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1. Venous Access
Matthew L. Paden, MD
Emory University
Children’s Healthcare of Atlanta at Egleston

2. Peripheral IV
 Butterfly & angiocaths
– Short catheters generally placed in forearm, hand
or scalp veins
– Short term therapy and unable to handle caustic
chemicals (chemotherapy)

3. Peripheral Sites
 Veins of the Forearm
 1. Cephalic vein
2. Median Cubital vein
3. Accessory Cephalic
vein
4. Basilic vein
5. Cephalic vein
6. Median antebrachial
vein

4. Peripheral Sites
 Veins of the Hand
 1. Digital Dorsal veins
2. Dorsal Metacarpal veins
3. Dorsal venous network
4. Cephalic vein
5. Basilic vein

5. Peripheral IVs
 Try to cannulate the most distal veins first
– Drugs or fluids put through the cannula may
extravasate at the upstream failed cannula site
 Transillumination
 Topical nitropaste

6. Infiltration

7. Extravasation

8. Extravasation

9. Phlebitis

10. Cellulitis

11. Types of Central Vascular Access
Devices
 Non-tunneling
 Tunneling
 Implanted

12. Non-Tunneling
 Direct venipuncture through the skin into a
selected vein.
– Peripheral IV
– Peripherally inserted central catheter
– Percutaneous catheters

13. Non-Tunneling - PICC
 Peripherally inserted central catheters
(PICC)
– Midline
 Central venous catheter inserted at or
above the antecubital space and then
advanced until the distal tip of the
catheter is positioned at the superior vena
cava or superior vena cava and right atrial
junction.

14. Non-tunneling - PICC
 Useful for patient receiving
long term medication
therapy, chemotherapy or
TPN
 Used for frequent blood
sampling
 Distal end positioned at the
superior vena cava or
junction of superior vena
cava and right atrium

15. Non-Tunneling - PICC
 Peripherally inserted central catheters
(PICC)

16. Non-Tunneling - Midlines
 Used for shorter term
intravenous therapy
(up to 4 weeks)
 Used for frequent
blood sampling
 Distal end positioned
at the proximal end of
the upper extremity

17. PICC versus Midline

18. Non-Tunneling – PICC and Midline
examples at the antecubital & above

19. Non-Tunneling – CVC
 Percutaneous catheters
 Also known as: Central Venous Catheters
(CVC)
– Subclavian, femoral or internal jugular
– Single, double or triple lumen

20. Non-tunneling - CVC
 Tip advanced to superior
vena cava or SVC and
right atrium junction
 As with PICC, appropriate
for patients requiring long
term chemotherapy or
TPN

21. Non-tunneling CVC subclavian site

22. Tunneling
 Hickman®
 Broviac®
 Groshong®

23. Tunneling
 Inserted into a central
vein via percutaneous
venipuncture or cut down
 Catheter then tunneled
under the skin in the
subcutaneous tissue and
exited in a convenient
location
 Dacron cuff hold the
catheter in place

24. Tunneled
Hickman
Catheter

25. Tunneling - Broviac®
 Similar to the Hickman
catheter, but is of smaller
size.
 This catheter is mostly
used for pediatric
patients.

26. Tunneling - Groshong®
 Similar to Hickman®
and Broviac® with
closed ended patented
3-way valve.

27. Implanted VADs - Ports
 Catheter attached to a
self-sealing silicone
septum surrounded by a
titanium, stainless steal
or plastic port
 Port sutured under the
skin
 Some brand names:
– Port-a-cath®
– Infus-a-port®
– Power Port ®

28. Implanted VADs - Ports
 Catheter runs from
port to superior
vena cava at the
right atrium
 No part of the
device is exposed
outside the body
 Can deliver
chemotherapy,
TPN, antibiotics,
blood products and
blood sampling

29. Implanted VADs - Ports
 Can only be accessed
with special needle
called a HUBER needle
 Contains a deflecting,
non-coring point

30. Insertion Complications
 Inadvertent Arterial Puncture
 Hematoma Formation
 Extravasation
 Infection
 Phlebitis
 Pneumothorax

