central line in kids?

[nocallaochicas]

I was trying to study for step 2 when I came across a question asking about access in hemodynamically unstable 3yo (likely septic) girl that needed quick access after peripheral attempts failed. The question asked how it should be done in the ED. I choose intraosseus (correct answer)...but other options included femoral line and subclavian. These seemed reasonable to me also.

The answer key says, yes, IO is best. However, it then goes on to say "central line access in children should only be done by highly-skilled individuals, and is therefore not reccommneded in the ED."

After ignoring the implication that individuals in the ED are not highly skilled enough, I began to wonder how often central lines are stuck in kids in the ED. Do you guys do them?

My critical peds EM exposure is minimal (I guessed IO above mostly because of adverts in EM journals!), but central IV access doesn't seem that out of the question to me.

Please tell me what it is like in the real world. Thanks, ncc

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[Apollyon]

I've never seen a central line in a kid beyond the PICU or the OR (except for the story to follow). Even for the femoral triple lumina, it was the PGY-5 PICU fellow doing it.

A few years back, there was this patient that was 22 or 23, but looked like an achondroplastic 8 year old, due to multiple medical problems. The attending in the peds ED that day was a covering pediatrician, and he'd never put in a triple lumen in a patient. The MICU (adult) fellow was a condescending prick (who is now a condescending prick attending at Duke) who was (sight unseen) demeaning this attending in the Peds ED about requesting his help, so he went down and put in the smallest triple lumen (like, 4 or 5 inches long) into this patient, with marked difficulty. Then, because of her age, he accepted this patient from the Peds ED to the MICU! Unfortunately, a few days later, she died.

 

[southerndoc]

I've inserted double lumens in kids (<5 years old). I can still count all of them on one hand. Three were in the PICU, one in the ED of a children's hospital, and one in our community ED. Two of the PICU DL's were IJ's. All others were femoral.

 

[The White Coat Investor]

I was trying to study for step 2 when I came across a question asking about access in hemodynamically unstable 3yo (likely septic) girl that needed quick access after peripheral attempts failed. The question asked how it should be done in the ED. I choose intraosseus (correct answer)...but other options included femoral line and subclavian. These seemed reasonable to me also.

The answer key says, yes, IO is best. However, it then goes on to say "central line access in children should only be done by highly-skilled individuals, and is therefore not reccommneded in the ED."

After ignoring the implication that individuals in the ED are not highly skilled enough, I began to wonder how often central lines are stuck in kids in the ED. Do you guys do them?

My critical peds EM exposure is minimal (I guessed IO above mostly because of adverts in EM journals!), but central IV access doesn't seem that out of the question to me.

Please tell me what it is like in the real world. Thanks, ncc

An IO is an easy, fast procedure that is hard to F--- up. A central line in an adult is an easy, fast procedure that is hard to F--- up. A central line in an infant/toddler is a difficult, time-consuming procedure that sometimes requires two or three different pediatric intensivists (attendings) to try the procedure before someone finally gets it. Needless to say, EPs don't put them in very often and so, aren't even as good at it as the Peds intensivists. In a kid who needs a line now, the go-to line is the IO.

 

[southerndoc]

In a kid who needs a line now, the go-to line is the IO.

Agreed. It does take a while to get a central line in really young kids. Trouble finding the vein (not a problem if you use ultrasound), trouble threading the wire, etc.

 

[doctawife]

I've seen femoral lines put in children fairly often in the ED - usually by pedi ED fellows. I haven't actually seen that many IO's 'cause our nurses rock so hard with the IVs. Two big lines - avoiding using both antecubes (leaving one for the PICC that the kiddo will probably need) - in under 90 seconds? No problem!

Those guys and gals rule.

 

[mikecwru]

Agreed. It does take a while to get a central line in really young kids. Trouble finding the vein (not a problem if you use ultrasound), trouble threading the wire, etc.

I put a fem line in an infant that was actively seizing.

I have 12 lb balls.

mike

 

[The White Coat Investor]

I put a fem line in an infant that was actively seizing.

I have 12 lb balls.

mike

Clearly, those 12 lbers must stabilize your hands.

