Pediatric IR · Procedure Reference
Central Venous Access
Indications & Contraindications
Indications
Therapeutic: administration of blood products, parenteral nutrition, antibiotics, chemotherapy, and dialysis or apheresis access.
Contraindications
- Infection — active local or systemic infection at the access site.
- SVC syndrome — if upper extremity or neck access is planned.
- Coagulopathy — platelet count <50,000/μL, or INR >1.5 for elective cases.
Pre-Procedure Workup
Review & Consent
- ✓ Comprehensive review of all available non-invasive imaging to optimize approach and minimize contrast; detailed knowledge of cardiac anatomy and prior repairs where relevant.
- ✓ Allergy history, including contrast and antiseptic solutions.
- ✓ Medication review, including anticoagulation.
- ✓ Confirm the IR consult specifies catheter type, size, and intended access site.
- ✓ Determine catheter category: PICC vs. CVL vs. port-a-cath.
- ✓ Informed consent, including benefits, risks, and alternatives.
Imaging
- ✓ Preprocedural ultrasound to assess target vein patency and compressibility.
- ✓ Permanent images archived (e.g., to PACS) to document baseline anatomy.
Labs
- ✓ Complete blood count with platelet count and differential.
- ✓ Comprehensive metabolic panel — BUN, creatinine, electrolytes, glucose.
- ✓ Coagulation studies (PT, INR, aPTT), with attention to age-related normal values.
Labs are only necessary if there is suspicion of thrombocytopenia or coagulopathy.
Catheter Sizing Guidelines
| Patient Weight | Single Lumen | Double Lumen |
|---|---|---|
| Infants & toddlers (<15 kg) | 1.9–3.0 Fr | 2.6–4.0 Fr |
| Older children (>15 kg) | 3–4 Fr | 4–6 Fr |
PICC Product Reference — Medcomp & Bard
Sizing, guidewire compatibility, and power-injection status for the PICC lines most commonly stocked for pediatric IR. Guidewire diameters below reflect the wire supplied with the manufacturer's own procedure set; always confirm against the current IFU before insertion, since revisions and regional kit variants differ.
Medical Components, Inc.
| Product | Lumens | French size(s) | Length(s) | Material | Guidewire | Power injectable | Notes for the placer |
|---|---|---|---|---|---|---|---|
| Vascu-PICC® TLS | Single, Dual | 1.9 Fr, 2.6 Fr | 20 cm, 50 cm | Silicone | 0.014–0.018 in (size-dependent) | No | Medcomp's smallest PICC — the workhorse for neonates and small infants. Taperless lumen. Pairs with a 24G angiocath/Galt needle for the 1.9 Fr size. |
| Vascu-PICC® TL (taperless) | Single, Dual | 3 Fr, 4 Fr, 5 Fr | 60 cm | Silicone | ~0.018 in | No | Constant internal diameter along the shaft (no step-down at the hub) — modestly better flow for a given French size than a tapered design. |
| Pro-PICC® / Valved Pro-PICC® | Single, Dual, Triple | 3, 4, 5, 6 Fr | 55 cm, 60 cm | Polyurethane | 0.018 in (0.47 mm), 70 cm | Yes — 5 mL/sec @ 300 psi | Matched peelable introducer scales with catheter size (3.5–6.5 Fr). Valved version is clamp-free; both have a reverse-taper hub. |
PowerPICC®
| Product | Lumens | French size(s) | Material | Guidewire | Power injectable | Notes for the placer |
|---|---|---|---|---|---|---|
| PowerPICC® SV | Single, Dual | Single: 3 Fr · Dual: 4 Fr | Polyurethane | 0.018 in, nitinol | Yes — 1 mL/sec (3 Fr SL) / 2.5 mL/sec (4 Fr DL) | The smallest-diameter power-injectable option in the Bard range — useful when a smaller child still needs CT power injection. |
| PowerPICC® (IR) | Single, Dual, Triple | Single: 4, 5 Fr · Dual: 5, 6 Fr · Triple: 5, 6 Fr | Polyurethane | 0.018 in — stainless steel or nitinol, gold-tungsten tip, 70 & 135 cm | Yes — 5 mL/sec @ 300 psi | Purple catheter body flags it as power-injectable at a glance. Reverse-taper hub; compatible with the Sherlock 3CG bedside tip-confirmation system. |
Silicone vs. polyurethane, in brief: silicone is softer and more biocompatible for long-dwell lines and tolerates alcohol-based locks well, but its lower tensile strength means thicker walls (smaller ID for a given French size) and it is generally not rated for power injection — don't power-inject a silicone catheter unless it is explicitly labeled for it. Polyurethane is stronger for a thinner wall (larger ID, higher flow for the same French size) and is the material used across every power-injectable PICC in this table, but it degrades with repeated or prolonged alcohol exposure, so avoid alcohol-based locking or soaking solutions on polyurethane catheters.