31. Adult Insertion Complications

32. Systemic Complications
 Infection
 Deep Vein Thrombosis
 Pulmonary Embolism
 Superior Vena Cava Syndrome

33. Mechanical Complication
 Catheter tip migration
 Broken or damaged catheter
 Catheter occlusion

34. Femoral Vein
 Adults –
– DVT
– Excess infection risk
– “Potentially inaccurate CVP”

35. Femoral Vein
 Kids –
– Better risk profile
– Ease of insertion, compressible
– No difference in DVT – ref 1-2
– Same infection risk (maybe lower) – ref 3-5
– Accurately reflects RAP if no increase in
abdominal pressures – ref 6-8
1. Beck C, et al. J Ped 1998;133:237-41.
2. Jacobs B, et al. Crit Care Med 1999;27:A29
3. Casado-Flores J, et al. Ped Crit Care Med 2001;2:57-
62.
4. Richards M, et al. NNIS Pediatrics 1999;103:103-9
5. Stenzel JP, et al. J Ped 1989;114:411-5.
6. Fernendez E, et al. Ped Crit Care Med 2004;5:14-18
7. Lloyd R, et al. Pediatrics 1992;89:506-8.
8. Ho K, et al. Crit Care Med 1998;26:461-4.

36. Femoral anatomy
 Vein is medial to the
artery
– Froehlich’s theorem
 Superficial distal to
inguinal ligament, then
dives deep
 0.5-2cm inferior to the
inguinal ligament

38. Quiz Question
 What are the anatomic landmarks to determine
where to stick for the femoral vein in a pulseless
patient?
– A. 1/3 of the distance from the anterior superior iliac spine
to the pubic tubercle
– B. ½ the distance between the pubic tubercle and the
anterior superior iliac spine
– C. 1/3 of the distance from the pubic tubercle and the
anterior superior iliac spine
– D. None of the above

39. Quiz answer
 D. None of the above
 The femoral ARTERY lies ½ the distance
between the pubic tubercle and the anterior
superior iliac spine.
 The femoral vein is 0.5-1.5 cm medial to this
depending on the size of the patient.

40. Straight vs. Frog leg
 “The optimal positioning
of the leg can vary
according to the
preference of the
operator.”
– Discuss

41. Procedure
 30-45 degree angle to skin
 2 methods
– Stick with negative pressure
on syringe while entering
and exiting
– Insert needle, and only
negative pressure on
removal
 Allows you to better
stabilize the needle by
resting your hand on the
thigh

42. Procedure
 Blood flash - Insert wire
– Wire not going smoothly
 Needle no longer in vessel
 False tracking in subcutaneous tissue
 Thrombus
 Advancing into lumbar veins
 Small incision
– Blade directed away from wire

43. Procedure
 Twisting motion of dilation
 Remove dilator
 Advance catheter
 Remove wire
 Aspirate and flush all ports
 Secure line with sutures
 Sterile dressing

44. Seldinger Technique

45. Procedure
 Wheeler – “Confirmation of proper CVC
position is required after placement of all
CVC’s”

46. Warnings
 If you hit the artery – pressure until hemostatic
 Wire should float – should never have resistance
 If can’t pull the wire through the needle – remove
both wire and needle together so you don’t sheer off
the wire
 Never let go of the wire
 Catheter tip “pointing too cephalad” – in lumbar veins

47. Complications
 74 of 89 (83%) – no complications
 Other 15 – minor bleeding/hematoma
 94.4% success rate
 Median duration 5 days
– 21% <3 days 26% 7-14 days
– 43% 4-7 days 10% >14 days
 Long term – 8 leg swelling, 11 BSI
Venkataraman, et al. Clin Ped 1997;36:311-9.

48. Complications
 45 months – 395 CVL – 162 femoral
 No insertion complications
 Mean duration 8.9 days
 9 noninfectious complications
– 4 thrombosis, 1 perforation, 1 embolism, 2 bleeding
 “The low incidence of complications in this study
suggests that the femoral vein is the preferred site in
most critically ill children when CVC is indicated.”
Stenzel JP, et al. J Ped 1989;114:411-5

52. 2/22/2023
Site Selection
Site Pro’s Con’s
Femoral  Easy access
 Large vessel
 Good access
during
resuscitation
 Decreased
mobility
 Increased risk
of thrombosis,
phlebitis &
infection
 Easily
contaminated
 Close to
femoral artery
 Dressing
difficult to
maintain

