FUNDAMENTALS OF

PEDIATRIC CENTRAL
VENOUS ACCESS
Emily Ochmanek, DO PGY2
Alex Covington, MD PGY2

The goal of CVAD* is to provide

reliable, safe access for infusion
therapies including:
Blood products
Parenteral nutrition/lipids
Antibiotics, chemotherapy and other

medications
Dialysis/apheresis
Fluids/electrolytes
Phlebotomy
*Central Venous Access Device(s)

Risks/Complications: Patient Factors

Known medical allergies
Immune compromise

Chronic disease
Current infection, prior catheter related infection
Coagulopathy
History of difficult access

Known venous anomalies/abnormalities

Complex congenital heart disease
Coexisting CV access or implanted devices (pacemaker, shunt)
Major surgery

Trauma
ICU admission
Severe malnutrition
Morbid obesity

Risks/Complications: Procedural Factors

Arterial puncture
Pneumothorax

Nerve injury
Thrombosis
Hematoma
Delayed treatment from failure of placement
Death

Risks/Complications
A recent article by Bruzoni, et al published

in the surgery literature found decreased

complications using ultrasound compared
to the traditional landmark based approach
in a randomized study
Interventional Radiologists are uniquely
qualified in this regard given expertise in
use of imaging

Pre-procedure Workup
Referral should be for the medical indication, not just the

procedure
Diagnosis and comorbidities
Anticipate and bundle CVA into other procedures/referrals
(biopsy, abscess drain) to limit sedation, etc.
Venous history
Prior access, anomalies, review imaging
Premedication (anxiolytics; general anesthesia for
prepubescent or immature adolescents), labs (INR <1.5,
platelets >50,000 for elective procedures), antibiotic
prophylaxis (not usually needed)
Device selection: smallest diameter and least number of
lumens possible to decrease risk of infection and thrombosis

Considerations in Catheter Selection

Expected duration
Acute (hours to days)
temporary device (neck, groin)
replace within 5-10 days (with a permanent device PRN)

If longer term/permanent access needed

consider PICC or tunneled device with central tip

Intermittent access
indwelling subcutaneous port

Type of therapy prescribed

Age, developmental level, available veins to access
Patient/parent/clinician preference
Comfort and ease of use, especially in home care settings

Central Veins
IVC and SVC
Innominate
Subclavian

Additional Venous Access Sites

Right Sided Central Venogram

Catheter Sizing
The French scale or gauge system is commonly

used to measure the size of a catheter (most

often abbreviated Fr)
A catheter of 1 French has a diameter of 1/3 mm,
therefore the diameter (D) can be determined by
dividing the French size by 3:
D (mm) = Fr / 3
Fr = D (mm) * 3
Example: if the French size is 9, the diameter is 3
mm

Catheter Sizing
More examples:
French Gauge

Diameter (mm)

Diameter (in)

0.39

1.333

0.053

1.667

0.066

0.079

2.333

0.095

2.667

0.105

0.118

Etc.

Etc.

Etc.

Catheter Placement
Tip location is important for decreasing

complications and maximizing catheter dwell time

Optimal tip location for CVADs is usually the
distal SVC for upper extremity sites, and the IVC
for lower extremity sites
The vena cava rapidly dilutes infusates,
minimizing trauma to the vessel wall
High right atrium is optimal site for tunneled
hemodialysis and apheresis catheters to reduce
thrombus formation around tip and accommodate
high flow rates

Catheter Placement
Cavoatrial Junction

Seldinger Technique

Step 5. Threading of catheter to area of interest

Step 6. Removal of guidewire

Catheter Types: Midline Catheter

Single or dual lumen
Therapy between 5 days to 4 weeks
Length 3-8 inches
Typically inserted in upper extremity vein with

tip distal to shoulder

In infants can use lower extremity or scalp
veins, with tip below groin or in neck,
respectively
Infuse peripheral solutions only; avoid
continuous infusion

Midline Catheter

Catheter Types: Peripherally Inserted

Central Catheter (PICC)
Sizes: 2-7 Fr, some are Power Injectable
Single, dual or triple lumen
Therapy >5-7 days but <2 months, poor

peripheral access, need to infuse

irritants/vesicants
Upper extremity tip in low SVC or superior
cavoatrial junction (6th posterior intercostal space)
Lower extremity tip in IVC
Blood sampling OK if 3 Fr or larger

Peripherally Inserted Central Catheter

(PICC)
Usually placed via peripheral arm veins; less commonly, leg,

neck or scalp veins

In the arm, preferred vein is basilic vein running between brachialis

and biceps muscles

Second choices are brachial or cephalic veins
Risks: brachial nerve injury; cephalicprone to spasm, and in babies can

be difficult to cross the cephalic-subclavian confluence due to acute angle

Uses: Medication, blood products, blood sampling

Advantages over central lines: relative ease of placement,

safer in coagulopathic patients, can be placed under local

anesthesia or conscious sedation
Disadvantages compared to central lines: risk of exhaustion of
upper extremity veins in a young patient, interference with
vessel patency in future dialysis or graft candidates

PICC Placement Procedure

Surgical arm prep
Basilic or cephalic vein preferred
Ultrasound or arm venogram to confirm venous

anatomy/patency
Access vein with micropuncture needle
Advance wire to superior vena cava
Determine appropriate intravascular length of catheter;
tip should be in high right atrium
Insert peel-away sheath
Advance catheter through sheath
Secure to skin