Access Equipment & Anesthesia
Needles, Guide Wires & Sheaths
- A 21-gauge Echotip needle (or 22G angiocath) is most commonly used for ultrasound-guided venipuncture; both accommodate a 0.018" guidewire.
- For smaller veins, a 24-gauge angiocath or Galt needle accommodates a 0.014" guidewire (Floppy or Galt).
- Peel-away sheaths are used in most patients to facilitate catheter introduction.
Local Anesthesia
1% lidocaine is administered at both the access site and, when applicable, the tunneling site.
Technique
Steps are shown in the order they're typically performed. Tunneling is only relevant for tunneled catheters and can be skipped for non-tunneled lines.
Choose the access site based on vein patency and clinical context. Right or left basilic are the preferred veins in the upper extremities. For some patients with cardiac history, the team may request a lower extremity PICC — this can be a saphenous PICC or a tunneled femoral line. Check the order for location requests. Prep the skin and access area in sterile fashion; make a small nick with a #11 blade after local anesthesia.
Image the target vein continuously and advance the access needle under real-time ultrasound guidance. Save permanent images of both the vessel and needle entry for documentation.
Advance the appropriate wire (0.014" or 0.018") into the central circulation, often confirmed in the SVC/IVC by fluoroscopy.
Exchange the needle for a peel-away sheath (2.7–3 Fr) and advance it over the wire into the vein. Measure the wire to determine proper catheter length, then cut the catheter accordingly.
Advance the cut-to-length catheter through the peel-away sheath, then carefully remove the sheath while maintaining catheter position. Verify final positioning with fluoroscopy — tip in the lower SVC or upper IVC, near the cavoatrial junction.
Establish a separate exit site. Use a tunneling device or suture to pull the catheter from the venipuncture site to the exit site, keeping appropriate distance from the skin entry point. Confirm final tip position, then close the exit site with sutures before dressing.
Secure the catheter (e.g., StatLock, or sutures for a left internal jugular approach), apply a Biopatch, then a sterile occlusive dressing. Confirm tip placement with fluoroscopy or radiography and rule out complications. Flush and aspirate well; heparin lock at 10 units/mL unless the line is immediately attached to an infusion.
Complications
Immediate / Periprocedural
- Vascular injury — arterial puncture, vessel perforation, or arrhythmia.
- Air embolism — reduced by peel-away sheath valves and proper positioning.
- Pneumothorax — chiefly with subclavian or jugular access; minimized with real-time ultrasound guidance.
Mechanical
- Malposition / kinking — from inadequate wire placement or catheter measurement.
- Pinch-off syndrome — typically subclavian access; mechanical compression leading to eventual fracture.
- Catheter-related thrombosis.
Infectious
- CRBSI — catheter-related bloodstream infection; underscores strict sterile technique and dressing protocol.
Post-Procedure Care
Hemostasis
- Manual compression for adequate hemostasis.
- Stat-Seal or SecurePortIV can be used for persistent oozing at a PICC site.
Infection Prevention
- ✓ Hand hygiene before and after all catheter manipulations.
- ✓ Sterile technique for dressing changes, accessing ports, and blood sampling.
- ✓ Catheter hub disinfection with 70% isopropyl alcohol or chlorhexidine before access.
- ✓ Minimal manipulation — reduce unnecessary catheter access and consolidate blood draws.
- ✓ Daily necessity assessment — remove the catheter as soon as it's no longer needed.
References
Show 8 references
- Polderman KH, Girbes AR. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med. 2002;28(1):1-17.
- Frykholm P, Pikwer A, Hammarskjöld F, et al. Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand. 2014;58(5):508-524.
- Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105-1117.
- Rupp SM, Apfelbaum JL, Blitt C, et al. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116(3):539-573.
- Moureau NL, Trick N, Nifong T, et al. Vessel health and preservation (part 1): a new evidence-based approach to vascular access selection and management. J Vasc Access. 2012;13(3):351-356.
- O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. 2011;52(RR-9):1-32.
- Andropoulos DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg. 2001;93(4):883-886.
- Casado-Flores J, Barja J, Martino R, et al. Complications of central venous catheterization in critically ill children. Pediatr Crit Care Med. 2001;2(1):57-62.