53. Subclavian Vein
 When to use it
– May be better for long term access
– Obese – clavicle gives you a landmark
– Shock – less likely to collapse
 Relative contraindications
– Trauma to the area
– Coagulopathic

54. Subclavian Anatomy
 Begins as axillary vein,
eventually joins the IJ
to become the
inominate or
brachiocephalic
 Anterior scalene
separates the SCA from
SCV
 Most common is
infraclavicular approach

56. Positioning
 Head down 15-30
degrees
 Rolled towel placed
longitudinally between
scapulae
 Tilt head toward side of
catheterization
– Reduced catheter
malposition in infants

57. Quiz Question
 What is the anatomic landmark on the
clavicle where you insert the needle?
– A. 1 cm below the junction of the middle and
lateral thirds of the clavicle
– B. 1 cm below the junction of the middle and
medial thirds of the clavicle
– C. 1 cm below the middle third of the clavicle
– D. 1 cm below the lateral third of the clavicle

58. Quiz Answer
 What is the anatomic
landmark on the
clavicle where you
insert the needle?
– B. 1 cm below the
junction of the middle
and medial thirds of the
clavicle

59. Procedure
 Needle inserted 1 cm below
junction of middle and
medial thirds of the clavicle
 Marched down clavicle and
parallel to frontal plane
 Bevel directed caudal
 Blood flash during insertion
or withdrawal

60. Procedure
 Regular Seldinger
technique
 Watch for dysrhythmias
with wire insertion

61. Confirmation
 Position should be in
the distal SVC
 FDA – “the catheter tip
should not be placed in
or allowed to migrate
into the heart”
 34% mortality rate with
CVC related pericardial
effusions in pediatrics

62. Complications
 Inability to cannulate
 SCA puncture/cannulation
 Catheter misplacement
 Pneumothorax
 Hemothorax
 Nerve injury

63. Complications
 100 patients - 1/3 of patients <1 year
 92% overall success rate
– 89% in emergencies
 Major complications
– 4 pneumothorax, 2 BSI
Venkataraman, et al. J peds 1998;113:480-5.

67. 2/22/2023
Site Selection
Site Pro’s Con’s
Subclavian  Large vessel
 Can tolerate
high flow
 Dressing easy
to maintain
 Less
restrictive for
patient
 Lowest sepsis
rate
 Close to lung
apex, risk of
pneumothorax
 Close to
subclavian
artery
 Hard to control
bleeding

68. Internal Jugular Vein
 When to use it
– High rate of success
– Compressible if coagulopathic
– Lung hyperinflation (less likely to get
pneumothorax than subclavian)
– Transvenous pacing via RIJ
 Relative contraindications
– Ongoing CPR – difficult to access
– Cervical trauma/increased ICP

69. Internal Jugular Anatomy
 Lateral to carotid artery
in sheath
 Beneath the triangle
formed by the sternal
and clavicular heads of
the SCM and the
clavicle

71. Quiz Question
 All of the following are correct about a left internal
jugular cannulation EXCEPT:
– A. LIJ has a more acute angle at connection with
subclavian
– B. Lower pneumothorax risk compared to right because
right pleural dome is higher
– C. Lymphatic duct adjacent to junction of LIJ and
innominate vein
– D. Reduced risk of carotid puncture because of its caudo-
cephalad structure

72. Quiz answer
 B is the correct answer to the question
 Reasons to go right –
 The left has :
– More acute angle at connection with subclavian
– Left pleural dome is higher (more pneumothorax
risk)
– Lymphatic duct adjacent to junction of LIJ and
innominate

73. Internal Jugular Positioning
 Trendelenberg 15-30
degrees
 Shoulder roll
 Head turned away from
side of insertion

74. Procedure – Median approach
 Needle insertion –
approximately one half
the distance between
the mastoid and the
sternal notch
 20-30 degree needle
angle
 Seldinger technique –
watch for dysrhythmias

75. Posterior Approach

76. Anterior Approach

77. Procedure
 Finder needle
techniques
– Consider when:
 Poor landmarks (obese)
 Coagulopathic
 Carotid artery disease
in adults
 Ultrasound

78. Ultrasound Image of Right Neck

79. Correct IJ placement
CXR provided by Jeremy P. Feldman, MD
E-Bay Fellow in Pulmonary Vascular Disease

81. Complications
 Arterial puncture more common than
subclavian
 Pneumo/hemo thorax very rare
 Catheter malpositioning similar to subclavian

