![]() ![]() A 27- or 30-gauge needle is used to anesthetize the skin and subcutaneous tissue around the entry site with buffered 1% lidocaine. To minimize risk of contamination, a large sterile field is prepped using sterile sheets. After the venous access site is selected, the skin of the upper arm entry site is sterilized and draped. Therefore, the cephalic vein is usually not our first choice in this sub-population. In children who are less than 1 year of age, the cephalic vein may have a normally smaller diameter of the medial segment that can prevent central catheter positioning. Of the three veins in the upper arm (basilic, cephalic, and brachial) above the ante-cubital fossa, the most commonly selected vein is the basilic vein. The venous anatomy is assessed with ultrasound and the most desirable vein is selected for access. The patient is positioned supine with the upper extremity secured to an arm board at a right angle to the trunk. Prophylactic antibiotics were found to not decrease PICC-related infections and are not routinely adminstered. Though infrequently needed before the procedure, tests for CBC, platelet count, PT, and PTT may be indicated in patients with suspected bleeding diathesis. However, if a J-tip is used the site may be anesthetized immediately prior to the procedure. Topical anesthesia with EMLA requires application approximately one hour before the procedure. Children are kept NPO for six hours prior to PICC insertion if sedation is considered. Older and mature children may have PICC insertion using a combination of topical or local anesthetics alone or in combination with intravenous sedation. PICC placement is commonly performed under general anesthesia in young children. These catheters are inserted via a peel away sheath with a stiffening wire inside the catheter. In very small infants, a smaller gauge needle and guide wire may be needed, while in neonates catheter size may be 2.6 French or smaller and does not easily go over a guide wire. For venipuncture, a sheathed needle or single wall needle are preferred with the recommendation that the bore is large enough (≥22 gauge) to allow insertion of at least an 0.018-inch guide wire, but small enough to minimize the risk of vasospasm. When deciding which equipment to select, the weight, age, and condition of the patient along with the preference and expertise of the proceduralist are considered for needle, catheter, and guide wire selection. Predominantly, they are used for long-term parenteral nutrition, long-term delivery of chemotherapy, prolonged antibiotic course, blood draws, fluids/electrolyte maintainence, and used for frequent blood sampling in children of all ages especially those with challenging venous access. While originally predominantly used as a substitute for serial peripheral angio-catheters, PICCs are currently utilized for many of the applications of tunneled central venous catheters. The indications for PICC insertion have expanded since its introduction to a broader sphere of use. In most cases, a 3 French single-lumen or 4 French double-lumen non-tunneled PICC is inserted for children weighing less than or greater than 10 kg respectively. When the femoral vein is selected, it is generally tunneled to create an entry site away from the diaper area to minimize the chance for infection. Children less than 1 year of age are also candidates for PICC insertion although alternative sites such as saphenous vein or femoral veins may be utilized 3. PICCs are favored in children who are older (greater than one year) with larger peripheral veins and preferred in patients with need for 2-4 weeks of central venous access, and/or those with pulmonary disease or dysfunction. The decision to place a central venous catheter (CVC) or a PICC follows no standardized criteria and is currently based on maximizing venous conservation, predicted length of time central access is needed, vessel patency, patient age and size, illnesses, as well as patient, physician or venous access nurse preference. Ideal catheter placement is generally assisted by fluoroscopic or ultrasound guidance, or less commonly by using alternatives such as intra-atrial EKG monitoring. Although the upper arm is the most common entry site, any peripheral vein may be utilized if the diameter is large enough and if the vein is in continuity with central veins and the right atrium. Initially introduced in the 1970s for parenteral nutrition, 1,2 silastic or polyurethane peripherally inserted central catheters (PICC) are inserted via a peripheral vein. ![]() Complex central venous access has been a mainstay of the pediatric interventionalist’s practice. ![]()
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