 

[The White Coat Investor]

I've seen femoral lines put in children fairly often in the ED - usually by pedi ED fellows. I haven't actually seen that many IO's 'cause our nurses rock so hard with the IVs. Two big lines - avoiding using both antecubes (leaving one for the PICC that the kiddo will probably need) - in under 90 seconds? No problem!

Those guys and gals rule.

I trained at a place where the nurses/techs always got the IVs too. Now the help I have isn't nearly as good, but it does give me more opportunities for IOs!

 

[doctawife]

I put a fem line in an infant that was actively seizing.

I have 12 lb balls.

mike

You can use those 12 lbs balls to weigh down the torso and limb in question so they don't move. That's the beautiful thing about babies - they're small and weak.

Toddlers, now those 3 year olds can get away from ya, but babies are eminently maneuverable.

 

[mikecwru]

I trained at a place where the nurses/techs always got the IVs too. Now the help I have isn't nearly as good, but it does give me more opportunities for IOs!

The nurses usually get lines fairly easily for us, too. The majority of IOs I do are probably on SIDS babies.

Do you have any devices for adult IOs?

mike

 

[mikecwru]

You can use those 12 lbs balls to weigh down the torso and limb in question so they don't move. That's the beautiful thing about babies - they're small and weak.

Toddlers, now those 3 year olds can get away from ya, but babies are eminently maneuverable.

You should have seen my nasal swab technique when I did peds floor. The 3 year olds had a hard time moving too.

Is the nasal swab supposed to come back "normal neuron?"

mike

 

[doctawife]

You should have seen my nasal swab technique when I did peds floor. The 3 year olds had a hard time moving too.

Is the nasal swab supposed to come back "normal neuron?"

mike

That's freaking awesome! The only thing better would have been 'normal occipital hair follicle"

Heh.

 

[RuralMedicine]

If you needed a line five minutes ago (and you can't get it peripherally) then you're probably going to get that IO a lot faster than a CVL. Venous cutdown is another option (or just try for that saphenous PIV) but that's not a seconds procedure like your IO is with any luck. We're expanding the upper age limit for IOs it seems every few years so keep it in mind when you're desperate.

As a resident our ED nurses were very good with IVs as well. I miss them a lot now. Most of the peds CVLs I did as a resident were in the PICU or in the OR. I did I think two physically in the ED (not counting a few incarcerated sickle cell teens (15-17 years old their physiology was more like adults I'd argue) without access that ended up on my medicine service at our county hospital because pediatrics didn't take incarcerated youth unless they were under 13

 

[12R34Y]

It's interesting that Rural medicine states that they are expanding IO upper age limit every year when they are now routinely (and indicated) for adults.

what do you mean by expanding the upper age limit? IO's go in every Joe-blow now.

just curious.

later

 

[Quimby2]

Despite clear indications, we still do not perform adult IO's in our ED. I haven't even seen one done. Anyone here performing them? Maybe share your advice on technique.

--that is technique on selling it to our antiquated attendings.

 

[DropkickMurphy]

I've seen a few done in the ED, but we utilize them with regularly frequency for codes in the field in adults with no ready IV access (general rule is 1 failed IV attempt then go for the IO; personally I think going for the IO first then sticking for the IV would probably be more expedient but that's just me).

 

[RuralMedicine]

It's interesting that Rural medicine states that they are expanding IO upper age limit every year when they are now routinely (and indicated) for adults.

what do you mean by expanding the upper age limit? IO's go in every Joe-blow now.

just curious.

later

I believe that the 2005 revisions were the first to list ACLS revisions to list IO access as Class IIa for adults. From a practical standpoint I haven't been coding adults without any access (although I probably place more CVLs for "no access" than I did as a resident because well I was spoiled by our nurses PIV skills) since the latest revisions came out about a year ago. I'm curious is your institution really using IOs in "everyone"? This is not the practice here (or for my EM friends in urban academia)

 

[12R34Y]

I believe that the 2005 revisions were the first to list ACLS revisions to list IO access as Class IIa for adults. From a practical standpoint I haven't been coding adults without any access (although I probably place more CVLs for "no access" than I did as a resident because well I was spoiled by our nurses PIV skills) since the latest revisions came out about a year ago. I'm curious is your institution really using IOs in "everyone"? This is not the practice here (or for my EM friends in urban academia)

Yeah, IO's are becoming more and more common now. The prehospital folks (ie flight crews and busy EMS systems) are using them as quick IV access in code blues and traumas/medical patients who are sick/shocky that need access and they're having trouble. They're stupid proof. EZ-IO is what most use in my experience.

