access sites, describes central venous catheterization techniques, and delineates associated risks and complications. Decisions regarding the “best” site for central venous cannulation depend upon patient specific clinical variables, risk of complications, operator experience, future vascular access needs, and projected length of time the catheter will remain in place. In 2011, the Centers for Disease Control (CDC) published updated recommendations regarding the selection, insertion, maintenance, and discontinuation of central lines. This guideline deserves review by practitioners who insert and/or maintain central venous lines in children (see Table 29.1). The femoral vein is the most common site for central venous access in children. This site may have the lowest insertion risk profile and a high degree of operator experience across multiple specialties. In adult patients, IJ and subclavian vessels are preferred sites because the rates of infection and deep venous thrombosis may be less than that found with femoral venous catheterization, however in children these differences are less clear. In children, operator experience and need for minimal sedation when placing femoral catheters, are important drivers in site choice. The subclavian vein is the preferred route for long-term venous access in children because it is easily inserted via the tunneled approach, is well tolerated, and is associated with few complications. Standard landmark insertion techniques still apply however the role of ultrasound guided CVC placement is growing in popularity and is recommended by some regulatory groups. Inexperienced operators may benefit most from ultrasound guided insertion. Pediatric providers should use their judgment about when to apply this important adjunct for line placement.