82. 2/22/2023
Site Selection
Site Pro’s Con’s
Internal
Jugular
 Large vessel
 Easily located
 Easy access
 Short, straight
path to
superior vena
cava
 Decreased risk
of
pneumothorax
 Uncomfortable
for patient
 Difficult to
maintain
dressing
 Close to
carotid artery
 Easily
contaminated
 Difficult
maintenance
with trach or
neck injury

83. Axillary Vein
 Find axillary artery
 Get PIV just inferior to it in axillary vein
 Wire it up
 Appropriate size catheter?
 226 neonates done with 9 failures
 47 critically ill kids (14d-9y)
– 79% cannulation rate
 Rare complications – similar thrombosis rates to
subclavian and internal jugular

84. Temporary Dialysis Catheters
 We have available :
– 7 French Triple Lumen regular CVL
– 7 French 10 cm Double Lumen Medcomp
– 8 French 9cm Double Lumen Mahurkar
– 12 French 13 cm Triple Lumen Mahurkar
– 12 French 20 cm Triple Lumen Mahurkar

85. PATIENT SIZE CATHETER SIZE &
SOURCE
SITE OF INSERTION
NEONATE Single-lumen 5 Fr (COOK) Femoral artery or vein
Dual-Lumen 7.0 French
(COOK/MEDCOMP)
Femoral vein
3-6 KG Dual-Lumen 7.0 French
(COOK/MEDCOMP)
Internal/External-Jugular,
Subclavian or Femoral vein
Triple-Lumen 7.0 Fr
(MEDCOMP)
Internal/External-Jugular,
Subclavian or Femoral vein
6-30 KG Dual-Lumen 8.0 French
(KENDALL, ARROW)
Internal/External-Jugular,
Subclavian or Femoral vein
>15-KG Dual-Lumen 9.0 French
(MEDCOMP)
Internal/External-Jugular,
Subclavian or Femoral vein
>30 KG Dual-Lumen 10.0 French
(ARROW, KENDALL)
Internal/External-Jugular,
Subclavian or Femoral vein
>30 KG Triple-Lumen 12.5 French
(ARROW, KENDALL)
Internal/External-Jugular,
Subclavian or Femoral vein

86. Vascular Access for Pediatric CRRT: Pros
and Cons of Femoral Site
 Relatively larger vessel may
allow for
– larger catheter
– higher flows
 Ease of placement
 No risk of pneumothorax
 Preserve potential future
vessels for chronic HD
 Shorter femoral catheters with
increased % recirculation
 Poor performance in patients
with ascites/increased abdominal
pressure
 Trauma to venous anastamosis
site for future transplant
PROS CONS

87. Vascular Access for Pediatric CRRT: Pros
and Cons of IJ/SCV Site
 Tip placement in right atrium
decreases recirculation
 Not affected by ascites
 Preserve potential vein
needed for transplant
 SCV stenosis (SCV)
 Superior vena cava
syndrome
 Risk of pneumothorax in
patients with high PEEP
 Trauma to veins needed
potentially for future HD
access
PROS CONS

88. Femoral versus IJ catheter performance
 26 femoral
– 19 > 20 cm
– 7 < 20cm
 13 IJ
 Qb 250 ml/min (ultrasound dilution)
 Recirculation measurement by ultrasound
dilution method
Little et al: AJKD 36:1135-9, 2000

89. Femoral versus IJ catheter performance
Type Number Qb (ml/min) Recirculation(%) 95% CI
Femoral 26 237.1 13.1* 7.6 to 18.6
> 20cm 19 233.3 8.5** 2.9 to 13.7
< 20cm 7 247.5 26.3** 17.1 to 35.5
Jugular 13 226.4 0.4* -0.1 to 1.0
Little et al: AJKD 36:1135-9, 2000
* p<0.001
** p<0.007

90. Femoral versus IJ catheter performance:
Pediatrics
103 102
118 119
219
174
3 4
0
50
100
150
200
250
BFR
(mls/min)
Venous P
(mm Hg)
Arterial P
(mm Hg)
%Recirc
IJ/SC
Femoral
P value NS NS NS NS
(Gardner et al, CRRT 1997
Quinton 8 Fr; n = 20; 120 Treatments)