![]() PICCs are inserted into the basilic and cephalic veins, with the right side generally preferred for its more direct approachĪt the UM PICU, fellows may attempt PICC placement on one arm but if unsuccessful, should generally reserve the other arm for the vascular access PICC team. 5Fr triple lumen power PICCs can be used in older/larger children (~10 yrs +, 35 kg+) in those that may require contrast injections 4Fr double lumen PICCs are the most common PICCs inserted in the PICU and will work for most patients. 3Fr PICCs can be used in infants and toddlers although they are single lumen. In general, neonates and small infants require 1.9Fr PICCs. PICCs are often used for longer term access (weeks to months) and may be a reasonable option in many of our patientsĬatheter selection depends on the size of the patient and the intended use.ĭrawing blood: PICCs less than 3Fr in size cannot be used to draw bloodĬontrast injections (ie CT scans): Power PICCs (5Fr) should be inserted if this is anticipated Peripherally Inserted Central Catheter (PICC) Needle puncture should occur at the juncture of the medial and distal third of the clavicle Needle puncture occurs at the apex of the triangle formed by the clavicle and the sternal and clavicular heads of the sternocleidomastoid (for standard medial/central approach).įor subclavian access, the child should be in Trendelenburg with a rolled towel placed between the scapula along the spine to extend the back. ![]() Generally the right internal jugular is preferred because the path is more direct and there is less risk of pneumothorax or damage to the thoracic duct. Needle puncture occurs medial to the femoral artery pulsation ( NAVEL ) generally at the level of the femoral crease (1-2 fingerbreadths below the inguinal ligament).įor internal jugular access, the child should be placed in 30 degrees of Trendelenburg with the head turned away from the site of cannulation in slight extension. Positioning for central venous catheterization is critical.įor femoral venous access, a roll can be placed under the buttocks to better expose the femoral vein and the hip should be slightly flexed and externally rotated. This was done in 3027 critically ill adult patients.Ĭentral venous catheter insertion is generally performed using the modified Seldinger technique with ultrasound guidance. 4,5 More recently, a RCT from France ( Parienti et al, NEJM 2015 ) demonstrated lower rates of bloodstream infection and symptomatic thrombosis but higher risk of pneumothorax with subclavian CVC vs. While traditionally thought of as a "dirtier" site associated with more infections, femoral venous cannulation has been associated with lower rates of complications and recent meta-analyses from adult populations have called this teaching into question. The femoral vein is the most commonly accessed site for resuscitation due to its location away from the site of chest compressions and airway control. Site: The most common sites used for central venous access include the femoral vein, subclavian vein, and internal jugular vein. Limiting the number of lumens may reduce the rate of catheter related bloodstream infection, although this is not clear. single lumen simply for extended IV antibiotic use). double or triple lumen if anticipating multiple infusions or worsening trajectory vs. Number of lumens should be appropriate for anticipated use (i.e. These distances can be approximated before choosing a catheter length. In general, newborns or very small infants 25 kg that may need aggressive fluid resuscitation.Ĭatheter length will depend on the site with the goal of an upper CVL (IJ, subclavian) terminating at the SVC/RA junction and a femoral CVL generally terminating in the external or common iliac vein. Thus, a peripheral IV may be better than a triple lumen PICC line.Ĭatheter size is based upon both patient size and anticipated use. Hence, for pushing fluids rapidly, you want a large, short catheter. This is described by Poiseuille's Equation. Resistance to flow decreases by the fourth power of the change in radius as the radius of the catheter increases. Flow rate through a catheter is directly proportional to the internal diameter of the catheter and inversely proportional to its length.
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