A variety of nutritional access devices are available to provide enteral supplementation and parenteral nutrition (PN) safely and effectively to children.
PARENTERAL ACCESS DEVICES
Peripheral intravenous access is usually insufficient to provide adequate nutrition to patients as the nutrient concentrations need to be limited to prevent thrombophlebitis. Central venous line access is essential to patients requiring long- and short-term intravenous nutrition. A central venous access device (CVAD) is a line with a catheter tip that lies in the subclavian vein, superior/inferior vena cava, or right atrium. The type of CVAD is determined by the medical diagnosis and length of therapy. Insertion sites may include jugular, subclavian, femoral, antecubital, and umbilical veins. These lines may be tunneled or non-tunneled and may have 1 or more lumens. Line placement can be done in surgery, in interventional radiology, or at the bedside.
Tunneled central lines (Broviac/Hickman, Cook, Groshong) are placed through a subcutaneous tunnel away from the vein insertion site. These lines have a Dacron cuff to provide stability to the line and function as an antimicrobial barrier. Both placement and removal of tunneled central lines are done by a surgeon or radiologist. Children requiring prolonged PN need a tunneled central venous line.
Non-tunneled central venous catheters are generally placed directly into a jugular, subclavian, or femoral vein. These lines are typically placed in the hospital setting at the bedside for use while the patient is in the hospital. Since they do not have a Dacron cuff, they are sutured into place. They can also be removed at the bedside.
Peripherally inserted central catheters (PICC lines) are chosen for short-term intravenous therapies lasting weeks or months. Generally, they are placed in an arm or a leg and threaded to a central vein or right atrium. These lines can be placed at the bedside or in interventional radiology.
Implanted medication ports are tunneled lines implanted beneath the skin that contain a single or double reservoir pocketed between the subcutaneous layers and sutured in place. Placement is done in surgery or interventional radiology. Access to the reservoir is obtained with a non-coring needle. These ports are ideal for patients needing repeated but intermittent therapies, such as chemotherapy. They only need special care when accessed.
CARE AND MANAGEMENT OF CVADs
Presence of a CVAD increases a child’s risk for central line–associated bloodstream infection (CLABSI). It is of utmost importance that CVADs are managed using a “bundle” of care activities that include using sterile technique when accessing the line; scrubbing the access points with appropriate products; and keeping the dressing dry, intact, and occlusive. Many national initiatives have focused on CLABSI prevention, as CLABSI is a known source of morbidity and mortality. All levels of care providers/caregivers should be well versed in CLABSI prevention.