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  • • Emergency resuscitation requiring administration of large amounts of fluids.

    • Need for central venous pressure monitoring.

    • Placement of a pulmonary artery catheter.

    • Need for frequent blood draws.

    • Infusion of hyperalimentation.

    • Infusion of agents that can extravasate and cause soft tissue necrosis.

    • • Concentrated solutions (ie, KCl, dextrose concentrations > 12.5%, chemotherapeutic agents, hyperosmolar saline).

      • Vasoactive drugs (ie, dopamine and norepinephrine).

    • Need for hemodialysis.

    • Central access needed in a patient for which femoral vein catheterization is not possible due to poor landmarks or known thrombus.

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• Internal jugular and subclavian catheters are central lines placed percutaneously; they provide an alternative to femoral venous catheterization (see Chapter 10) when central venous access is needed.
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  • • Infection.

    • Bleeding.

    • Arrhythmias; can occur if the catheter or guidewire comes in contact with the heart.

    • Cardiac tamponade.

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  • • Internal jugular and subclavian catheters have certain advantages over femoral venous catheters, including the following:

    • • A pulmonary artery catheter is placed more easily from the internal jugular vein because there is an almost a straight course to the superior vena cava and right atrium of the heart.

      • Placement of a subclavian catheter uses a “blind” approach with good external landmarks; therefore, the operator may have more success in patients in shock or cardiopulmonary arrest where arterial pulsations are difficult to palpate.

      • Catheters are minimally affected by ambulation and may be preferable in very mobile patients.

      • Site of insertion is considered relatively “clean,” compared with the femoral location.

    • Keep in mind that in a patient receiving anticoagulation therapy, bleeding can be controlled more easily using internal jugular puncture.

    • However, there is a slightly higher incidence of failure using the internal jugular approach compared with the subclavian approach.

    • Securing the catheter can be difficult in a child with a small neck.

    • To avoid aspiration during intubation or conscious sedation, the procedure should be delayed 6 hours after the ingestion of solid food and 4 hours after the ingestion of clear liquids, unless central access is needed emergently.

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  • • Inform parents of the indications and risks of the procedure.

    • Inform parents about how long the catheter is likely to remain in place.

    • Inform parents in advance that their child may be sedated or intubated for the procedure and what risks each incurs.

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• Because of the risks and potential complications, only anesthesiologists, intensivists, some cardiologists, and surgeons perform this procedure.
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  • • Internal jugular and subclavian catheters are placed using the Seldinger technique (Figure 57–1) based on identifying external landmarks (Figure 57–2).

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  • • Please see Chapter 10, Femoral Venous Catheterization, for a detailed description of this technique.

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