It'll take a few years for the new ACLS guidlines to kick into everyone's habit/institution, but its just a matter of time.

later

 

[basementbeastie]

i have 12 lbs buns....

question: is the issue (difficulty) with peds c-lines that the central veins are so small and are thus hard to cannulate? or is it something else? 😕

(note: i have not placed any peds c-lines....)

 

[ER-ER-Oh]

i have 12 lbs buns....

question: is the issue (difficulty) with peds c-lines that the central veins are so small and are thus hard to cannulate? or is it something else? 😕

(note: i have not placed any peds c-lines....)

I've done 3 femoral lines in kids under 2 years old, 2 in the PICU during rotation there under the guidance of the PICU attending, and 1 in the ED during a trauma. Maybe I was totally naive and didn't know any better but they all went in quite easily. The attending told me to frog leg the kid, palpate the femoral artery, go 2 finger breadths below where I felt it, go one finger breadth medially, stick the needle all the way down to the femur, then gently pull back, and, bingo, it was right there. It was actually easier than many of the adults I've done. I haven't had to do one since, so I don't know if I'd hit it so easily now that you've let the cat out of the bag about how difficult it is.

 

[DropkickMurphy]

You should have seen my nasal swab technique when I did peds floor. The 3 year olds had a hard time moving too.

Is the nasal swab supposed to come back "normal neuron?"

mike

That's great......thanks Mike, you've vastly improved how my night was going.

 

[The White Coat Investor]

i have 12 lbs buns....

question: is the issue (difficulty) with peds c-lines that the central veins are so small and are thus hard to cannulate? or is it something else? 😕

(note: i have not placed any peds c-lines....)

Yes, it is purely a size thing (assuming they are completely sedated. If not, it's a sedation thing too.)

Small central veins, small needle etc.

 

[FDNewbie]

Back from the dead! haha.

I was just wondering about this the other day, esp. since we've had to transfer kids to outside facilities with PICUs with I/Os - and I've definitely seen them fail suddenly, despite being placed correctly and working well initially (and for quite some time). Plus if the kid is THAT sick, and I need antibiotics, fluids, possibly even pressors, I'll need multiple lines; an I/O isn't gonna cut it. So this is what I came across: http://emedicine.medscape.com/article/940865-overview. In short:

1) Subclavian is the preferred location, but the RIGHT subclavian (vs. the left; they say the dome of the right lung sits lower than the left, decreasing the chance of a PTX). Interestingly, there are a couple articles floating around (the last one I read was by Peds Anesthesiologists) for obtaining subclavian central access under ultrasound guidance (holding the ultrasound in the supraclavicular location, and cannulating from the typical infraclavicular approach). Here's said article: http://bja.oxfordjournals.org/content/98/4/509.full

2) Femoral is preferred in code situations (duh).

Yes, it is purely a size thing (assuming they are completely sedated. If not, it's a sedation thing too.)

Small central veins, small needle etc.

That's #3. It becomes a size issue. I can't recall offhand the diameter of our Arrow triple lumen CVL kits, but you gotta make sure you're not trying to cannulate with something too large. They had a really nice chart about age vs. vein/line diameter:

Having said that, I still have never done a CVL in a kiddo, but can imagine in very rare instances when it's not just indicated, but probably essential (triple lumen for multiple access).

 

[KYTNOH]

I've placed a few in the PICU. I just recently placed a femoral arterial line and femoral venous line in the ED on a 2 month old post-code (used an IO for the resuscitation). I used ultrasound guidance for both, and both were easy.

In general, I think pediatrics as a whole is less procedure driven and pediatricians are therefore less competent at procedures. The writers of questions are generally pediatricians, so they think every pediatric procedure is difficult even though we do them all the time.

On a side note, I've put in a few adult IOs, but it is rare that EMS does get at least two 18 gauges or larger in place before they arrive.

