Paediatrics: Central venous catheterization via a peripheral vein

Central venous catheterization via a peripheral vein

For administration of prolonged or concentrated IV fluids or drugs.

Sites

Suitable sites include the veins of the antecubital fossa, or long saphenous vein anterior to the medial malleolus or inferior–medial to the knee. Less preferred sites include the axillary or scalp veins.

Equipment

• Sterile surgical instruments including fine forceps and scissors.

• Sterile gloves, gauze swabs, gown, and drapes.

• Antiseptic solution, e.g. 0.5% chlorhexidine.

• 23 or 27G silastic long line catheter. 27G should only be used when a 23G line cannot be inserted.

• 2–5mL syringe and heparinized (1U/mL) saline solution.

• Introducer, e.g. 19G butterfly needle, 20G IV cannula.

• Sterile adhesive tape and transparent occlusive dressing.

Procedure

• Measure distance from insertion site to just above the right atrium. Placing the catheter tip in the right atrium risks pericardial tamponade.

• Catheter insertion should be performed using strict aseptic technique.

• Wash hands and put on sterile gloves, gown, +/– surgical mask.

• Set out equipment and prime catheter with sterile heparinized saline.

• Apply tourniquet proximal to selected insertion point.

• Immobilize relevant limb, then clean insertion site with antiseptic.

• Place sterile drapes around insertion point to create sterile field.

• Insert introducer needle into the vein until blood flashes back. If using a cannula, remove stylet.

• With fine forceps advance catheter through introducer needle/cannula.

• Continue to advance catheter into vein until the desired distance is reached. Tip: often the catheter will meet resistance as it becomes wedged against a kinked vein or valve. Milking in a proximal direction with a finger over the catheter tip may facilitate further advancement.

• Remove tourniquet and then flush catheter with heparinized saline.

• Once fully inserted, withdraw introducer needle/cannula. Remove from line after unscrewing catheter hub. Reconnect hub to catheter.

• Ensure haemostasis at puncture site by applying gentle pressure with sterile gauze swab. This may take some considerable time!

• Secure line in place by using thin strips of sterile adhesive tape and sterile transparent occlusive dressing.

• Start infusion of heparinized saline (1U/mL) to keep line patent.

• Confirm catheter tip placement with CXR. This may be aided by the injection into the line of 0.5mL of contrast solution immediately before X-ray. Ideally, the catheter tip should lie just proximal to the right atrium. Withdraw the catheter before use if it is in the right atrium.