Chapter 57

• • 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.

 • 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.

• • Infection.

• Bleeding.

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

• • 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.

• • 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.

 • Because of the risks and potential complications, only anesthesiologists, intensivists, some cardiologists, and surgeons perform this procedure.

• • Internal jugular and subclavian catheters are placed using the Seldinger technique (Figure 57–1) based on identifying external landmarks (Figure 57–2).

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

###### Figure 57–1.

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

## Subscription Options

### AccessPediatrics Full Site: One-Year Subscription

Connect to the full suite of AccessPediatrics content and resources including 20+ textbooks such as Rudolph’s Pediatrics and The Pediatric Practice series, high-quality procedural videos, images, and animations, interactive board review, an integrated pediatric drug database, and more.