 

[Groove]

IO is def first "go-to", but I'd attempt a line if I had UTZ handy, but I'll be honest... just about any procedure on a kid I approach with an extra dose of sphincter tone. I put a chest tube in a tension PTX 4-5yo (forget the age) who was crashing and thought I was going lateral to the nipple, (forgetting that the nurse was yanking his arms way over his head, and this was all with trauma team looking on with approving eyes) and I put it....between the 1st and 2nd ribs. Worked great, I was meticulous and careful, like I always am... knew it felt high as I was frantically trying to throw it in to save this kid but when I saw the CXR, thanked my higher power I hadn't played around with the forceps too much or been too vigorous in my insertion. I can't imagine how I would have felt if I had damaged some of the anatomically important vessels that tend to go through that general vicinity. Kid ended up doing fine... The trauma chief came down later and told me in confidence that he had actually done the same thing one time except that he lacerated the subclavian and the kid didn't end up doing so well...

I'll never forget that case and it was a good learning moment. These kids are tiny, what feels like 1-2 rib counts is often 5.

 

[Apollyon]

IO is def first "go-to", but I'd attempt a line if I had UTZ handy

What is with the abbreviations? Utz, like potato chips? I am being completely serious here.

 

[Stitch]

IO is def first "go-to", but I'd attempt a line if I had UTZ handy, but I'll be honest... just about any procedure on a kid I approach with an extra dose of sphincter tone. I put a chest tube in a tension PTX 4-5yo (forget the age) who was crashing and thought I was going lateral to the nipple, (forgetting that the nurse was yanking his arms way over his head, and this was all with trauma team looking on with approving eyes) and I put it....between the 1st and 2nd ribs. Worked great, I was meticulous and careful, like I always am... knew it felt high as I was frantically trying to throw it in to save this kid but when I saw the CXR, thanked my higher power I hadn't played around with the forceps too much or been too vigorous in my insertion. I can't imagine how I would have felt if I had damaged some of the anatomically important vessels that tend to go through that general vicinity. Kid ended up doing fine... The trauma chief came down later and told me in confidence that he had actually done the same thing one time except that he lacerated the subclavian and the kid didn't end up doing so well...

I'll never forget that case and it was a good learning moment. These kids are tiny, what feels like 1-2 rib counts is often 5.

👍

I've placed a few in the PICU. I just recently placed a femoral arterial line and femoral venous line in the ED on a 2 month old post-code (used an IO for the resuscitation). I used ultrasound guidance for both, and both were easy.

In general, I think pediatrics as a whole is less procedure driven and pediatricians are therefore less competent at procedures. The writers of questions are generally pediatricians, so they think every pediatric procedure is difficult even though we do them all the time.

On a side note, I've put in a few adult IOs, but it is rare that EMS does get at least two 18 gauges or larger in place before they arrive.

See above; your 'n' may not be high enough. Lines can be easy, but they can also be problematic. Like anything else in medicine, the more you do, the better at it you are, so generally they are best left to those who do them often. Even when I was an attending in a dedicated peds ED, we didn't do many centrals. IOs worked fine most of the time, and we were able to get them into the PICU fast enough.

These questions tend to be written by pediatric fellowship trained sub specialists, who do plenty of procedures. They are trying to make you approach children with a sense of caution because we have all seen an overconfident (though perfectly good) adult type physician really screw a kid up through a procedure. And I don't mean any disrespect to my EM colleagues by that.

 

[FDNewbie]

I've placed a few in the PICU. I just recently placed a femoral arterial line and femoral venous line in the ED on a 2 month old post-code (used an IO for the resuscitation). I used ultrasound guidance for both, and both were easy.

Awesome. What line did you use? A peripheral IV? I know the Arrow fem line catheter is pretty darn small (in caliber) so I'd be comfy placing it (probably not the whole way in though, cuz it's REALLY long for a 2 month old's body size/length). But I'm pretty sure a standard Arrow triple lumen is too large for a femoral line (and again too long)?

That article I quoted above re: Peds Anesthesia doing U/S-guided subclavians, I triple read it and they didn't identify the actual kit/line equipment they were using. But it sounded like they were using peripheral lines for central access.

In general, I think pediatrics as a whole is less procedure driven and pediatricians are therefore less competent at procedures. The writers of questions are generally pediatricians, so they think every pediatric procedure is difficult even though we do them all the time.