Upper Extremity Anatomy Under US

BR Brachial, BA Basilic, A Brachial Artery

BR=brachial vein, BA=basilic vein, A=brachial artery

Catheter Types: PICC

PICC

Catheter Types: Non-tunneled CVC

Single, dual or triple lumen
Urgent access, critically ill patient, short

term therapy (<7 days), failed attempt at

other CVADs
Commonly inserted in subclavian, jugular
or femoral vein, with tip in distal SVC or
IVC
Not intended for home care setting due to
risk or infection and air embolism

IJ access under ultrasound guidance

Images

V- Internal Jugular Vein

V Internal Jugular Vein
A Common Carotid Artery

Catheter Types: Non-tunneled CVCs

Right IJ Access

Right Subclavian Access

Catheter Types: Tunneled CVC (AKA

Hickman or Broviac)
Single, dual or triple lumen
Long term (6>weeks) or frequent access
Commonly inserted into chest, and tunneled

under skin
Right IJ approach is most common

Dacron cuff scars into tissues over days to

weeks, helping to prevent bacterial infection and

migration of the catheter
Placed/removed by IR or Surgery

Tunneled CVC Placement Procedure

Confirm patency of access vein
Surgical skin prep
+/- Prophylactic antibiotics
Surgical scrub operator hands

Image-guided access; micropuncture needle

Determine appropriate intravascular length with guidewire; tip

should be in high right atrium

Tunnel catheter to puncture site; tunnel on chest wall should have
gentle curve to access site
Insert catheter through peel-away sheath; Valsalva, Trendelenburg
position to prevent air embolism during catheter insertion
Close venous access site
Secure catheter to skin

Tunneled CVC (AKA Hickman or Broviac)

Tunneled CVC (AKA Hickman or Broviac)

Tunneled CVC (AKA Hickman or Broviac)

Tip terminates in superior right atrium

Catheter Types: Implanted Port

Single or dual lumen
Long term or intermittent therapy
Inserted in chest or arm, with reservoir implanted

under the skin

Placed/removed by IR or Surgery
Consider antibiotic prophylaxis to cover skin flora
Access with aseptic technique using Huber noncoring needle; if not being accessed regularly,
flush every 30 days with heparinized saline
Power Injectable vs. Non-Power Injectable

Port Placement Procedure

Confirm patency of access site

Surgical skin prep
Prophylactic antibiotics
Surgical scrub operator hands
Image-guided access; micropuncture needle
Insert catheter through peel-away sheath; Valsalva, Trendelenburg
position to prevent air embolism
Position catheter tip in high right atrium
Create pocket
Tunnel catheter retrograde into pocket
Trim catheter, assemble port, flush
Place port in pocket, secure with 3-0 absorbable sutures
Close skin in layers; 3-0 absorbable suture deep layer; 4-0 or 5-0
absorbable suture subcuticular skin
Close venous access site
Access port, confirm correct function, flush

Implanted Ports

CVAD Care/Maintenance
Flushing
Verifies patency (stop if resistance is met!)
Prevents precipitation of infusates
Prevents fibrin sheath formation (especially in small catheters),
which has been linked to central line associated bloodstream
infections (CLABSI) in pediatrics
Preservative free normal saline is most commonly used (but
heparinized saline, 5% dextrose in water, and ethanol are used
when medications are not compatible with normal saline, such as
amphotericin)
Volume of flush should be at least twice the internal volume of the
catheter
10mL syringe is recommended for initial and routine flushing;
smaller syringes can generate excessive intraluminal pressure and
damage the catheter

CVAD Care/Maintenance
Locking: instilling a solution in the catheter

lumen to maintain patency

For non-implanted ports: 1 to 3 mL of

heparinized saline (10 units/mL)

For implanted ports: 5mL of heparinized saline
(100 units/ml)

CVAD Care/Maintenance
Other elements include:
Needleless connector/injection cap care: a solution of at least 70%

alcohol has been found to be very effective following a 15-second

scrub and a relatively short drying time, and may be the most cost
effective option for needleless connector antisepsis
Blood sampling: a CVAD tip that resides in the SVC or IVC should
flush and aspirate freely. Limit to 3 mL/kg/day in a 24 hour period to
minimize the volume of blood loss
Tubing/add-on devices: changed based on type of infusate
Dressing (changes): prevent microbial colonization and catheter
migration; use skin antiseptic such as Chlorhexidine
Securement: catheter movement increases risk of phlebitis, infection
and dislodgment
Patient/caregiver education

References
Baskin KM. Central venous access and related interventions. In: Temple M, Marshalleck FE, editors. Pediatric
interventional radiology: Handbook of vascular and non-vascular interventions. New York: Springer; 2014. p. 107-132.
Bruzoni M, Slater BJ, Wall J, St Peter SD, Dutta S. A prospective randomized trial of ultrasound- vs landmark-guided
central venous access in the pediatric population. J Am Coll Surg. 2013 May; 216(5):939-43.
Donaldson JS. Pediatric vascular access. Pediatr Radiol. 2006; 36: 386-97.
French catheter scale. Retrieved 2014 Sept 27, from http://en.wikipedia.org/wiki/French_catheter_scale
Kaufman JA, Lee MJ. Vascular and interventional radiology: The requisites, 2nd ed. Philadelphia: Elsevier; 2014.
Kramer N, Doellman D, Curley M, Wall JL. Central vascular access device guidelines for pediatric home-based patients:
Driving best practices. J Assoc Vasc Access. 2013; 18(2):103-13.
Vo JN, Hoffer FA, Shaw DW. Techniques in vascular and interventional radiology: pediatric central venous access. Tech
Vasc Interv Radiol. 2010 Dec; 13(4): 250-7.