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FOCUS POINTS
Establishing and maintaining adequate and reliable vascular access is one of the most critical aspects of pediatric anesthesiology.
Internal jugular, subclavian, and femoral central venous access sites are commonly used in pediatrics. Considerations for site selection include indications for placement, anticipated duration, patient-specific factors, and operator experience.
Infectious complications can be markedly reduced with universal precautions and good aseptic technique. Strict sterile barrier precautions should be employed including a mask, cap, sterile gown, and gloves. Chlorhexidine solutions are preferred to the use of povidone-iodine solutions for skin preparation.
Ultrasound guidance is recommended for central venous cannulation in children. It is also commonly used during placement of peripherally inserted central catheters and difficult peripheral venous line placement.
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CENTRAL VENOUS ACCESS
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Although there are no absolute indications for intraoperative central venous pressure (CVP) monitoring in pediatrics, the insertion of a central venous catheter (CVC) is warranted if it contributes to the management of a safe anesthetic. CVP monitoring can provide an estimate of right ventricular filling pressures and intravascular volume status. This information can be used to guide fluid resuscitation during procedures associated with significant blood loss, large fluid shifts, and hemodynamic instability. CVCs also serve as reliable access for the central administration of vasoactive medications, delivery of blood products, blood sampling, and central venous oxygen tension analysis. A multi-orifice CVC positioned at the superior vena cava (SVC) and right atrial (RA) junction allows for aspiration of entrained air in patients at risk for venous air emboli. Finally, insertion of a CVC may be the only option in cases where establishment of peripheral intravenous access is unsuccessful.
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In children with chronic diseases, several therapeutic interventions that extend beyond the operating room are made possible with the use of specialized CVCs. In larger cardiac patients, these catheters can serve as conduits for the insertion of transvenous electrodes for cardiac pacing and the placement of pulmonary artery catheters for more comprehensive hemodynamic monitoring. In critically ill patients, these catheters can also be used for temporary hemodialysis, continuous venovenous hemofiltration, and plasmapheresis. Administration of chemotherapy, long-term antibiotics, parenteral nutrition, and the delivery of other chronic continuous intravenous medications such as epoprostenol and milrinone are also common indications for CVCs in pediatric patients. This long-term access requirement usually involves the surgical placement of tunneled catheters that provide better long-term stability and reduced infection risk such as a subcutaneous port, Broviac, or Hickman catheter.
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As in adults, there are no absolute contraindications to the placement of CVCs in children. Relative contraindications include coagulopathy/thrombocytopenia, localized infection over the insertion site, target vessel stenosis/thrombosis, anatomical abnormalities/tumor presence, and parental/patient refusal. The use of antimicrobial/antiseptic impregnated CVCs has increased in recent years in pediatric patients in whom catheter is expected to remain in place for greater than 5 days. It is important to ...