I hear you 100%

On a side note, I've put in a few adult IOs, but it is rare that EMS does get at least two 18 gauges or larger in place before they arrive.

I don't hesitate to do so if need be, including placing sternal IOs. But I've typically found that I can get a femoral triple lumen in during a code in about 30 more seconds than it takes to place an I/O, plus I can grab tons of labs offa the line & have 3 lines available. So that's my first choice.

 

[Socrates25]

I've placed a few in the PICU. I just recently placed a femoral arterial line and femoral venous line in the ED on a 2 month old post-code (used an IO for the resuscitation). I used ultrasound guidance for both, and both were easy.

In general, I think pediatrics as a whole is less procedure driven and pediatricians are therefore less competent at procedures. The writers of questions are generally pediatricians, so they think every pediatric procedure is difficult even though we do them all the time.

On a side note, I've put in a few adult IOs, but it is rare that EMS does get at least two 18 gauges or larger in place before they arrive.

Easy there cowboy. I count 4-5 attendings on this thread who have a combined experience of 8-10 central lines between them. I'd hardly call that "doing them all the time" type experience.

As a peds resident, I've done probably 20-30 central lines in kids, all but 2 of them were in the PICU, and I dont consider myself anywhere near "competent"

The only people I view as truly competent to do CVCs on a routine basis in kids are PICU attendings, peds EM trained guys, and peds surgeons. For the rest of us, there simply arent enough patient numbers to get the experience you need.

 

[TrustMe]

I have done a few CVL's in kids but not that many. Smallest was a 3kg kiddo for VSD repair. I have found that other than the small size of the veins is that the vessels in kids are much more compressable than in adults. This makes it more difficult to cannulate the vessel because it collapses with the smallest amount of pressure. It is difficult not to go "through and through" to get blood return. So, if you are not using U/S you may hit the vein several times but will not get blood return because it will collapse as soon as you hit it. Can be very frustrating, even sometimes when using U/S.

If the RN's are having difficulty, the saphenous vein is a great option for peripheral access. It is easily and reliably located anatomically and is able to be cannulated "blindly" most of the time.

In regards to size. For the kids under 1 y/o that I have done I typically use a 4Fr., 5cm double lumen catheter.

 

[KYTNOH]

Awesome. What line did you use? A peripheral IV? I know the Arrow fem line catheter is pretty darn small (in caliber) so I'd be comfy placing it (probably not the whole way in though, cuz it's REALLY long for a 2 month old's body size/length). But I'm pretty sure a standard Arrow triple lumen is too large for a femoral line (and again too long)?

I used a 20 gauge peripheral IV for the femoral arterial line in the two month old. I'll occasionally use peripheral IVs in my adult radial art lines, but I usually use the Arrows. For my adult femoral art lines (which I absolutely hate - I think they are the hardest line to place) I use a pediatric central line kit. For the central line I used a 4 french 5 cm double lumen.

Easy there cowboy. I count 4-5 attendings on this thread who have a combined experience of 8-10 central lines between them. I'd hardly call that "doing them all the time" type experience.

As a peds resident, I've done probably 20-30 central lines in kids, all but 2 of them were in the PICU, and I dont consider myself anywhere near "competent"

The only people I view as truly competent to do CVCs on a routine basis in kids are PICU attendings, peds EM trained guys, and peds surgeons. For the rest of us, there simply arent enough patient numbers to get the experience you need.

I didn't mean we necessarily do them on peds patients, but I can't even count how many central lines I've done on adults. Others may disagree, but there really isn't that big of a difference between the two as long as you are using ultrasound. I think the PICU attendings I worked with thought there was a big difference, but after doing several ultrasound guided lines in both populations I respectfully disagree. To me the most similar procedure to an ultrasound guided pediatric (<2 yrs) femoral CVC is an adult ultrasound guided basilic vein IV placement. The veins are almost exactly the same diameter and the depth is almost exactly the same in a non-obese adult. I would add that I have never done a subclavian CVC in anyone less than teen years, so I can't comment on the similarity between peds subclavians and adult subclavians. I would also add that I don't think all procedures cross over from adult to peds. Intubations in kids less than 2 years or so, I feel, are significantly different. Chest tubes in kids are different than chest tubes in adults, and unless its a crashing patient I will defer to peds surgery to place a chest tube in a young kid.

On a side note, you have a tremendous number of lines for a pediatrics resident. Count yourself lucky. Most of the peds residents I rotated with in the PICU had NEVER placed a CVC.

 

[crewmaster1]

I've only put in one central line in any child under 12 y/o and it was in the picu. After about 12 years-old most kids these days are the size of a small adult!

I've put in probably 20 I/Os into adults. Started using them working on the helicopter for sick patients. Basically if you're sick and need intubated fast, if the RN didn't have an IV line by the time I had the tube set up and drugs ready, you got an I/O. It is super fast, easy and effective. Same thing now in the ED, if you're coding and I need a line now I can have an I/O in in less than 10 seconds. They are actually pretty reasonable in awake patients that are sick too. They can buy you a bit of time to put in a cleaner central line, just give them a little lidocaine to help ease the pain of the I/O infusion (25mg or 1/4 of a cardiac lido amp). I put one in a co-resident a few years back as a grand rounds demonstration. I just injected a small amount of dermal lidocaine (1% with epi), then put int he I/O and gave some of the cardiac lido, then fluid. The most painful part of the whole thing is infusing fluid into the bone marrow cavity can be very painful (15/10), the lido helps.

 

[FDNewbie]

I put one in a co-resident a few years back as a grand rounds demonstration.

😱

LOL but seriously...did you really?!?!

 

[Groove]

What is with the abbreviations? Utz, like potato chips? I am being completely serious here.

Well, US for ultrasound is sooo yesterday. I've boycotted it altogether and gone straight for UTZ. Now, if you google it... let's forget that the first couple of links refer you to Greenland Western Standard Time (UTZ) and let's focus on links like this, which means it's already spreading like wildfire.... I couldn't be happier.

Never heard of UTZ chips...but then again, never heard of a potato chip maker with 3 lb refill boxes. 👍

 

[Arcan57]

I put one in a co-resident a few years back as a grand rounds demonstration. I just injected a small amount of dermal lidocaine (1% with epi), then put int he I/O and gave some of the cardiac lido, then fluid. The most painful part of the whole thing is infusing fluid into the bone marrow cavity can be very painful (15/10), the lido helps.

I thought we raised you to have better sense than that.

 

[Socrates25]

On a side note, you have a tremendous number of lines for a pediatrics resident. Count yourself lucky. Most of the peds residents I rotated with in the PICU had NEVER placed a CVC.

My subjective opinion is that PICU attendings are MUCH MORE directly involved in the care of their patients compared to their MICU colleagues.

The MICU attitude is "hey go do this central line, I'm going home." with the unsaid assumption there being "its no big deal if you cant get it, the guy was probably going to die anyways."

I've never seen a PICU attending let a resident, even a senior resident with lots of experience, do a central line solo in a kid, even if the kid is semi-stable.

 

[iridesingltrack]

I've only put in one central line in any child under 12 y/o and it was in the picu. After about 12 years-old most kids these days are the size of a small adult!

I've put in probably 20 I/Os into adults. Started using them working on the helicopter for sick patients. Basically if you're sick and need intubated fast, if the RN didn't have an IV line by the time I had the tube set up and drugs ready, you got an I/O. It is super fast, easy and effective. Same thing now in the ED, if you're coding and I need a line now I can have an I/O in in less than 10 seconds. They are actually pretty reasonable in awake patients that are sick too. They can buy you a bit of time to put in a cleaner central line, just give them a little lidocaine to help ease the pain of the I/O infusion (25mg or 1/4 of a cardiac lido amp). I put one in a co-resident a few years back as a grand rounds demonstration. I just injected a small amount of dermal lidocaine (1% with epi), then put int he I/O and gave some of the cardiac lido, then fluid. The most painful part of the whole thing is infusing fluid into the bone marrow cavity can be very painful (15/10), the lido helps.

Ditto, 1 central line in any kid <12y/o.

That I/O demonstration was one of the most memorable grand rounds I have ever seen. I remember at the beginning thinking, "difficult access in the pods are gonna get I/O's...nope, that looks terrible." Now, I use them only on the silly sick that need instant access. Wow, that seems like yesterday...Arcan57, you and your lot, raised Crewmaster to be a knuckledragger, seriously.

iride